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The Oregon Administrative Rules contain OARs filed through August 15, 2014
 
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OREGON HEALTH INSURANCE EXCHANGE

 

DIVISION 20

CERTIFICATION OF PLANS AS QUALIFIED HEALTH PLANS

945-020-0010

Statutory Authority; Purpose; Applicability

(1) OAR chapter 945, division 20 is adopted pursuant to the general rulemaking authority of the Exchange in ORS 741.002.

(2) The purpose of OAR chapter 945, division 20 is to establish the process for certification of health plans as qualified health plans.

(3) OAR chapter 945, division 20 applies to all qualified health plans offered through the Exchange, except the following:

(a) Multistate plans, as defined in section 1334 of the Affordable Care Act.

(b) Consumer Operated and Oriented Plans (CO-OPs), as defined in section 1322 of the Affordable Care Act.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.310
Hist.: OHIE 3-2012(Temp), f. 9-13-12, cert. ef. 10-1-12 thru 3-13-13; OHIE 4-2012, f. & cert. ef. 12-13-12

945-020-0020

Certification of Qualified Health Plans

Each health benefit plan offered through the Oregon Health Insurance Exchange (Exchange) must have in effect a certification issued by the Exchange. This certification demonstrates that the health benefit plan is a qualified health plan (QHP).

(1) The Exchange will issue a request for applications (RFA). To be considered for participation and plan certification, a health insurance issuer must submit a completed application to the Exchange in the form and manner, and within the timeframes specified by the Exchange.

(2) Conditional approval to participate in the Exchange will be granted to applicants who

(a) Are licensed and in good standing to offer health insurance in Oregon;

(b) Agree to offer at least one standardized QHP at the bronze, silver, and gold levels of coverage;

(c) Meet any other performance standards that may be adopted by the Exchange; and

(d) Agree to contract with the Exchange to offer QHPs. Contracts will require issuers to comply with Exchange standards and requirements, including but not limited to the following:

(A) Transparency in coverage standards;

(B) Accreditation requirements;

(C) Network adequacy standards;

(D) Exchange administrative fees and assessments;

(E) Quality improvement strategies, quality reporting, and enrollee satisfaction surveys;

(F) Exchange agent management program requirements;

(G) Tribal requirements;

(H) Premium tax credit and cost sharing reductions; and

(I) Exchange processes and procedures, including those related to enrollment, enrollment periods, premium payment, terminations of coverage, customer service, and QHP recertification and decertification.

(3) Issuer approval is conditioned upon certification of their health benefit plans. Issuers will be approved for a two-year period. No new issuers will be considered for participation during those two years unless there is a significant loss of statewide coverage.

(4) A loss of statewide coverage may include, but is not limited to, plan discontinuance, withdrawal, decertification, or enrollment closures that result in a lack of coverage choices in a geographic area(s) of the state.

(5) Any health benefit plan an approved issuer wants to offer through the Exchange must be filed with the Oregon Insurance Division and determined to meet applicable benefit design standards and all other insurance regulations as required under state and federal law.

(6) Benefit design standards means coverage that includes, but is not limited to, the following:

(a) The essential health benefits as described in section 1302(b) of the Affordable Care Act;

(b) Cost sharing limits as described in section 1302(c) of the Affordable Care Act; and

(c) A bronze, silver, gold, or platinum level of coverage as described in section 1302(d) of the Affordable Care Act, or is a catastrophic plan as described in section 1302(e) of the Affordable Care Act

(7) Subject to any limitation on the number of plans that may be offered through the Exchange, the Exchange will certify health benefit plans that are submitted by approved issuers and determined by the Oregon Insurance Division to meet all applicable standards.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.310
Hist.: OHIE 3-2012(Temp), f. 9-13-12, cert. ef. 10-1-12 thru 3-13-13; OHIE 4-2012, f. & cert. ef. 12-13-12

945-020-0040

Qualified Health Plan Addendum for Indian Health Care Providers

(1) The Exchange adopts by reference the Qualified Health Plan (QHP) Addendum for Indian Health Care Providers.

(2) If a health insurer contracts with a Tribal Health Provider in the state of Oregon for services to be offered through a health benefit plan certified by the Exchange as a QHP, the issuer must:

(a) Use the QHP Addendum for Indian Health Care Providers to supplement and amend their existing provider contract, and

(b) Notify the Exchange of the contractual relationship by contacting an Exchange carrier account executive.

(3) The Exchange reserves the right to amend the QHP Addendum for Indian Health Care Providers using the rulemaking process. Contracted carriers and tribes will be required to amend their contracts to reflect any change to the QHP Addendum for Indian Health Care Providers within 90 days of adoption of the change.

[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.310
Hist.: OHIE 4-2013, f. & cert. ef. 7-9-13

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