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The Oregon Administrative Rules contain OARs filed through April 15, 2016
 
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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
HEALTH INSURANCE MARKETPLACE

 

DIVISION 20

QUALIFIED HEALTH PLANS; ADDENDUM FOR INDIAN HEALTH PROVIDERS

945-020-0010

Purpose; Applicability

(1) The purpose of OAR chapter 945, division 20 is to establish the process for certification of:

(a) Health plans as qualified health plans (QHPs); and

(b) Standalone dental plans (SADPs) as providing pediatric dental benefits.

(2) Except for multistate plans, as defined in 45 CFR 800.20, OAR chapter 945, division 20 applies to:

(a) All QHPs offered through the Marketplace; and

(b) All SADPs marketed through or outside the Marketplace as providing pediatric dental benefits.

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; OHIE 1-2015(Temp), f. & cert. ef. 3-11-15 thru 9-4-15; Administrative correction, 9-30-15; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

945-020-0020

Certification of QHPs and Marketplace SADPs

(1) Each health benefit plan or dental plan offered through the Oregon Health Insurance Marketplace must have in effect a certification issued by the Marketplace. This certification evidences that the health benefit plan is a QHP and that the dental plan is a SADP providing pediatric dental benefits.

(2) The Marketplace will issue a request for applications. To be considered for participation and plan certification, an insurer must submit a completed application to the Marketplace in the form and manner, and within the timeframes specified by the Marketplace.

(3) For QHPs, the Marketplace will grant conditional approval to participate in the Marketplace to an insurer whose application demonstrates the insurer:

(a) Has a certificate of authority and is in good standing with the Oregon Insurance Division to offer health benefit plans in Oregon;

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

(c) Will contract with the Marketplace to offer QHPs and abide by the terms of the contract, including but not limited to the following provisions:

(A) Transparency in coverage standards;

(B) Accreditation requirements;

(C) Network adequacy standards;

(D) Marketplace administrative fees and assessments;

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

(F) Tribal requirements;

(G) Premium tax credit and cost sharing reductions;

(H) Performance reporting standards; and

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

(4) For SADPs, the Marketplace will grant conditional approval to participate in the Marketplace to an insurer whose application demonstrates the insurer:

(a) Has a certificate of authority and is in good standing with the Oregon Insurance Division to offer dental plans in Oregon;

(b) Agrees to contract with the Marketplace to offer SADPs. Contracts will require insurers to comply with Marketplace standards and requirements, including but not limited to the following:

(A) Transparency in coverage standards;

(B) Network adequacy standards;

(C) Marketplace administrative fees and assessments; and

(D) Marketplace processes and procedures, including those related to enrollment, enrollment periods, premium payment, terminations of coverage, customer service, and SADP recertification and decertification.

(5) An insurer’s approval is conditioned on certification of its health benefit or dental plans. An insurer will be approved for a two-year period, subject to a decision by the Marketplace to issue another request for applications before the end of the two-year period. An insurer that did not participate in the request for application the process may not offer coverage through the Marketplace, unless the Marketplace determines that there is a significant loss of statewide coverage.

(6) A loss of statewide coverage may include, but is not limited to:

(A) Plan discontinuance;

(B) Plan withdrawal;

(C) Plan decertification; or

(D) Enrollment closures that result in inadequate coverage choices in one or more geographic areas of the state.

(7) Every QHP or SADP offered through the Marketplace 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.

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

(a) For QHPs, essential health benefits, or for SADPs, pediatric dental benefits;

(b) For QHPs:

(A) Cost sharing limits as defined in 45 CFR 156.130; and

(B) A bronze, silver, gold, or platinum level of coverage as defined in 45 CFR 156.140, or is a catastrophic plan as described in section 1302(e) of the Affordable Care Act.

(9) Subject to the limitation on the number of QHPs that may be offered through the Marketplace in the insurer’s contract with the Marketplace, the Marketplace will recertify health benefit or dental plans that are submitted by approved insurers and with benefit design standards and legal requirements in this rule.

(10) The Marketplace may at any time decertify a QHP or SADP if the Marketplace determines that the insurer or QHP or SADP is no longer in compliance with the Marketplace’s certification criteria. An insurer may appeal decertification of a QHP or SADP through the informal process specified in the insurer’s contract with the Marketplace. After resolution of the informal appeal, an aggrieved insurer may seek additional review through a contested case hearing as provided under ORS 183.411 to 183.471.

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; OHIE 1-2015(Temp), f. & cert. ef. 3-11-15 thru 9-4-15; Administrative correction, 9-30-15; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

945-020-0025

Certification of Non-Marketplace Stand-alone Dental Plans

This rule applies only to SADPs offered outside the Marketplace. The Marketplace will, upon satisfaction of the following criteria, certify as providing pediatric dental benefits a stand alone dental plan (SADP) that an insurer offers for sale outside of the Marketplace.

(1) To be considered for SADP certification, a dental plan must have its rates, form, and binder filed with and approved by the Oregon Insurance Division.

(2) For an SADP to be certified, the insurer must demonstrate to the Marketplace that the SADP:

(a) Provides pediatric dental benefits;

(b) Meets an actuarial value of 68% to 72% or 83% to 87%;

(c) For individual SADPs, imposes rates that are effective for the entire policy year;

(d) For small group SADPs, imposes rates that may be subject to increase every calendar quarter but that are effective for a specific group for the entire plan year; and

(e) Has been approved for sale in Oregon by the Oregon Insurance Division.

(3) The Marketplace will recertify an SADP that meets the criteria in paragraph (2) of this rule.

(4)(a) The Marketplace may at any time decertify an SADP if the Marketplace determines that the insurer or SADP no longer meets the Marketplace’s certification criteria described in this rule.

(b) The insurer may appeal decertification. Appeal requests must be submitted within 15 days from receipt of the notice from the Marketplace informing the insurer of the decertification. The insurer’s appeal request must be made in writing and must provide a thorough explanation of the grounds for appeal along with any supporting information. The Administrator of the Marketplace will rule on a valid and timely appeal request within 14 days of receipt of the request. If an insurer is unsatisfied with the Administrator’s ruling, the insurer may seek additional review through a contested case hearing as provided under ORS 183.411 to 183.471.

(c) Upon decertification of an SADP, the Marketplace will provide notice of decertification to the insurer and the Insurance Division, and the insurer shall not terminate coverage before giving notice to enrollees.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.310
Hist.: OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

945-020-0040

QHP Addendum for Indian Health Care Providers

(1) If a health insurer contracts with a Tribal Health Provider in the state of Oregon for services provided through a Marketplace QHP, the insurer shall:

(a) Use the QHP Addendum for Indian Health Care Providers, Exhibit 1 to this rule, to supplement and amend its existing provider contract, and

(b) Notify the Marketplace in writing of the contractual relationship by emailing the information to info.marketplace@Oregon.gov.

(2) The Marketplace may 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.

Exhibit 1: “QHP Addendum for Indian Health Care Providers”

[ED. NOTE: Exhibit referenced is not included in rule text. Click here for PDF copy of exhibit.]

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.310
Hist.: OHIE 4-2013, f. & cert. ef. 7-9-13; OHIE 3-2015, f. & cert. ef. 10-15-15; OHIE 4-2015, f. & cert. ef. 11-6-15

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