Chapter 391
AN ACT
HB 3103
Relating to public disclosure of rate filing
information; amending ORS 743.018, 743.737 and 743.760.
Be It Enacted by the People of
the State of
SECTION 1. ORS 743.018 is amended to read:
743.018. (1)
Except for group life and health insurance, and except as provided in ORS
743.015, every insurer shall file with the Director of the Department of
Consumer and Business Services all schedules and tables of premium rates for
life and health insurance to be used on risks in this state, and shall file any
amendments to or corrections of such schedules and tables.
(2) Except as
provided ORS 743.737 and 743.760 and subsection (3) of this section, a rate
filing by a carrier for any of the following health benefit plans subject to
ORS 743.730 to 743.773 shall be available for public inspection immediately
upon submission of the filing to the director:
(a) Health benefit plans
for small employers.
(b) Portability health
benefit plans.
(c) Individual health benefit
plans.
(3) The director, upon
request by a carrier, may exempt from disclosure any part of the filing that
the director determines to contain trade secrets and that would, if disclosed,
harm competition. The part that the director determines to be exempt from
disclosure shall be considered confidential for purposes of ORS 705.137. The
director may not disclose a part of a filing subject to a carrier’s request
pending the director’s determination under this subsection.
SECTION 2. ORS 743.737, as amended by section 6, chapter
599, Oregon Laws 2003, is amended to read:
743.737. Health benefit
plans covering small employers shall be subject to the following provisions:
(1) A preexisting
conditions provision in a small employer health benefit plan shall apply only
to a condition for which medical advice, diagnosis, care or treatment was
recommended or received during the six-month period immediately preceding the
enrollment date of an enrollee or late enrollee. As used in this section, the
enrollment date of an enrollee shall be the earlier of the effective date of
coverage or the first day of any required group eligibility waiting period and
the enrollment date of a late enrollee shall be the effective date of coverage.
(2) A preexisting
conditions provision in a small employer health benefit plan shall terminate
its effect as follows:
(a) For an enrollee, not
later than the first of the following dates:
(A) Six months following
the enrollee’s effective date of coverage; or
(B) Ten months following
the start of any required group eligibility waiting period.
(b) For a late enrollee,
not later than 12 months following the late enrollee’s effective date of
coverage.
(3) In applying a
preexisting conditions provision to an enrollee or late enrollee, except as
provided in this subsection, all small employer health benefit plans shall
reduce the duration of the provision by an amount equal to the enrollee’s or
late enrollee’s aggregate periods of creditable coverage if the most recent
period of creditable coverage is ongoing or ended within 63 days of the
enrollment date in the new small employer health benefit plan. The crediting of
prior coverage in accordance with this subsection shall be applied without
regard to the specific benefits covered during the prior period. This
subsection does not preclude, within a small employer health benefit plan,
application of:
(a) An affiliation
period that does not exceed two months for an enrollee or three months for a
late enrollee; or
(b) An exclusion period
for specified covered services, as established by the Health Insurance Reform
Advisory Committee, applicable to all individuals enrolling for the first time
in the small employer health benefit plan.
(4) Late enrollees may
be excluded from coverage for up to 12 months or may be subjected to a
preexisting conditions provision for up to 12 months. If both an exclusion from
coverage period and a preexisting conditions provision are applicable to a late
enrollee, the combined period shall not exceed 12 months.
(5) Each small employer
health benefit plan shall be renewable with respect to all eligible enrollees
at the option of the policyholder, small employer or contract holder except:
(a) For nonpayment of
the required premiums by the policyholder, small employer or contract holder.
(b) For fraud or
misrepresentation of the policyholder, small employer or contract holder or,
with respect to coverage of individual enrollees, the enrollees or their
representatives.
(c) When the number of
enrollees covered under the plan is less than the number or percentage of
enrollees required by participation requirements under the plan.
(d) For noncompliance
with the small employer carrier’s employer contribution requirements under the
health benefit plan.
(e) When the carrier
discontinues offering or renewing, or offering and renewing, all of its small employer health benefit plans in this state or in
a specified service area within this state. In order to discontinue plans under
this paragraph, the carrier:
(A) Must give notice of
the decision to the Director of the Department of Consumer and Business
Services and to all policyholders covered by the plans;
(B) May not cancel
coverage under the plans for 180 days after the date of the notice required
under subparagraph (A) of this paragraph if coverage is discontinued in the
entire state or, except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel
coverage under the plans for 90 days after the date of the notice required under
subparagraph (A) of this paragraph if coverage is discontinued in a specified
service area because of an inability to reach an agreement with the health care
providers or organization of health care providers to provide services under
the plans within the service area; and
(D) Must discontinue
offering or renewing, or offering and renewing, all health benefit plans issued
by the carrier in the small employer market in this state or in the specified
service area.
(f) When the carrier
discontinues offering and renewing a small employer health benefit plan in a
specified service area within this state because of an inability to reach an
agreement with the health care providers or organization of health care
providers to provide services under the plan within the service area. In order
to discontinue a plan under this paragraph, the carrier:
(A) Must give notice to
the director and to all policyholders covered by the plan;
(B) May not cancel
coverage under the plan for 90 days after the date of the notice required under
subparagraph (A) of this paragraph; and
(C) Must offer in
writing to each small employer covered by the plan, all other small employer
health benefit plans that the carrier offers in the specified service area. The
carrier shall issue any such plans pursuant to the provisions of ORS 743.733 to
743.737. The carrier shall offer the plans at least 90 days prior to
discontinuation.
(g) When the carrier
discontinues offering or renewing, or offering and renewing, a health benefit
plan for all small employers in this state or in a specified service area
within this state, other than a plan discontinued under paragraph (f) of this
subsection. With respect to plans that are being discontinued, the carrier
must:
(A) Offer in writing to
each small employer covered by the plan, all health benefit plans that the
carrier offers in the specified service area.
(B) Issue any such plans
pursuant to the provisions of ORS 743.733 to 743.737.
(C) Offer the plans at
least 90 days prior to discontinuation.
(D) Act uniformly
without regard to the claims experience of the affected policyholders or the
health status of any current or prospective enrollee.
(h) When the director
orders the carrier to discontinue coverage in accordance with procedures
specified or approved by the director upon finding that the continuation of the
coverage would:
(A) Not be in the best
interests of the enrollees; or
(B) Impair the carrier’s
ability to meet contractual obligations.
(i) When, in the case of
a small employer health benefit plan that delivers covered services through a
specified network of health care providers, there is no longer any enrollee who
lives, resides or works in the service area of the provider network.
(j) When, in the case of
a health benefit plan that is offered in the small employer market only through
one or more bona fide associations, the membership of an employer in the
association ceases and the termination of coverage is not related to the health
status of any enrollee.
(k) For misuse of a
provider network provision. As used in this paragraph, “misuse of a provider
network provision” means a disruptive, unruly or abusive action taken by an
enrollee that threatens the physical health or well-being of health care staff
and seriously impairs the ability of the carrier or its participating providers
to provide services to an enrollee. An enrollee under this paragraph retains
the rights of an enrollee under ORS 743.804.
(L) A small employer
carrier may modify a small employer health benefit plan at the time of coverage
renewal. The modification is not a discontinuation of the plan under paragraphs
(e) and (g) of this subsection.
(6) Notwithstanding any
provision of subsection (5) of this section to the contrary, any small employer
carrier health benefit plan subject to the provisions of ORS 743.733 to 743.737
may be rescinded by a small employer carrier for fraud, material
misrepresentation or concealment by a small employer and the coverage of an
enrollee may be rescinded for fraud, material misrepresentation or concealment
by the enrollee.
(7) A small employer
carrier may continue to enforce reasonable employer participation and
contribution requirements on small employers applying for coverage. However,
participation and contribution requirements shall be applied uniformly among
all small employer groups with the same number of eligible employees applying
for coverage or receiving coverage from the small employer carrier. In
determining minimum participation requirements, a carrier shall count only those
employees who are not covered by an existing group health benefit plan,
Medicaid, Medicare, CHAMPUS, Indian Health Service or a publicly sponsored or
subsidized health plan, including but not limited to the Oregon Health Plan.
(8) Premium rates for
small employer health benefit plans subject to ORS 743.733 to 743.737 shall be
subject to the following provisions:
(a) Each small employer
carrier issuing health benefit plans to small employers must file its
geographic average rate for a rating period with the director on or before
March 15 of each year.
(b)(A) The premium rates
charged during a rating period for health benefit plans issued to small
employers may not vary from the geographic average rate by more than the
following:
(i) 50 percent on October
1, 1996; and
(ii) 33 percent on
October 1, 1999.
(B) The variations in
premium rates described in subparagraph (A) of this paragraph shall be based
solely on differences in the ages of participating employees, except that the
premium rate may be adjusted to reflect the provision of benefits not required
to be covered by the basic health benefit plan and differences in family
composition. In addition:
(i) A small employer
carrier shall apply uniformly the carrier’s schedule of age adjustments for
small employer groups as approved by the director; and
(ii) Except as otherwise
provided in this section, the premium rate established for a health benefit
plan by a small employer carrier shall apply uniformly to all employees of the
small employer enrolled in that plan.
(c) The variation in
premium rates between different small employer health benefit plans offered by
a small employer carrier must be based solely on objective differences in plan
design or coverage and must not include differences based on the risk
characteristics of groups assumed to select a particular health benefit plan.
(d) A small employer
carrier may not increase the rates of a health benefit plan issued to a small
employer more than once in a 12-month period. Annual rate increases shall be
effective on the plan anniversary date of the health benefit plan issued to a
small employer. The percentage increase in the premium rate charged to a small
employer for a new rating period may not exceed the sum of the following:
(A) The percentage change
in the geographic average rate measured from the first day of the prior rating
period to the first day of the new period; and
(B) Any adjustment
attributable to changes in age, except an additional adjustment may be made to
reflect the provision of benefits not required to be covered by the basic
health benefit plan and differences in family composition.
(e) Premium rates for
health benefit plans shall comply with the requirements of this section.
(9) In connection with
the offering for sale of any health benefit plan to a small employer, each
small employer carrier shall make a reasonable disclosure as part of its
solicitation and sales materials of:
(a) The full array of
health benefit plans that are offered to small
employers by the carrier;
(b) The authority of the
carrier to adjust rates, and the extent to which the carrier will consider age,
family composition and geographic factors in establishing and adjusting rates;
(c) Provisions relating
to renewability of policies and contracts; and
(d) Provisions affecting
any preexisting conditions provision.
(10)(a) Each small
employer carrier shall maintain at its principal place of business a complete
and detailed description of its rating practices and renewal underwriting
practices, including information and documentation that demonstrate that its
rating methods and practices are based upon commonly accepted actuarial
practices and are in accordance with sound actuarial principles.
(b) Each small employer
carrier shall file with the director annually on or before March 15 an
actuarial certification that the carrier is in compliance with ORS 743.733 to
743.737 and that the rating methods of the small employer carrier are
actuarially sound. Each such certification shall be in a uniform form and manner
and shall contain such information as specified by the director. A copy of such
certification shall be retained by the small employer carrier at its principal
place of business.
(c) A small employer
carrier shall make the information and documentation described in paragraph (a)
of this subsection available to the director upon request. Except as
provided in ORS 743.018 and except in cases of violations of ORS 743.733 to
743.737, the information shall be considered proprietary and trade secret
information and shall not be subject to disclosure by the director to persons
outside the Department of Consumer and Business Services except as agreed to by
the small employer carrier or as ordered by a court of competent jurisdiction.
(11) A small employer
carrier shall not provide any financial or other incentive to any insurance
producer that would encourage the insurance producer to market and sell health
benefit plans of the carrier to small employer groups based on a small employer
group’s anticipated claims experience.
(12) For purposes of
this section, the date a small employer health benefit plan is continued shall
be the anniversary date of the first issuance of the health benefit plan.
(13) A small employer
carrier must include a provision that offers coverage to all eligible employees
and to all dependents to the extent the employer chooses to offer coverage to
dependents.
(14) All small employer
health benefit plans shall contain special enrollment periods during which
eligible employees and dependents may enroll for coverage, as provided in 42
U.S.C. 300gg as amended and in effect on July 1, 1997.
SECTION 3. ORS 743.760 is amended to read:
743.760. (1) As used in this section:
(a) “Carrier” means an
insurer authorized to issue a policy of health insurance in this state. “Carrier”
does not include a multiple employer welfare arrangement.
(b)(A) “Eligible
individual” means an individual who:
(i) Has left coverage
that was continuously in effect for a period of 180 days or more under one or
more Oregon group health benefit plans, has applied for portability coverage
not later than the 63rd day after termination of group coverage issued by an
Oregon carrier and is an Oregon resident at the time of such application; or
(ii) On or after January
1, 1998, meets the eligibility requirements of 42 U.S.C.
300gg-41, as amended and in effect on January 1, 1998, has applied for
portability coverage not later than the 63rd day after termination of group
coverage issued by an
(B) Except as provided
in subsection (12) of this section, “eligible individual” does not include an
individual who remains eligible for the individual’s prior group coverage or
would remain eligible for prior group coverage in a plan under the federal
Employee Retirement Income Security Act of 1974, as amended, were it not for
action by the plan sponsor relating to the actual or expected health condition
of the individual, or who is covered under another health benefit plan at the
time that portability coverage would commence or is eligible for the federal
Medicare program.
(c) “Portability health
benefit plans” and “portability plans” mean health benefit plans for eligible
individuals that are required to be offered by all carriers offering group
health benefit plans and that have been approved by the Director of the
Department of Consumer and Business Services in accordance with this section.
(2)(a) In order to
improve the availability and affordability of health benefit plans for
individuals leaving coverage under group health benefit plans, the Health
Insurance Reform Advisory Committee created under ORS 743.745 shall submit to
the director two portability health benefit plans pursuant to ORS 743.745. One
plan shall be in the form of insurance and the second plan shall be consistent
with the type of coverage provided by health maintenance organizations. For
each type of portability plan, the committee shall design and submit to the
director:
(A) A prevailing benefit
plan, which shall reflect the benefit coverages that are prevalent in the group
health insurance market; and
(B) A low cost benefit
plan, which shall emphasize affordability for eligible individuals.
(b) Except as provided
in ORS 743.730 to 743.773, no law requiring the coverage or the offer of
coverage of a health care service or benefit shall apply to portability health
benefit plans.
(3) The director shall
approve the portability health benefit plans if the director determines that
the plans provide for appropriate accessibility and affordability of needed
health care services and comply with all other provisions of this section.
(4) After the director’s
approval of the portability plans submitted by the committee under this
section, each carrier offering group health benefit plans shall submit to the
director the policy form or forms containing at least one low cost benefit and
one prevailing benefit portability plan offered by the carrier that meets the
required standards. Each policy form must be submitted as prescribed by the
director and is subject to review and approval pursuant to ORS 742.003.
(5) Within 180 days
after approval by the director of the portability plans submitted by the
committee, as a condition of transacting group health insurance in this state,
each carrier offering group health benefit plans shall make available to
eligible individuals the prevailing benefit and low cost benefit portability
plans that have been submitted by the carrier and approved by the director
under subsection (4) of this section.
(6) A carrier offering
group health benefit plans shall issue to an eligible individual who is leaving
or has left group coverage provided by that carrier any portability plan
offered by the carrier if the eligible individual applies for the plan within
63 days of termination of prior coverage and agrees to make the required
premium payments and to satisfy the other provisions of the portability plan.
(7) Premium rates for
portability plans shall be subject to the following provisions:
(a) Each carrier must
file the geographic average rate for each of its portability health benefit
plans for a rating period with the director on or before March 15 of each year.
(b) The premium rates
charged during the rating period for each portability health benefit plan shall
not vary from the geographic average rate, except that the premium rate may be
adjusted to reflect differences in benefit design, family composition and age.
Adjustments for age shall comply with the following:
(A) For each plan, the
variation between the lowest premium rate and the highest premium rate shall
not exceed 100 percent of the lowest premium rate.
(B) Premium variations
shall be determined by applying uniformly the carrier’s schedule of age
adjustments for portability plans as approved by the director.
(c) Premium variations
between the portability plans and the rest of the carrier’s group plans must be
based solely on objective differences in plan design or coverage and must not
include differences based on the actual or expected health status of
individuals who select portability health benefit plans. For purposes of
determining the premium variations under this paragraph, a carrier may:
(A) Pool all portability
plans with all group health benefit plans; or
(B) Pool all portability
plans for eligible individuals leaving small employer group health benefit plan
coverage with all plans offered to small employers and pool all portability
plans for eligible individuals leaving other group health benefit plan coverage
with all health benefit plans offered to such other groups.
(d) A carrier may not
increase the rates of a portability plan issued to an enrollee more than once
in any 12-month period. Annual rate increases shall be effective on the
anniversary date of the plan issued to the enrollee. The percentage increase in
the premium rate charged to an enrollee for a new rating period may not exceed
the average increase in the rest of the carrier’s applicable group health
benefit plans plus an adjustment for age.
(8) No portability plans
under this section may contain preexisting conditions provisions, exclusion
periods, waiting periods or other similar limitations on coverage.
(9) Portability health
benefit plans shall be renewable with respect to all enrollees at the option of
the enrollee, except:
(a) For nonpayment of
the required premiums by the policyholder;
(b) For fraud or
misrepresentation by the policyholder;
(c) When the carrier
elects to discontinue offering all of its group health benefit plans in
accordance with ORS 743.737 and 743.754; or
(d) When the director
orders the carrier to discontinue coverage in accordance with procedures
specified or approved by the director upon finding that the continuation of the
coverage would:
(A) Not be in the best
interests of the enrollees; or
(B) Impair the carrier’s
ability to meet its contractual obligations.
(10)(a) Each carrier
offering group health benefit plans shall maintain at its principal place of
business a complete and detailed description of its rating practices and
renewal underwriting practices relating to its portability plans, including
information and documentation that demonstrate that its rating methods and
practices are based upon commonly accepted actuarial practices and are in accordance
with sound actuarial principles.
(b) Each such carrier
shall file with the director annually on or before March 15 an actuarial
certification that the carrier is in compliance with this section and that its
rating methods are actuarially sound. Each such certification shall be in a
form and manner and shall contain such information as specified by the
director. A copy of such certification shall be retained by the carrier at its
principal place of business.
(c) Each such carrier
shall make the information and documentation described in paragraph (a) of this
subsection available to the director upon request. Except as provided in ORS
743.018 and except in cases of violations of the Insurance Code, the
information is proprietary and trade secret information and shall not be
subject to disclosure by the director to persons outside the Department of
Consumer and Business Services except as agreed to by the carrier or as ordered
by a court of competent jurisdiction.
(11) A carrier offering
group health benefit plans shall not provide any financial or other incentive
to any insurance producer that would encourage the insurance producer to market
and sell portability plans of the carrier on the basis of an eligible
individual’s anticipated claims experience.
(12) An individual who
is eligible to obtain a portability plan in accordance with this section may
obtain such a plan regardless of whether the eligible individual qualifies for
a period of continuation coverage under federal law or under ORS 743.600 or
743.610. However, an individual who has elected such continuation coverage is
not eligible to obtain a portability plan until the continuation coverage has
been discontinued by the individual or has been exhausted.
Approved by the Governor June 13, 2007
Filed in the office of Secretary of State June 13, 2007
Effective date January 1, 2008
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