75th OREGON LEGISLATIVE ASSEMBLY--2009 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 1568
House Bill 2656
Sponsored by Representative BUCKLEY
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Equates mandated health insurance coverage of biological child
with mandated health insurance coverage of adopted child.
A BILL FOR AN ACT
Relating to health insurance coverage of dependent child;
creating new provisions; and amending ORS 743.730 and 743A.090.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 743A.090 is amended to read:
743A.090. (1) All individual and group health insurance
policies providing hospital, medical or surgical expense benefits
that include coverage for a family member of the insured shall
also provide that the health insurance benefits { - applicable
for children in the family - } shall be payable with respect to:
(a) A { - newly born - } { + biological + } child of the
insured from the moment of birth; and
(b) An adopted child effective upon placement for adoption.
(2) The coverage { - of newly born and adopted children - }
required by subsection (1) of this section shall consist of
coverage of injury or sickness, including the necessary care and
treatment of medically diagnosed congenital defects and birth
abnormalities.
(3) If payment of a specific premium is required to provide
coverage for a child, the policy may require that notification of
the birth of the child or of the placement for adoption of the
child and payment of the premium be furnished the insurer within
31 days after the date of birth or date of placement in order to
have the coverage extended beyond the 31-day period.
(4) The following requirements apply to coverage of an adopted
child required by subsection (1)(b) of this section:
(a) In any case in which a policy provides coverage for
dependent children of { - participants or beneficiaries - }
{ + an insured + }, the policy shall provide benefits to
dependent children placed with { - participants or
beneficiaries - } { + an insured + } for adoption under the
same terms and conditions as apply to the natural, dependent
children of the { - participants and beneficiaries - } { +
insured + }, regardless of whether the adoption has become final.
(b) A policy may not restrict coverage of any dependent child
adopted by { - a participant or beneficiary - } { + an
insured + }, or placed with { - a participant or
beneficiary - } { + an insured + } for adoption, solely on the
basis of a preexisting condition of the child at the time that
the child would otherwise become eligible for coverage under the
plan if the adoption or placement for adoption occurs while the
{ - participant or beneficiary - } { + insured + } is eligible
for coverage under the plan.
(5) As used in this section:
(a) 'Child' means { - , in connection with any adoption, or
placement for adoption of the child, an individual who has not
attained 18 years of age as of the date of the adoption or
placement for adoption. - } { + an individual who qualifies for
coverage as a dependent child under the insured's policy of
insurance. + }
(b) 'Placement for adoption' means the assumption and retention
by a person of a legal obligation for total or partial support of
a child in anticipation of the adoption of the child. The
child's placement with a person terminates upon the termination
of such legal obligations.
(6) The provisions of ORS 743A.001 do not apply to this
section.
SECTION 2. ORS 743.730 is amended to read:
743.730. For purposes of ORS 743.730 to 743.773:
(1) 'Actuarial certification' means a written statement by a
member of the American Academy of Actuaries or other individual
acceptable to the Director of the Department of Consumer and
Business Services that a carrier is in compliance with the
provisions of ORS 743.736, 743.760 or 743.761, based upon the
person's examination, including a review of the appropriate
records and of the actuarial assumptions and methods used by the
carrier in establishing premium rates for small employer and
portability health benefit plans.
(2) 'Affiliate' of, or person 'affiliated' with, a specified
person means any carrier who, directly or indirectly through one
or more intermediaries, controls or is controlled by or is under
common control with a specified person. For purposes of this
definition, 'control' has the meaning given that term in ORS
732.548.
(3) 'Affiliation period' means, under the terms of a group
health benefit plan issued by a health care service contractor, a
period:
(a) That is applied uniformly and without regard to any health
status related factors to an enrollee or late enrollee in lieu of
a preexisting conditions provision;
(b) That must expire before any coverage becomes effective
under the plan for the enrollee or late enrollee;
(c) During which no premium shall be charged to the enrollee or
late enrollee; and
(d) That begins on the enrollee's or late enrollee's first date
of eligibility for coverage and runs concurrently with any
eligibility waiting period under the plan.
(4) 'Basic health benefit plan' means a health benefit plan for
small employers that is required to be offered by all small
employer carriers and approved by the Director of the Department
of Consumer and Business Services in accordance with ORS 743.736.
(5) 'Bona fide association' means an association that meets the
requirements of 42 U.S.C. 300gg-11 as amended and in effect on
July 1, 1997.
(6) 'Carrier' means any person who provides health benefit
plans in this state, including a licensed insurance company, a
health care service contractor, a health maintenance
organization, an association or group of employers that provides
benefits by means of a multiple employer welfare arrangement or
any other person or corporation responsible for the payment of
benefits or provision of services.
(7) 'Committee' means the Health Insurance Reform Advisory
Committee created under ORS 743.745.
(8) 'Creditable coverage' means prior health care coverage as
defined in 42 U.S.C. 300gg as amended and in effect on July 1,
1997, and includes coverage remaining in force at the time the
enrollee obtains new coverage.
(9) 'Department' means the Department of Consumer and Business
Services.
(10) 'Dependent' means the spouse or child of an eligible
employee, subject to applicable terms of the health benefit plan
covering the employee.
(11) 'Director' means the Director of the Department of
Consumer and Business Services.
(12) 'Eligible employee' means an employee of a small employer
who works on a regularly scheduled basis, with a normal work week
of 17.5 or more hours. The employer may determine hours worked
for eligibility between 17.5 and 40 hours per week subject to
rules of the carrier. 'Eligible employee' does not include
employees who work on a temporary, seasonal or substitute basis.
Employees who have been employed by the small employer for fewer
than 90 days are not eligible employees unless the small employer
so allows.
(13) 'Employee' means any individual employed by an employer.
(14) 'Enrollee' means an employee, dependent of the employee or
an individual otherwise eligible for a group, individual or
portability health benefit plan who has enrolled for coverage
under the terms of the plan.
(15) 'Exclusion period' means a period during which specified
treatments or services are excluded from coverage.
(16) 'Financially impaired' means a member that is not
insolvent and is:
(a) Considered by the Director of the Department of Consumer
and Business Services to be potentially unable to fulfill its
contractual obligations; or
(b) Placed under an order of rehabilitation or conservation by
a court of competent jurisdiction.
(17)(a) 'Geographic average rate' means the arithmetical
average of the lowest premium and the corresponding highest
premium to be charged by a carrier in a geographic area
established by the director for the carrier's:
(A) Small employer group health benefit plans;
(B) Individual health benefit plans; or
(C) Portability health benefit plans.
(b) 'Geographic average rate' does not include premium
differences that are due to differences in benefit design or
family composition.
(18) 'Group eligibility waiting period' means, with respect to
a group health benefit plan, the period of employment or
membership with the group that a prospective enrollee must
complete before plan coverage begins.
(19)(a) 'Health benefit plan' means any hospital expense,
medical expense or hospital or medical expense policy or
certificate, health care service contractor or health maintenance
organization subscriber contract, any plan provided by a multiple
employer welfare arrangement or by another benefit arrangement
defined in the federal Employee Retirement Income Security Act of
1974, as amended.
(b) 'Health benefit plan' does not include coverage for
accident only, specific disease or condition only, credit,
disability income, coverage of Medicare services pursuant to
contracts with the federal government, Medicare supplement
insurance policies, coverage of CHAMPUS services pursuant to
contracts with the federal government, benefits delivered through
a flexible spending arrangement established pursuant to section
125 of the Internal Revenue Code of 1986, as amended, when the
benefits are provided in addition to a group health benefit plan,
long term care insurance, hospital indemnity only, short term
health insurance policies (the duration of which does not exceed
six months including renewals), student accident and health
insurance policies, dental only, vision only, a policy of
stop-loss coverage that meets the requirements of ORS 742.065,
coverage issued as a supplement to liability insurance, insurance
arising out of a workers' compensation or similar law, automobile
medical payment insurance or insurance under which benefits are
payable with or without regard to fault and that is statutorily
required to be contained in any liability insurance policy or
equivalent self-insurance.
(c) Nothing in this subsection shall be construed to regulate
any employee welfare benefit plan that is exempt from state
regulation because of the federal Employee Retirement Income
Security Act of 1974, as amended.
(20) 'Health statement' means any information that is intended
to inform the carrier or insurance producer of the health status
of an enrollee or prospective enrollee in a health benefit plan.
'Health statement' includes the standard health statement
developed by the Health Insurance Reform Advisory Committee.
(21) 'Implementation of chapter 836, Oregon Laws 1989 ' means
that the Health Services Commission has prepared a priority list,
the Legislative Assembly has enacted funding of the list and all
necessary federal approval, including waivers, has been obtained.
(22) 'Individual coverage waiting period' means a period in an
individual health benefit plan during which no premiums may be
collected and health benefit plan coverage issued is not
effective.
(23) 'Initial enrollment period' means a period of at least 30
days following commencement of the first eligibility period for
an individual.
(24) 'Late enrollee' means an individual who enrolls in a group
health benefit plan subsequent to the initial enrollment period
during which the individual was eligible for coverage but
declined to enroll. However, an eligible individual shall not be
considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg as amended and in effect on July
1, 1997;
(b) The individual applies for coverage during an open
enrollment period;
(c) A court has ordered that coverage be provided for a spouse
or minor child under a covered employee's health benefit plan and
request for enrollment is made within 30 days after issuance of
the court order;
(d) The individual is employed by an employer who offers
multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period;
or
(e) The individual's coverage under Medicaid, Medicare,
CHAMPUS, Indian Health Service or a publicly sponsored or
subsidized health plan, including but not limited to the Oregon
Health Plan, has been involuntarily terminated within 63 days of
applying for coverage in a group health benefit plan.
(25) 'Multiple employer welfare arrangement' means a multiple
employer welfare arrangement as defined in section 3 of the
federal Employee Retirement Income Security Act of 1974, as
amended, 29 U.S.C. 1002, that is subject to ORS 750.301 to
750.341.
(26) 'Oregon Medical Insurance Pool' means the pool created
under ORS 735.610.
(27) 'Preexisting conditions provision' means a health benefit
plan provision applicable to an enrollee or late enrollee that
excludes coverage for services, charges or expenses incurred
during a specified period immediately following enrollment for a
condition for which medical advice, diagnosis, care or treatment
was recommended or received during a specified period immediately
preceding enrollment. For purposes of ORS 743.730 to 743.773:
(a) Pregnancy does not constitute a preexisting condition
except as provided in ORS 743.766;
(b) Genetic information does not constitute a preexisting
condition in the absence of a diagnosis of the condition related
to such information; and
(c) A preexisting conditions provision shall not be applied to
a { - newborn child or adopted - } child who obtains coverage
in accordance with ORS 743A.090.
(28) 'Premium' includes insurance premiums or other fees
charged for a health benefit plan, including the costs of
benefits paid or reimbursements made to or on behalf of enrollees
covered by the plan.
(29) 'Rating period' means the 12-month calendar period for
which premium rates established by a carrier are in effect, as
determined by the carrier.
(30)(a) 'Small employer' means an employer that employed an
average of at least two but not more than 50 employees on
business days during the preceding calendar year, the majority of
whom are employed within this state, and that employs at least
two eligible employees on the date on which coverage takes effect
under a health benefit plan issued by a small employer carrier.
(b) Any person that is treated as a single employer under
subsection (b), (c), (m) or (o) of section 414 of the Internal
Revenue Code of 1986 shall be treated as one employer for
purposes of this subsection.
(c) The determination of whether an employer that was not in
existence throughout the preceding calendar year is a small
employer shall be based on the average number of employees that
it is reasonably expected the employer will employ on business
days in the current calendar year.
(31) 'Small employer carrier' means any carrier that offers
health benefit plans covering eligible employees of one or more
small employers. A fully insured multiple employer welfare
arrangement otherwise exempt under ORS 750.303 (4) may elect to
be a small employer carrier governed by the provisions of ORS
743.733 to 743.737.
SECTION 3. { + The amendments to ORS 743A.090 by section 1 of
this 2009 Act apply to policies of health insurance issued or
renewed on or after the effective date of this 2009 Act. + }
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