Chapter 500
Oregon Laws 2011
AN ACT
SB 89
Relating to
health insurance; creating new provisions; amending ORS 413.032, 743.405,
743.601, 743.610, 743.730, 743.731, 743.733, 743.734, 743.736, 743.737,
743.745, 743.748, 743.751, 743.754, 743.758, 743.760, 743.761, 743.766,
743.767, 743.801, 743.804, 743.806, 743.807, 743.845, 743.857, 743.859,
743.861, 743.862, 743.863, 743.864, 743.878, 743A.012, 743A.080, 743A.090,
743A.110, 743A.141, 746.650, 750.055 and 750.333 and sections 12 and 13,
chapter 752, Oregon Laws 2007, section 2, chapter 73, Oregon Laws 2009, section
4, chapter 75, Oregon Laws 2010, and section 6, chapter 322, Oregon Laws 2011
(Enrolled Senate Bill 91); repealing sections 2 and 5, chapter 73, Oregon Laws
2009, and section 5, chapter 322, Oregon Laws 2011 (Enrolled Senate Bill 91);
and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. Section 2 of this 2011 Act is added to and made a part of ORS 743.730 to
743.773.
SECTION 2. Notwithstanding any
other provision of law, a health benefit plan that is not a grandfathered
health plan:
(1) Must provide coverage of
preventive health services as prescribed by the United States Department of
Health and Human Services pursuant to 42 U.S.C. 300gg-13; and
(2) May not impose cost-sharing
requirements on an enrollee for preventive health services, except as allowed
by federal law.
SECTION 3. Sections 4 and 4a of
this 2011 Act are added to and made a part of the Insurance Code.
SECTION 4. (1) As used in this section,
“rescind” means to retroactively cancel or discontinue coverage under a health
benefit plan or group or individual health insurance policy for reasons other
than failure to timely pay required premiums or required contributions toward
the cost of coverage.
(2) An insurer may not rescind
coverage of an individual under a health benefit plan or group or individual
health insurance policy unless:
(a) The individual or a person seeking
coverage on behalf of the individual:
(A) Performs an act, practice or
omission that constitutes fraud; or
(B) Makes an intentional
misrepresentation of a material fact as prohibited by the terms of the plan or
policy; and
(b) The insurer provides at least 30
days’ advance written notice, in the form and manner prescribed by the
Department of Consumer and Business Services, to the individual.
(3) An insurer may not rescind
coverage of a group under a health benefit plan unless:
(a) The plan sponsor:
(A) Performs an act, practice or
omission that constitutes fraud; or
(B) Makes an intentional
misrepresentation of a material fact as prohibited by the terms of the plan;
and
(b) The insurer provides at least 30
days’ advance written notice, in the form and manner prescribed by the
department, to each plan enrollee or policy holder who would be affected by the
rescission of coverage.
(4) An insurer that rescinds a plan or
policy must provide notice of the rescission to the department in the form,
manner and time frame prescribed by the department by rule.
SECTION 4a. (1) As used in this
section, “health benefit plan” has the meaning given that term in ORS 743.730.
(2) An insurer shall notify a
policyholder in writing if the insurer cancels or does not renew the
policyholder’s individual health benefit plan. The notice shall be sent to the
policyholder’s last-known mailing address by first class mail in a specially
marked envelope or, if the policyholder has elected to receive communications
from the insurer electronically, to the policyholder’s last-known electronic
mail address using a mechanism that will confirm delivery to the address.
(3) If the cancellation or nonrenewal
results in a refund to the policyholder of all or part of a premium, the
insurer must mail with the refund a written explanation that includes:
(a) The effective date of the
cancellation;
(b) The reason for the cancellation;
and
(c) The time period to which the
refund is applicable.
(4) For any cancellation or nonrenewal
due to a reported death of the policyholder, the insurer must:
(a) Confirm the accuracy of the
reported death.
(b) If the death is confirmed:
(A) Provide any dependents covered by
the plan with information about how to continue coverage or obtain alternative
coverage; and
(B) Issue any refund that is due to
the estate of the deceased in accordance with subsection (3) of this section.
(5) If an insurer cancels or does not
renew an individual health benefit plan and fails to comply with the
requirements of this section, the insurer shall continue the coverage under the
plan for the policyholder and any dependents covered by the plan until the date
that the insurer has complied with the requirements of this section. The
insurer shall waive any premiums owed for the period during which the coverage
was continued under this subsection and shall process all claims incurred by
the policyholder or any covered dependents according to the terms of the plan.
(6) This section does not apply:
(a) To a cancellation requested by the
policyholder if the insurer documents the request and confirms the request with
the policyholder; or
(b) To a cancellation or nonrenewal
that results from a policyholder making a change in coverage with the same
insurer.
SECTION 5. ORS 413.032 is amended to
read:
413.032. (1) The Oregon Health
Authority is established. The authority shall:
(a) Carry out policies adopted by the
Oregon Health Policy Board;
(b) Develop a plan for the Oregon
Health Insurance Exchange in accordance with section 17, chapter 595, Oregon
Laws 2009;
(c) Administer the Oregon Prescription
Drug Program;
(d) Administer the Family Health
Insurance Assistance Program;
(e) Provide regular reports to the
board with respect to the performance of health services contractors serving
recipients of medical assistance, including reports of trends in health
services and enrollee satisfaction;
(f) Guide and support, with the
authorization of the board, community-centered health initiatives designed to
address critical risk factors, especially those that contribute to chronic
disease;
(g) Be the state Medicaid agency for
the administration of funds from Titles XIX and XXI of the Social Security Act
and administer medical assistance under ORS chapter 414;
(h) In consultation with the Director
of the Department of Consumer and Business Services, periodically review and
recommend standards and methodologies to the Legislative Assembly for:
(A) Review of administrative expenses
of health insurers;
(B) Approval of rates; and
(C) Enforcement of rating rules
adopted by the Department of Consumer and Business Services;
(i) Structure reimbursement rates for
providers that serve recipients of medical assistance to reward comprehensive
management of diseases, quality outcomes and the efficient use of resources and
to promote cost-effective procedures, services and programs including, without
limitation, preventive health, dental and primary care services, web-based
office visits, telephone consultations and telemedicine consultations;
(j) Guide and support community
three-share agreements in which an employer, state or local government and an
individual all contribute a portion of a premium for a community-centered
health initiative or for insurance coverage; and
(k) Develop, in consultation with the
Department of Consumer and Business Services [and the Health Insurance Reform Advisory Committee], one or more
products designed to provide more affordable options for the small group
market.
(2) The Oregon Health Authority is
authorized to:
(a) Create an all-claims, all-payer
database to collect health care data and monitor and evaluate health care
reform in Oregon and to provide comparative cost and quality information to
consumers, providers and purchasers of health care about Oregon’s health care
systems and health plan networks in order to provide comparative information to
consumers.
(b) Develop uniform contracting
standards for the purchase of health care, including the following:
(A) Uniform quality standards and
performance measures;
(B) Evidence-based guidelines for
major chronic disease management and health care services with unexplained
variations in frequency or cost;
(C) Evidence-based effectiveness
guidelines for select new technologies and medical equipment; and
(D) A statewide drug formulary that
may be used by publicly funded health benefit plans.
(c) Submit directly to the Legislative
Counsel, no later than October 1 of each even-numbered year, requests for
measures necessary to provide statutory authorization to carry out any of the
authority’s duties or to implement any of the board’s recommendations. The
measures may be filed prior to the beginning of the legislative session in
accordance with the rules of the House of Representatives and the Senate.
(3) The enumeration of duties,
functions and powers in this section is not intended to be exclusive nor to
limit the duties, functions and powers imposed on or vested in the Oregon
Health Authority by ORS 413.006 to 413.064 or by other statutes.
SECTION 6. ORS 743.405 is amended to
read:
743.405. An individual health
insurance policy must meet the following requirements:
(1) The entire money and other
considerations therefor shall be expressed therein.
(2) The time at which the insurance
takes effect and terminates shall be expressed therein.
(3) It shall purport to insure only
one person, except that a policy may insure, originally or by subsequent
amendment, upon the application of an adult member of a family who shall be
deemed the policyholder, any two or more eligible members of that family,
including husband, wife, dependent children or any children under a specified
age[, which shall not exceed 19 years,]
and any other person dependent upon the policyholder.
(4) The policy may not be issued
individually to an individual in a group of persons as described in ORS 743.522
for the purpose of separating the individual from health insurance benefits
offered or provided in connection with a group health benefit plan.
(5) Except as provided in ORS 743.498,
the style, arrangement and overall appearance of the policy may not give undue
prominence to any portion of the text, and every printed portion of the text of
the policy and of any indorsements or attached papers shall be plainly printed
in lightfaced type of a style in general use, the size of which shall be
uniform and not less than 10 point with a lower case unspaced alphabet length
not less than 120 point. Captions shall be printed in not less than 12-point
type. As used in this subsection, “text” includes all printed matter except the
name and address of the insurer, name or title of the policy, the brief
description if any, and captions and subcaptions.
(6) The exceptions and reductions of
indemnity must be set forth in the policy. Except those required by ORS 743.411
to 743.477 [and 743A.160], exceptions
and reductions shall be printed at the insurer’s option either included with
the applicable benefit provision or under an appropriate caption such as
EXCEPTIONS, or EXCEPTIONS AND REDUCTIONS. However, if an exception or reduction
specifically applies only to a particular benefit of the policy, a statement of
the exception or reduction must be included with the applicable benefit
provision.
(7) Each form constituting the policy,
including riders and indorsements, must be identified by a form number in the
lower left-hand corner of the first page of the policy.
(8) The policy may not contain
provisions purporting to make any portion of the charter, rules, constitution
or bylaws of the insurer a part of the policy unless such portion is set forth
in full in the policy, except in the case of the incorporation of or reference
to a statement of rates or classification of risks, or short rate table filed
with the Director of the Department of Consumer and Business Services.
SECTION 6a. ORS 743.601 is amended to
read:
743.601. (1) As used in subsections
(1) to (6) of this section, “plan administrator” means:
(a) The person designated as the plan
administrator by the instrument under which the group health insurance plan is
operated; or
(b) If no plan administrator is
designated, the plan sponsor.
(2) Within 60 days of legal separation
or the entry of a judgment of dissolution of marriage, a legally separated or
divorced spouse eligible for continued coverage under ORS 743.600 who seeks
such coverage shall give the plan administrator written notice of the legal
separation or dissolution. The notice shall include the mailing address of the
legally separated or divorced spouse.
(3) Within 30 days of the death of a [certificate holder] covered person
whose surviving spouse is eligible for continued coverage under ORS 743.600,
the group policyholder shall give the plan administrator written notice of the
death and of the mailing address of the surviving spouse.
(4) Within 14 days of receipt of
notice under subsection (2) or (3) of this section, the plan administrator
shall notify the legally separated, divorced or surviving spouse that the
policy may be continued. The notice shall be mailed to the mailing address
provided to the plan administrator and shall include:
(a) A form for election to continue
the coverage;
(b) A statement of the amount of
periodic premiums to be charged for the continuation of coverage and of the
method and place of payment; and
(c) Instructions for returning the
election form by mail within 60 days after the date of mailing of the notice by
the plan administrator.
(5) Failure of the legally separated,
divorced or surviving spouse to exercise the election in accordance with
subsection (4) of this section shall terminate the right to continuation of
benefits.
(6) If a plan administrator fails to
notify the legally separated, divorced or surviving spouse as required by
subsection (4) of this section, premiums shall be waived from the date the
notice was required until the date notice is received by the legally separated,
divorced or surviving spouse.
(7) The provisions of this section
and ORS 743.600 [to] and743.602
apply only to employers with 20 or more employees and group health insurance
plans with 20 or more [certificate
holders] enrollees on a typical business day during the preceding
calendar year.
SECTION 6b. ORS 743.610 is amended to
read:
743.610. (1) As used in this
section and section 2, chapter 73, Oregon Laws 2009:
(a) “Covered person” means an
individual who was a certificate holder under a group health insurance policy:
(A) On the day before a qualifying
event; and
(B) During the three-month period
ending on the date of the qualifying event.
(b) “Qualified beneficiary” means:
(A) A spouse or dependent child of a
covered person who, on the day before a qualifying event, was insured under the
covered person’s group health insurance policy; or
(B) A child born to or adopted by a
covered person during the period of the continuation of coverage under this
section who would have been insured under the covered person’s policy if the
child had been born or adopted on the day before the qualifying event.
(c) “Qualifying event” means the loss
of membership in a group health insurance policy caused by:
(A) Voluntary or involuntary
termination of the employment of a covered person;
(B) A reduction in hours worked by a
covered person;
(C) A covered person becoming eligible
for Medicare;
(D) A qualified beneficiary losing
dependent child status under a covered person’s group health insurance policy;
(E) Termination of membership in the
group covered by the group health insurance policy; or
(F) The death of a covered person.
[(1)]
(2) A group health insurance policy providing coverage for hospital or
medical expenses, other than coverage limited to expenses from accidents or
specific diseases, must contain a provision that [certificate holders whose coverage under the policy otherwise would
terminate because of termination of employment or membership may continue
coverage under the policy for themselves and their eligible dependents as
provided in this section] a covered person and any qualified beneficiary
may continue coverage under the policy as provided in this section.
[(2)
Continuation of coverage is available only to a certificate holder who has been
insured continuously under the policy or similar predecessor policy during the
three-month period ending on the date of the termination of employment or
membership.]
(3) Continuation of coverage is not
available to a [certificate holder]
covered person or qualified beneficiary who is eligible for:
(a) [Federal] Medicare [coverage];
or
(b) Coverage for hospital or medical
expenses under any other program [which
was not covering the certificate holder immediately before the certificate
holder’s termination of employment or membership] that was not covering
the covered person or qualified beneficiary on the day before a qualifying
event.
(4) The continued coverage need not
include benefits for dental, vision care or prescription drug expense, or any
other benefits under the policy [additional
to] other than hospital and medical expense benefits.
(5) Except as provided by rule by the
Director of the Department of Consumer and Business Services under section 2,
chapter 73, Oregon Laws 2009, [a
certificate holder who has terminated employment or membership and who wishes
to continue coverage must request continuation in writing:]
[(a)
not later than 10 days after the later of the date on which employment or
membership terminated and the date on which the employer or group policyholder
gave the certificate holder notice of the right to continue coverage; and]
[(b)
Not more than 31 days after the date of termination of employment or
membership.] a covered person or qualified beneficiary who wishes to
continue coverage must provide the insurer with a written request for
continuation no later than 10 days after the later of the date of a qualifying
event or the date the insurer provides the notice required by subsection (10)
of this section.
(6) A [certificate holder] covered person or qualified beneficiary
who requests continuation of coverage shall pay the premium on a monthly basis
and in advance[, as provided in this
subsection. The certificate holder shall pay the premium] to the insurer or
to the employer or policyholder, whichever the group policy provides. The
required premium payment may not exceed the group premium rate for the
insurance being continued under the group policy as of the date the premium
payment is due. [Except as otherwise
provided by rule by the director under section 2, chapter 73, Oregon Laws 2009,
the certificate holder must pay the first premium not later than 31 days after
the date on which the certificate holder’s coverage under the policy otherwise
would end.]
(7) Except as otherwise provided by
rule by the director under section 2, chapter 73, Oregon Laws 2009,
continuation of coverage as provided under this section ends on the earliest of
the following dates:
[(a)
Nine months after the date on which the certificate holder’s coverage under the
policy otherwise would have ended because of termination of employment or
membership.]
[(b)
The end of the period for which the certificate holder last made timely premium
payment, if the certificate holder fails to make timely payment of a required
premium payment.]
[(c)
The premium payment due date coinciding with or next following the date the
certificate holder becomes eligible for federal Medicare coverage.]
[(d)
The date on which the policy is terminated or the certificate holder’s employer
terminates participation under the policy. However, if the employer replaces
the coverage which is terminating for the certificate holder with similar
coverage under another group policy:]
[(A)
The certificate holder may obtain coverage under the replacement group policy
for the balance of the period that the certificate holder would have remained
covered under the replaced group policy under this section;]
[(B)
The replacement group policy must provide, at a minimum, the applicable level
of benefits of the replaced policy reduced by any benefits still payable under
that policy; and]
[(C)
The replaced policy must continue to provide benefits to the certificate holder
to the extent of that policy’s accrued liabilities and extensions of benefits as
if the replacement had not occurred.]
(a) Nine months after the date of
the qualifying event that was the basis for the continuation of coverage.
(b) The end of the period for which
the last timely premium payment for the coverage is received by the insurer.
(c) The premium payment due date
coinciding with or next following the date that continuation of coverage ceases
to be available in accordance with subsection (3) of this section.
(d) The date that the policy is
terminated. However, if the policyholder replaces the terminated policy with
similar coverage under another group health insurance policy:
(A) The covered person and qualified
beneficiaries may obtain coverage under the replacement policy for the balance
of the period that the covered person or qualified beneficiary would have
remained covered under the terminated policy in accordance with this section;
and
(B) The terminated policy must
continue to provide benefits to the covered person and qualified beneficiaries
to the extent of that policy’s accrued liabilities and extensions of benefits
as if the replacement had not occurred.
[(8)
The group health insurance policy must contain a provision that:]
[(a)
The surviving spouse of a certificate holder, if any, who is not eligible for
continuation of coverage under ORS 743.600 may continue coverage under the
policy, at the death of the certificate holder, with respect to the spouse and
any dependent children whose coverage under the policy otherwise would
terminate because of the death, in the same manner that a certificate holder
may exercise the right under this section.]
[(b)
The spouse of a certificate holder, if any, who is not eligible for
continuation of coverage under ORS 743.600 may continue coverage under the
policy, upon dissolution of marriage with the certificate holder, with respect
to the spouse and any children whose coverage under the policy otherwise would
terminate because of the dissolution of marriage, in the same manner that a
certificate holder may exercise the right under this section.]
[(c)
A spouse who requests continuation of coverage under this subsection must pay
the premium for the spouse and any dependent children, on a monthly basis and
in advance, as provided in this paragraph. The spouse shall pay the premium to
the insurer or to the employer or policyholder, whichever the group policy
provides. The required premium payment under this subsection may not exceed the
group premium rate, for the insurance being continued under the group policy,
as of the date the premium payment is due.]
(8) A qualified beneficiary who is
not eligible for continuation of coverage under ORS 743.600 may continue
coverage under this section upon the dissolution of marriage with or the death
of the covered person in the same manner that a covered person may exercise the
right to continue coverage under this section.
(9) [A certificate holder who has terminated employment by reason of layoff
may not be subject upon any rehire that occurs within nine months of the time
of the layoff to any waiting period prerequisite to] A covered person
rehired by an employer no later than nine months after the layoff of the
covered person by the employer may not be subjected to a waiting period for coverage
under the employer’s group health insurance policy if the [certificate holder] covered person was eligible for coverage
at the time of the [termination and]
layoff, regardless of whether the [certificate
holder] covered person continued coverage during the layoff.
(10) If an insurer terminates the
group health insurance coverage of a covered person or qualified beneficiary
without providing replacement coverage that meets the criteria in subsection
(7)(d) of this section, the insurer shall provide written notice to the covered
person and any qualified beneficiary no later than 10 days after the insurer is
notified of the qualifying event under subsection (5) of this section. The
notice shall include at least the following information:
(a) Contact information for the
insurer;
(b) Forms necessary to request
continuation of coverage and instructions for completing the forms;
(c) Information sufficient to
determine premium rates for continuation of coverage and instructions for
paying premiums;
(d) A clear statement of who is
eligible to continue coverage;
(e) Enrollment information relating to
other coverage issued by the insurer that is held by the employer or group and
for which the covered person or a qualified beneficiary may be eligible;
(f) An explanation of the process to
appeal a denial of a claim under the continuation of coverage;
(g) Information, in a form approved by
the director, about how to contact the consumer advocacy unit of the Insurance
Division of the Department of Consumer and Business Services; and
(h) Other information required by the
director.
[(10)]
(11) This section applies only to employers who are not required to make
available continuation of health insurance benefits under Titles X and XXII of
the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, P.L. 99-272,
April 7, 1986.
SECTION 6c. ORS 743.610, as amended
by section 4, chapter 73, Oregon Laws 2009, is amended to read:
743.610. (1) As used in this
section:
(a) “Covered person” means an
individual who was a certificate holder under a group health insurance policy:
(A) On the day before a qualifying
event; and
(B) During the three-month period
ending on the date of the qualifying event.
(b) “Qualified beneficiary” means:
(A) A spouse or dependent child of a
covered person who, on the day before a qualifying event, was insured under the
covered person’s group health insurance policy; or
(B) A child born to or adopted by a
covered person during the period of the continuation of coverage under this
section who would have been insured under the covered person’s policy if the
child had been born or adopted on the day before the qualifying event.
(c) “Qualifying event” means the loss
of membership in a group health insurance policy caused by:
(A) Voluntary or involuntary
termination of the employment of a covered person;
(B) A reduction in hours worked by a
covered person;
(C) A covered person becoming eligible
for Medicare;
(D) A qualified beneficiary losing
dependent child status under a covered person’s group health insurance policy;
(E) Termination of membership in the
group covered by the group health insurance policy; or
(F) The death of a covered person.
[(1)]
(2) A group health insurance policy providing coverage for hospital or
medical expenses, other than coverage limited to expenses from accidents or
specific diseases, must contain a provision that [certificate holders whose coverage under the policy otherwise would
terminate because of termination of employment or membership may continue
coverage under the policy for themselves and their eligible dependents as
provided in this section] a covered person and any qualified beneficiary
may continue coverage under the policy as provided in this section.
[(2)
Continuation of coverage is available only to a certificate holder who has been
insured continuously under the policy or similar predecessor policy during the
three-month period ending on the date of the termination of employment or
membership.]
(3) Continuation of coverage is not
available to a [certificate holder]
covered person or qualified beneficiary who is eligible for:
(a) [Federal] Medicare [coverage];
or
(b) Coverage for hospital or medical
expenses under any other program [which
was not covering the certificate holder immediately before the certificate
holder’s termination of employment or membership] that was not covering
the covered person or qualified beneficiary on the day before a qualifying
event.
(4) The continued coverage need not
include benefits for dental, vision care or prescription drug expense, or any
other benefits under the policy [additional
to] other than hospital and medical expense benefits.
(5) [A certificate holder who has terminated employment or membership and
who wishes to continue coverage must request continuation in writing:] A
covered person or qualified beneficiary who wishes to continue coverage must
provide the insurer with a written request for continuation no later than 10
days after the later of the date of a qualifying event or the date the insurer
provides the notice required by subsection (10) of this section.
[(a)
Not later than 10 days after the later of the date on which employment or
membership terminated and the date on which the employer or group policyholder
gave the certificate holder notice of the right to continue coverage; and]
[(b)
Not more than 31 days after the date of termination of employment or
membership.]
(6) A [certificate holder] covered person or qualified beneficiary
who requests continuation of coverage shall pay the premium on a monthly basis
and in advance[, as provided in this
subsection. The certificate holder shall pay the premium] to the insurer or
to the employer or policyholder, whichever the group policy provides. The
required premium payment may not exceed the group premium rate for the
insurance being continued under the group policy as of the date the premium
payment is due. [The certificate holder
must pay the first premium not later than 31 days after the date on which the
certificate holder’s coverage under the policy otherwise would end.]
(7) Continuation of coverage as
provided under this section ends on the earliest of the following dates:
[(a)
Nine months after the date on which the certificate holder’s coverage under the
policy otherwise would have ended because of termination of employment or membership.]
[(b)
The end of the period for which the certificate holder last made timely premium
payment, if the certificate holder fails to make timely payment of a required
premium payment.]
[(c)
The premium payment due date coinciding with or next following the date the
certificate holder becomes eligible for federal Medicare coverage.]
[(d)
The date on which the policy is terminated or the certificate holder’s employer
terminates participation under the policy. However, if the employer replaces
the coverage which is terminating for the certificate holder with similar
coverage under another group policy:]
[(A)
The certificate holder may obtain coverage under the replacement group policy
for the balance of the period that the certificate holder would have remained
covered under the replaced group policy under this section;]
[(B)
The replacement group policy must provide, at a minimum, the applicable level
of benefits of the replaced policy reduced by any benefits still payable under
that policy; and]
[(C)
The replaced policy must continue to provide benefits to the certificate holder
to the extent of that policy’s accrued liabilities and extensions of benefits
as if the replacement had not occurred.]
(a) Nine months after the date of
the qualifying event that was the basis for the continuation of coverage.
(b) The end of the period for which
the last timely premium payment for the coverage is received by the insurer.
(c) The premium payment due date
coinciding with or next following the date that continuation of coverage ceases
to be available in accordance with subsection (3) of this section.
(d) The date that the policy is
terminated. However, if the policyholder replaces the terminated policy with
similar coverage under another group health insurance policy:
(A) The covered person and qualified
beneficiaries may obtain coverage under the replacement policy for the balance
of the period that the covered person or qualified beneficiary would have
remained covered under the terminated policy in accordance with this section;
and
(B) The terminated policy must
continue to provide benefits to the covered person and qualified beneficiaries
to the extent of that policy’s accrued liabilities and extensions of benefits
as if the replacement had not occurred.
[(8)
The group health insurance policy must contain a provision that:]
[(a)
The surviving spouse of a certificate holder, if any, who is not eligible for
continuation of coverage under ORS 743.600 may continue coverage under the
policy, at the death of the certificate holder, with respect to the spouse and
any dependent children whose coverage under the policy otherwise would
terminate because of the death, in the same manner that a certificate holder
may exercise the right under this section.]
[(b)
The spouse of a certificate holder, if any, who is not eligible for
continuation of coverage under ORS 743.600 may continue coverage under the
policy, upon dissolution of marriage with the certificate holder, with respect
to the spouse and any children whose coverage under the policy otherwise would
terminate because of the dissolution of marriage, in the same manner that a
certificate holder may exercise the right under this section.]
[(c)
A spouse who requests continuation of coverage under this subsection must pay
the premium for the spouse and any dependent children, on a monthly basis and
in advance, as provided in this paragraph. The spouse shall pay the premium to
the insurer or to the employer or policyholder, whichever the group policy
provides. The required premium payment under this subsection may not exceed the
group premium rate, for the insurance being continued under the group policy,
as of the date the premium payment is due.]
(8) A qualified beneficiary who is
not eligible for continuation of coverage under ORS 743.600 may continue
coverage under this section upon the dissolution of marriage with or the death
of the covered person in the same manner that a covered person may exercise the
right to continue coverage under this section.
(9) [A certificate holder who has terminated employment by reason of layoff
may not be subject upon any rehire that occurs within nine months of the time
of the layoff to any waiting period prerequisite to] A covered person
rehired by an employer no later than nine months after the layoff of the
covered person by the employer may not be subjected to a waiting period for
coverage under the employer’s group health insurance policy if the [certificate holder] covered person
was eligible for coverage at the time of the [termination and] layoff, regardless of whether the [certificate holder] covered person
continued coverage during the layoff.
(10) If an insurer terminates the
group health insurance coverage of a covered person or qualified beneficiary
without providing replacement coverage that meets the criteria in subsection
(7)(d) of this section, the insurer shall provide written notice to the covered
person and any qualified beneficiary no later than 10 days after the insurer is
notified of the qualifying event under subsection (5) of this section. The
notice shall include at least the following information:
(a) Contact information for the
insurer;
(b) Forms necessary to request
continuation of coverage and instructions for completing the forms;
(c) Information sufficient to
determine premium rates for continuation of coverage and instructions for
paying premiums;
(d) A clear statement of who is
eligible to continue coverage;
(e) Enrollment information relating to
other coverage issued by the insurer that is held by the employer or group and
for which the covered person or a qualified beneficiary may be eligible;
(f) An explanation of the process to
appeal a denial of a claim under the continuation of coverage;
(g) Information, in a form approved by
the Director of the Department of Consumer and Business Services, about how to
contact the consumer advocacy unit of the Insurance Division of the Department
of Consumer and Business Services; and
(h) Other information required by the
director.
[(10)]
(11) This section applies only to employers who are not required to make
available continuation of health insurance benefits under Titles X and XXII of
the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, P.L.
99-272, April 7, 1986.
SECTION 6d. Section 2, chapter 73,
Oregon Laws 2009, is amended to read:
Sec. 2. (1) Notwithstanding the
limitations of ORS 743.610, the Director of the Department of Consumer and
Business Services by rule may extend the period of time during which coverage
is available to a [certificate holder]
covered person or qualified beneficiary and may open a new period of time
during which a [certificate holder]
covered person or qualified beneficiary may request continuation of [health benefit coverage under the state
continuation of benefits program] coverage as described in ORS
743.610 if:
(a) The establishment of the extension
[and] or new request period is
in response to and consistent with federal legislation relating to the
continuation of [health benefit]
coverage; and
(b) The director finds that the rule
is necessary to take advantage of a benefit provided to insurers, employers or
employees by the federal legislation relating to the continuation of [health benefit] coverage.
(2) The rules adopted by the director
under subsection (1) of this section may include but need not be limited to:
(a) Changes to the maximum period of
coverage;
(b) Adoption of notice requirements
for insurers, plan administrators, employers, group policyholders [and certificate holders], covered persons
and qualified beneficiaries;
(c) Criteria to determine if a [certificate holder] covered person or
qualified beneficiary is eligible for a benefit;
(d) Procedures to allow an additional
opportunity [to request continuation
coverage under ORS 743.610 (5) to a certificate holder whose employment was
involuntarily terminated between September 1, 2008, and the effective date of
this 2009 Act] for the covered person or qualified beneficiary to
request continuation of coverage under ORS 743.610 if the employment of the
covered person was involuntarily terminated between September 1, 2008, and May
31, 2010;
(e) Any necessary extension of the
time by which the [certificate holder]
covered person or qualified beneficiary must pay the first premium as required
under ORS 743.610; and
(f) Any necessary extension of the
time by which the [certificate holder]
covered person or qualified beneficiary must request or elect continuation of
coverage.
SECTION 7. 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] condition exclusion;
(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] approved by the Department of Consumer and
Business Services under ORS 743.736.
(5) “Bona fide association” means an
association that meets the requirements of 42 U.S.C. [300gg-11] 300gg-91 as amended and in effect on [July 1, 1997] March 23, 2010.
(6) “Carrier,” except as
provided in ORS 743.760, 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.]:
(a) A licensed insurance company;
(b) A health care service contractor;
(c) A health maintenance organization;
(d) An association or group of
employers that provides benefits by means of a multiple employer welfare
arrangement and that:
(A) Is subject to ORS 750.301 to
750.341; or
(B) Is fully insured and otherwise
exempt under ORS 750.303 (4) but elects to be governed by ORS 743.733 to
743.737; or
(e) 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)]
(7) “Creditable coverage” means prior health care coverage as defined in 42
U.S.C. 300gg as amended and in effect on [July
1, 1997] February 17, 2009, 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)]
(8) “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)]
(9) “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)]
(10) “Employee” means any individual employed by an employer.
[(14)]
(11) “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)]
(12) “Exclusion period” means a period during which specified treatments or
services are excluded from coverage.
[(16)]
(13) “Financially impaired” means a [member]
carrier 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)]
(14)(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.
(15) “Grandfathered health plan”
has the meaning prescribed by the United States Secretaries of Labor, Health
and Human Services and the Treasury pursuant to 42 U.S.C. 18011(e).
[(18)]
(16) “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)]
(17)(a) “Health benefit plan” means any:
(A)
Hospital expense, medical expense or hospital or medical expense policy or
certificate[,];
(B) Health
care service contractor or health maintenance organization subscriber contract[, any]; or
(C) 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, to the extent that the plan is subject to state regulation.
(b) “Health benefit plan” does not
include:
(A)
Coverage for accident only, specific disease or condition only, credit[,] or disability income[,];
(B)
Coverage of Medicare services pursuant to contracts with the federal
government[,];
(C)
Medicare supplement insurance policies[,];
(D)
Coverage of [CHAMPUS] TRICARE
services pursuant to contracts with the federal government[,];
(E)
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[,];
(F) Separately offered
long term care insurance, including, but not limited to, coverage of nursing
home care, home health care and community-based care;
(G) [hospital indemnity only,]
Independent, noncoordinated, hospital-only indemnity insurance or other fixed
indemnity insurance;
(H) Short
term health insurance policies [(the
duration of which does not exceed six months including renewals), student
accident and health insurance policies,] that are in effect for periods
of 12 months or less, including the term of a renewal of the policy;
(I) Dental
only[,] coverage;
(J) Vision
only[,] coverage;
(K) [a policy of] Stop-loss coverage that
meets the requirements of ORS 742.065[,];
(L)
Coverage issued as a supplement to liability insurance[,];
(M)
Insurance arising out of a workers’ compensation or similar law[,];
(N)
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[.]; or
(O) Any employee welfare benefit plan
that is exempt from state regulation because of the federal Employee Retirement
Income Security Act of 1974, as amended.
[(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.]
(c) For purposes of this
subsection, renewal of a short term health insurance policy includes the
issuance of a new short term health insurance policy by an insurer to a
policyholder within 60 days after the expiration of a policy previously issued
by the insurer to the policyholder.
[(20)]
(18) “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] approved by the director
under ORS 743.745.
[(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)]
(19) “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)]
(20) “Initial enrollment period” means a period of at least 30 days
following commencement of the first eligibility period for an individual.
[(24)]
(21) “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] February
17, 2009;
(b) The individual applies for
coverage during an open enrollment period;
(c) A court [has ordered] issues an order that coverage be provided for a
spouse or minor child under [a covered]
an employee’s employer sponsored 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] that 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]
TRICARE, Indian Health Service or a publicly sponsored or subsidized health
plan, including, but not limited to, the medical assistance
program under ORS chapter 414, has been involuntarily terminated within 63 days
[of] after applying for
coverage in a group health benefit plan.
[(25)]
(22) “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)]
(23) “Oregon Medical Insurance Pool” means the pool created under ORS
735.610.
[(27)]
(24) “Preexisting [conditions
provision] condition exclusion” 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) Except for coverage under an
individual grandfathered health plan, a preexisting [conditions provision shall not be applied to a newborn child or adopted
child who obtains coverage in accordance with ORS 743A.090] condition
exclusion may not exclude coverage for services, charges or expenses incurred
by an individual who is under 19 years of age.
[(28)]
(25) “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)]
(26) “Rating period” means the 12-month calendar period for which premium
rates established by a carrier are in effect, as determined by the carrier.
(27) “Representative” does not
include an insurance producer or an employee or authorized representative of an
insurance producer or carrier.
[(30)(a)]
(28)(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] offered by the employer.
(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 8. ORS 743.731 is amended to
read:
743.731. The purposes of ORS 743.730
to 743.773 are:
(1) To promote the availability of
health insurance coverage to groups regardless of their enrollees’ health
status or claims experience;
(2) To prevent abusive rating
practices;
(3) To require disclosure of rating
practices to purchasers of small employer, portability and individual health
benefit plans;
(4) To establish limitations on the
use of preexisting [conditions provisions]
condition exclusions;
(5) To make basic health benefit plans
available to all small employers;
(6) To encourage the availability of
portability and individual health benefit plans for individuals who are not
enrolled in group health benefit plans;
(7) To improve renewability and
continuity of coverage for employers and covered individuals;
(8) To improve the efficiency and
fairness of the health insurance marketplace; and
(9) To ensure that health insurance
coverage in Oregon satisfies the requirements of the Health Insurance
Portability and Accountability Act of 1996 (P.L. 104-191) and the Patient
Protection and Affordable Care Act (P.L. 111-148) as amended by the Health Care
and Education Reconciliation Act (P.L. 111-152),and that enforcement
authority for those requirements is retained by the Director of the Department
of Consumer and Business Services.
SECTION 9. ORS 743.733 is amended to
read:
743.733. (1) If an affiliated group of
employers is treated as a single employer under subsection (b), (c), (m) or (o)
of section 414 of the Internal Revenue Code of 1986, a carrier may issue a
single group health benefit plan to the affiliated group on the basis of the
number of employees in the affiliated group if the group requests such
coverage.
(2) If a [small employer] carrier determines that an employer has more than
50 employees, the carrier may provide a quote for a group health benefit plan
that is not subject to ORS 743.733 to 743.737. If the employer’s workforce
consists of at least two but not more than 50 eligible employees, the [small group] carrier shall inform the
employer that if coverage is limited to the eligible employees, the carrier
must treat the employer as a small employer and shall provide a separate quote
on that basis.
(3) Subsequent to the issuance of a
health benefit plan to a small employer, a [small
employer] carrier shall determine annually the number of employees of the
employer for purposes of determining the employer’s ongoing eligibility as a
small employer. The provisions of ORS 743.733 to 743.737 shall continue to
apply to a health benefit plan issued to a small employer until the plan
anniversary date following the date the employer no longer meets the definition
of a small employer.
SECTION 10. Section 13, chapter 752,
Oregon Laws 2007, as amended by section 4, chapter 81, Oregon Laws 2010, is
amended to read:
Sec. 13. The amendments to ORS
731.146, 731.484, 731.486, 743.734 and 743.748 by sections 6 to 8 [and 10], chapter 752, Oregon Laws 2007,
and [section 3 of this 2010 Act] sections
13 and 18 of this 2011 Act become operative on January 2, 2014.
SECTION 11. Section 12, chapter 752,
Oregon Laws 2007, is amended to read:
Sec. 12. [(1) ORS 743.734, as amended by section 4 of
this 2007 Act, applies to health benefit plans issued or renewed on or after
the effective date of this 2007 Act and before January 2, 2014.]
[(2)]
An association health plan issued to a group described in ORS 743.522 (2) prior
to May 1, 2007, to an association or trust approved prior to May 1, 2007, or to
a multiple employer welfare arrangement authorized prior to May 1, 2007, is not
subject to the requirements of ORS 743.734 (7)(b)(C) with respect to membership
requirements in effect prior to May 1, 2007.
SECTION 12. ORS 743.734, as amended
by section 9, chapter 752, Oregon Laws 2007, and sections 2 and 3, chapter 81,
Oregon Laws 2010, is amended to read:
743.734. (1) Every [group] health benefit plan shall be
subject to the provisions of ORS 743.733 to 743.737, if the plan provides
health benefits covering one or more employees of a small employer and if any
one of the following conditions is met:
(a) Any portion of the premium or
benefits is paid by a small employer or any eligible employee is reimbursed,
whether through wage adjustments or otherwise, by a small employer for any
portion of the health benefit plan premium; or
(b) The health benefit plan is treated
by the employer or any of the eligible employees as part of a plan or program
for the purposes of section 106, section 125 or section 162 of the Internal
Revenue Code of 1986, as amended.
(2) Except as provided in ORS 743.733
to 743.737 and 743A.012 and section 2 of this 2011 Act, no state
law requiring the coverage or the offer of coverage of a health care service or
benefit applies to the basic health benefit plans offered or delivered to a
small employer.
(3) Except as otherwise provided by [law or] ORS 743.733 to 743.737 or
other law, no health benefit plan offered to a small employer shall:
(a) Inhibit a [small employer] carrier from contracting with providers or groups
of providers with respect to health care services or benefits; or
(b) Impose any restriction on the
ability of a [small employer] carrier
to negotiate with providers regarding the level or method of reimbursing care
or services provided under health benefit plans.
(4) Except to determine the
application of a preexisting [conditions
provision] condition exclusion for a late enrollee who is 19
years of age or older, a [small
employer] carrier shall not use health statements when offering small
employer health benefit plans and shall not use any other method to determine
the actual or expected health status of eligible enrollees. Nothing in this
subsection shall prevent a carrier from using health statements or other
information after enrollment for the purpose of providing services or arranging
for the provision of services under a health benefit plan.
(5) Except [in the case of a late enrollee and as otherwise provided in this
section] as provided in this section and ORS 743.737, a [small employer] carrier shall not impose
different terms or conditions on the coverage, premiums or contributions of any
eligible employee [in] of a
small employer [group] that are based
on the actual or expected health status of any eligible employee.
(6)(a) A [small employer] carrier may provide different health benefit plans
to different categories of employees of a small employer that has at least
26 but no more than 50 eligible employees when the employer has chosen to
establish different categories of employees in a manner that does not relate to
the actual or expected health status of such employees or their dependents. The
categories must be based on bona fide employment-based classifications that are
consistent with the employer’s usual business practice. [Except as provided in ORS 743.736 (10):]
[(a)]
(b) [When] Except as provided
in ORS 743.736 (9), a [small employer]
carrier that offers coverage to a small employer with no more than 25
eligible employees[, the small employer
carrier] shall offer coverage to all eligible employees of the small
employer, without regard to the actual or expected health status of any
eligible employee.
[(b)
When a small employer carrier offers coverage to a small employer with at least
26 but not more than 50 eligible employees, the small employer carrier may
limit coverage to the categories of employees that the small employer has
established as eligible for coverage, provided that the categories are based on
bona fide employment-based classifications that are consistent with the
employer’s usual business practice.]
(c) If [the] a small employer elects to offer coverage to dependents
of eligible employees, the [small employer]
carrier shall offer coverage to all dependents of eligible employees, without
regard to the actual or expected health status of any eligible dependent.
(7) A health benefit plan issued to
a small employer group through an association health plan is exempt from
subsection (1) of this section. For purposes of this subsection, an association
health plan is group health insurance described in ORS 743.522 (2) or a health
benefit plan that:
(a) Is delivered or issued for
delivery to:
(A) An association or trust
established in this state, that meets applicable requirements of ORS 743.524 or
743.526, or to a multiple employer welfare arrangement located inside this
state, subject to ORS 750.301 to 750.341; or
(B) An association or trust
established in another state, that is approved by the Director of the
Department of Consumer and Business Services under ORS 731.486 (7), or a
multiple employer welfare arrangement located in another state that complies
with ORS 750.311; and
(b) Satisfies all of the following:
(A) The initial premium rate for the
association health plan does not vary by more than 50 percent across the groups
of small employers under the plan.
(B) The association policyholder does
not discriminate in membership requirements based on actual or expected health
status of individual enrollees or prospective enrollees, in accordance with ORS
743.752 (5).
(C) Small employer groups that have
two or more eligible employees and that meet the membership requirements for
the association are not excluded from the association health plan.
(D) Except as provided in subsection
(8) of this section, the association health plan maintains a 95 percent
retention rate.
(8)(a) The 95 percent retention rate
required under subsection (7) of this section does not apply to employer groups
that:
(A) Go out of business, whether
through merger, acquisition or any other reason;
(B) No longer meet eligibility
requirements for membership in the association, including failure to pay
association dues;
(C) No longer meet participation
requirements for employers that are set forth in the plan documents; or
(D) Fail to pay premiums.
(b) An association health plan that
fails to maintain the 95 percent retention rate during any year may have 12
months to correct the retention level before losing the exemption under
subsection (7) of this section.
(c) The director may exempt an
association health plan from the 95 percent retention rate requirement in
subsection (7) of this section according to criteria prescribed by the director
by rule.
(9) Notwithstanding any other
provision of law, an insurer may not deny, delay or terminate participation of
an individual in a group health benefit plan or exclude coverage otherwise
provided to an individual under a group health benefit plan based on a
preexisting condition of the individual if the individual is under 19 years of
age.
SECTION 13. ORS 743.734, as amended
by section 9, chapter 752, Oregon Laws 2007, sections 2 and 3, chapter 81,
Oregon Laws 2010, and section 12 of this 2011 Act, is amended to read:
743.734. (1) Every health benefit plan
shall be subject to the provisions of ORS 743.733 to 743.737, if the plan
provides health benefits covering one or more employees of a small employer and
if any one of the following conditions is met:
(a) Any portion of the premium or
benefits is paid by a small employer or any eligible employee is reimbursed,
whether through wage adjustments or otherwise, by a small employer for any
portion of the health benefit plan premium; or
(b) The health benefit plan is treated
by the employer or any of the eligible employees as part of a plan or program
for the purposes of section 106, section 125 or section 162 of the Internal
Revenue Code of 1986, as amended.
(2) Except as provided in ORS 743.733
to 743.737 and 743A.012 and section 2 of this 2011 Act, no state law requiring
the coverage or the offer of coverage of a health care service or benefit
applies to the basic health benefit plans offered or delivered to a small
employer.
(3) Except as otherwise provided by
ORS 743.733 to 743.737 or other law, no health benefit plan offered to a small
employer shall:
(a) Inhibit a carrier from contracting
with providers or groups of providers with respect to health care services or
benefits; or
(b) Impose any restriction on the
ability of a carrier to negotiate with providers regarding the level or method
of reimbursing care or services provided under health benefit plans.
(4) Except to determine the
application of a preexisting condition exclusion for a late enrollee who is 19
years of age or older, a carrier shall not use health statements when offering
small employer health benefit plans and shall not use any other method to
determine the actual or expected health status of eligible enrollees. Nothing
in this subsection shall prevent a carrier from using health statements or
other information after enrollment for the purpose of providing services or
arranging for the provision of services under a health benefit plan.
(5) Except as provided in this section
and ORS 743.737, a carrier shall not impose different terms or conditions on
the coverage, premiums or contributions of any eligible employee of a small
employer that are based on the actual or expected health status of any eligible
employee.
(6)(a) A carrier may provide different
health benefit plans to different categories of employees of a small employer
that has at least 26 but no more than 50 eligible employees when the employer
has chosen to establish different categories of employees in a manner that does
not relate to the actual or expected health status of such employees or their
dependents. The categories must be based on bona fide employment-based
classifications that are consistent with the employer’s usual business
practice.
(b) Except as provided in ORS 743.736
(9), a carrier that offers coverage to a small employer with no more than 25
eligible employees shall offer coverage to all eligible employees of the small
employer, without regard to the actual or expected health status of any eligible
employee.
(c) If a small employer elects to
offer coverage to dependents of eligible employees, the carrier shall offer
coverage to all dependents of eligible employees, without regard to the actual
or expected health status of any eligible dependent.
[(7)
A health benefit plan issued to a small employer group through an association
health plan is exempt from subsection (1) of this section. For purposes of this
subsection, an association health plan is group health insurance described in
ORS 743.522 (2) or a health benefit plan that:]
[(a)
Is delivered or issued for delivery to:]
[(A)
An association or trust established in this state, that meets applicable
requirements of ORS 743.524 or 743.526, or to a multiple employer welfare
arrangement located inside this state, subject to ORS 750.301 to 750.341; or]
[(B)
An association or trust established in another state, that is approved by the
Director of the Department of Consumer and Business Services under ORS 731.486
(7), or a multiple employer welfare arrangement located in another state that
complies with ORS 750.311; and]
[(b)
Satisfies all of the following:]
[(A)
The initial premium rate for the association health plan does not vary by more
than 50 percent across the groups of small employers under the plan.]
[(B)
The association policyholder does not discriminate in membership requirements
based on actual or expected health status of individual enrollees or
prospective enrollees, in accordance with ORS 743.752 (5).]
[(C)
Small employer groups that have two or more eligible employees and that meet
the membership requirements for the association are not excluded from the
association health plan.]
[(D)
Except as provided in subsection (8) of this section, the association health
plan maintains a 95 percent retention rate.]
[(8)(a)
The 95 percent retention rate required under subsection (7) of this section
does not apply to employer groups that:]
[(A)
Go out of business, whether through merger, acquisition or any other reason;]
[(B)
No longer meet eligibility requirements for membership in the association,
including failure to pay association dues;]
[(C)
No longer meet participation requirements for employers that are set forth in
the plan documents; or]
[(D)
Fail to pay premiums.]
[(b)
An association health plan that fails to maintain the 95 percent retention rate
during any year may have 12 months to correct the retention level before losing
the exemption under subsection (7) of this section.]
[(c)
The director may exempt an association health plan from the 95 percent
retention rate requirement in subsection (7) of this section according to
criteria prescribed by the director by rule.]
[(9)]
(7) Notwithstanding any other provision of law, an insurer may not deny,
delay or terminate participation of an individual in a group health benefit
plan or exclude coverage otherwise provided to an individual under a group
health benefit plan based on a preexisting condition of the individual if the
individual is under 19 years of age.
SECTION 14. ORS 743.736 is amended to
read:
743.736. [(1) In order to improve the availability and affordability of health
benefit coverage for small employers, the Health Insurance Reform Advisory
Committee created under ORS 743.745 shall submit to the Director of the Department
of Consumer and Business Services two basic 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 requirements of the federal Health Maintenance
Organization Act, 42 U.S.C. 300e et seq.]
[(2)(a)
The director shall approve the basic health benefit plans following a
determination that the plans provide for maximum accessibility and
affordability of needed health care services and following a determination that
the basic health benefit plans substantially meet the social values that
underlie the ranking of benefits by the Health Services Commission and that the
basic health benefit plans are substantially similar to the Medicaid reform
program under chapter 836, Oregon Laws 1989, funded by the Legislative
Assembly.]
[(b)
The basic health benefit plans shall include benefits mandated under ORS
743A.168 until mental health, alcohol and chemical dependency services are
fully integrated into the Health Services Commission’s priority list, and as
funded by the Legislative Assembly, and chapter 836, Oregon Laws 1989, is
implemented.]
[(c)
The commission shall aid the director by reviewing the basic health benefit
plans and commenting on the extent to which the plans meet these criteria.]
[(3)]
(1) [After the director’s approval
of the basic health benefit plans submitted by the committee pursuant to
subsection (1) of this section, each small employer] As a condition of
transacting business in the small employer health insurance market in this
state, a carrier shall offer small employers an approved basic health benefit
plan and all of the other plans of the carrier that have been approved by the
Department of Consumer and Business Services for use in the small employer
market.
(2) A carrier
shall submit to the [director] department,
for approval in accordance with ORS 742.003, the policy form or forms
containing its basic health benefit plan. [Each
policy form must be submitted as prescribed by the director and is subject to review
and approval pursuant to ORS 742.003.]
[(4)(a)
As a condition of transacting business in the small employer health insurance
market in this state, every small employer carrier shall offer small employers
an approved basic health benefit plan and any other plans that have been
submitted by the small employer carrier for use in the small employer market
and approved by the director.]
[(b)
Nothing in this subsection shall require a small employer carrier to resubmit
small employer health benefit plans that were approved by the director prior to
October 1, 1996, nor shall small employer carriers be required to reinitiate
new plan selection procedures for currently enrolled small employers prior to
the small employer’s next health benefit plan coverage anniversary date.]
[(c)]
(3) A carrier that offers a health benefit plan in the small employer
market only through one or more bona fide associations is not required to offer
that health benefit plan to small employers that are not members of the bona
fide association.
[(5)]
(4) A [small employer] carrier
shall issue to a small employer any [small
employer] health benefit plan, including a basic health benefit plan,
that is offered by the carrier if the small employer applies for the plan
and agrees to make the required premium payments and to satisfy the other
provisions of the health benefit plan.
[(6)]
(5) A multiple employer welfare arrangement, professional or trade
association or other similar arrangement established or maintained to provide
benefits to a particular trade, business, profession or industry or their
subsidiaries shall not issue coverage to a group or individual that is not in
the same trade, business, profession or industry as that covered by the
arrangement. The arrangement shall accept all groups and individuals in the
same trade, business, profession or industry or their subsidiaries that apply
for coverage under the arrangement and that meet the requirements for
membership in the arrangement. For purposes of this subsection, the requirements
for membership in an arrangement shall not include any requirements that relate
to the actual or expected health status of the prospective enrollee.
[(7)]
(6) A [small employer] carrier
shall, pursuant to [subsections (4) and
(5)] subsection (4) of this section, [offer coverage to or accept applications from a] accept
applications from and offer coverage to a small employer group covered
under an existing [small employer]
health benefit plan regardless of whether [or not] a prospective enrollee is excluded from coverage under the
existing plan because of late enrollment. When a [small employer] carrier accepts an application for [such] a small employer group, the
carrier may continue to exclude the prospective enrollee excluded from coverage
by the replaced plan until the prospective enrollee would have become eligible
for coverage under that replaced plan.
[(8)]
(7) [No small employer carrier
shall be required to offer coverage or accept applications pursuant to
subsections (4) and (5)] A carrier is not required to accept
applications from and offer coverage pursuant to subsection (4) of this
section if the [director]
department finds that acceptance of an application or applications would
endanger the carrier’s ability to fulfill its contractual obligations or result
in financial impairment of the carrier.
[(9)]
(8) [Every small employer]
A carrier shall market fairly all [small
employer] health benefit plans, including basic health benefit plans,
that are offered by the carrier to small employers in the geographical
areas in which the carrier makes coverage available or provides benefits.
[(10)(a)]
(9)(a) Subsection (4) of this section does not require a [No small employer] carrier [shall be required] to offer coverage to
or accept applications from [pursuant
to subsections (4) and (5) of this section in the case of any of the following]:
(A) [To] A small employer if the small employer is not physically
located in the carrier’s approved service area;
(B) [To] An employee of a small employer if the employee does not
work or reside within the carrier’s approved service areas; or
(C) Small employers located
within an area where the carrier reasonably anticipates, and demonstrates to
the [satisfaction of the director]
department, that it will not have the capacity in its network of providers
to deliver services adequately to the enrollees of those small employer
groups because of its obligations to existing small employer group
contract holders and enrollees.
(b) A carrier that does not offer
coverage pursuant to paragraph (a)(C) of this subsection shall not offer
coverage in the applicable service area to new employer groups other than small
employers until the carrier resumes enrolling groups of new small employers in
the applicable area.
[(11)]
(10) For purposes of ORS 743.733 to 743.737, except as provided in this
subsection, carriers that are affiliated carriers or that are eligible to file
a consolidated tax return pursuant to ORS 317.715 shall be treated as one
carrier and any restrictions or limitations imposed by ORS 743.733 to 743.737
apply as if all health benefit plans delivered or issued for delivery to small
employers in this state by the affiliated carriers were issued by one carrier.
However, any insurance company or health maintenance organization that is an
affiliate of a health care service contractor located in this state, or any
health maintenance organization located in this state that is an affiliate of
an insurance company or health care service contractor, may treat the health maintenance
organization as a separate carrier and each health maintenance organization
that operates only one health maintenance organization in a service area in
this state may be considered a separate carrier.
[(12)]
(11) A [small employer] carrier
that[, after September 29, 1991,]
elects to discontinue offering all of its [small
employer] health benefit plans to small employers under ORS 743.737
[(5)(e)] (6)(e), elects to
discontinue renewing all such plans or elects to discontinue offering and
renewing all such plans is prohibited from offering health benefit plans [in the small employer market] to
small employers in this state for a period of five years from one of the
following dates:
(a) The date of notice to the [director] department pursuant to
ORS 743.737 [(5)(e)] (6)(e);
or
(b) If notice is not provided under
paragraph (a) of this subsection, from the date on which the [director] department provides
notice to the carrier that the [director]
department has determined that the carrier has effectively discontinued
offering [small employer] health
benefit plans to small employers in this state.
(12) This section does not require
a carrier to actively market, offer, issue or accept applications for a
grandfathered health plan or from a small employer not eligible for coverage
under such a plan as provided by the Patient Protection and Affordable Care Act
(P.L. 111-148) as amended by the Health Care and Education Reconciliation Act
(P.L. 111-152).
SECTION 15. ORS 743.737 is amended to
read:
743.737. [Health benefit plans covering small employers shall be subject to the
following provisions:]
(1) A preexisting [conditions provision] condition exclusion
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] condition exclusion
in a small employer health benefit plan shall [terminate its effect] expire as follows:
(a) For an enrollee, [not later than the first of] on the
earlier of the following dates:
(A) Six months [following] after the enrollee’s effective date of coverage;
or
(B) Ten months [following] after the start of any required group eligibility
waiting period.
(b) For a late enrollee, not later
than 12 months [following] after
the late enrollee’s effective date of coverage.
(3) In applying a preexisting [conditions provision] condition exclusion
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] after
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] under ORS 743.745,
applicable to all individuals enrolling for the first time in the small
employer health benefit plan.
(4) A health benefit plan issued to
a small employer may not apply a preexisting condition exclusion to a person
under 19 years of age.
[(4)]
(5) Late enrollees in a small employer health benefit plan may be [excluded from coverage for] subjected
to a group eligibility waiting period of up to 12 months or, if 19 years
of age or older, may be subjected to a preexisting [conditions provision] condition exclusion for up to 12
months. If both [an exclusion from
coverage period] a waiting period and a preexisting [conditions provision] condition
exclusion are applicable to a late enrollee, the combined period shall not
exceed 12 months.
[(5)]
(6) 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] unless:
(a) [For nonpayment of the required premiums by] The policyholder, small
employer or contract holder fails to pay the required premiums.
(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]
an enrollee or a representative of an enrollee engages in fraud or makes an
intentional misrepresentation of a material fact as prohibited by the terms of
the plan.
(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] fails to comply with the 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] department 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 to small employers 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, other than a grandfathered health 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.
(h) The carrier discontinues
renewing or offering and renewing a grandfathered health 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.
(i) With
respect to plans that are being discontinued under paragraph (g) or (h) of
this subsection, the carrier must:
(A) Offer in writing to each small
employer covered by the plan, all other health benefit plans that the
carrier offers to small employers 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)]
(j) [When] The Director of the
Department of Consumer and Business Services 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)]
(k) [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)]
(L) [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)]
(7) 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)(e), (g) and (h) of this section.
[(6)]
(8) Notwithstanding any provision of subsection [(5)] (6) 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.] a carrier
may not rescind the coverage of an enrollee in a small employer health benefit
plan unless:
(a) The enrollee or a person seeking
coverage on behalf of the enrollee:
(A) Performs an act, practice or
omission that constitutes fraud; or
(B) Makes an intentional
misrepresentation of a material fact as prohibited by the terms of the plan;
(b) The carrier provides at least 30
days’ advance written notice, in the form and manner prescribed by the
department, to the enrollee; and
(c) The carrier provides notice of the
rescission to the department in the form, manner and time frame prescribed by
the department by rule.
(9) Notwithstanding any provision of
subsection (6) of this section to the contrary, a carrier may not rescind a
small employer health benefit plan unless:
(a) The small employer or a
representative of the small employer:
(A) Performs an act, practice or
omission that constitutes fraud; or
(B) Makes an intentional
misrepresentation of a material fact as prohibited by the terms of the plan;
(b) The carrier provides at least 30
days’ advance written notice, in the form and manner prescribed by the
department, to each plan enrollee who would be affected by the rescission of
coverage; and
(c) The carrier provides notice of the
rescission to the department in the form, manner and time frame prescribed by
the department by rule.
[(7)]
(10) 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] TRICARE, Indian Health Service or a publicly
sponsored or subsidized health plan, including but not limited to the medical
assistance program under ORS chapter 414.
[(8)]
(11) Premium rates for small employer health benefit plans 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 at least once every 12 months.] Each carrier must file with the
department the initial geographic average rate and any changes in the
geographic average rate with respect to each health benefit plan issued by the
carrier to small employers.
(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 50 percent on or after
January 1, 2008, except as provided in subparagraph (D) of this paragraph.
(B) The variations in premium rates
described in subparagraph (A) of this paragraph shall be based solely on the
factors specified in subparagraph (C) of this paragraph. A [small employer] carrier may elect which
of the factors specified in subparagraph (C) of this paragraph apply to premium
rates for health benefit plans for small employers. The factors that are
based on contributions or participation may vary with the size of the employer.
All other factors must be applied in the same actuarially sound way to all
small [employers] employer health
benefit plans.
(C) The variations in premium rates
described in subparagraph (A) of this paragraph may be based on one or more of
the following factors:
(i) The ages of enrolled employees and
their dependents;
(ii) The level at which the small
employer contributes to the premiums payable for enrolled employees and their
dependents;
(iii) The level at which eligible
employees participate in the health benefit plan;
(iv) The level at which enrolled
employees and their dependents engage in tobacco use;
(v) The level at which enrolled
employees and their dependents engage in health promotion, disease prevention
or wellness programs;
(vi) The period of time during which a
small employer retains uninterrupted coverage in force with the same [small employer] carrier; and
(vii) Adjustments to reflect the
provision of benefits not required to be covered by the basic health benefit
plan and differences in family composition.
(D)(i) The premium rates determined in
accordance with this paragraph may be further adjusted by a [small employer] carrier to reflect the
expected claims experience of [a]
the covered small employer, but the extent of this adjustment may not
exceed five percent of the annual premium rate otherwise payable by the small
employer. The adjustment under this subparagraph may not be cumulative from
year to year.
(ii) [Except for small employers with 25 or fewer employees,] The premium
rates adjusted under this subparagraph, except rates for small employers
with 25 or fewer employees, are not subject to the provisions of
subparagraph (A) of this paragraph.
(E) A [small employer] carrier shall apply the carrier’s schedule of
premium rate variations as approved by [the
Director of] the department [of
Consumer and Business Services] and in accordance with this paragraph.
Except as otherwise provided in this section, the premium rate established
by a carrier for a small employer health benefit plan [by a small employer carrier] shall apply
uniformly to all employees of the small employer enrolled in that plan.
(c) Except as provided in paragraph
(b) of this subsection, the variation in premium rates between different [small employer] health benefit plans
offered by a [small employer] carrier
to small employers 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 small
employer health benefit plans shall comply with the requirements of this
section.
[(9)]
(12) 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]
condition exclusion.
[(10)(a)]
(13)(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
relating to its small employer health benefit 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 small employer] A carrier offering a small employer
health benefit plan shall file with the [director] department at least once every 12 months 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] department. A copy of [such] each 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] department 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)]
(14) 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)]
(15) 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)]
(16) A [small employer] carrier
must include a provision that offers coverage to all eligible employees of a
small employer and to all dependents of the eligible employees to
the extent the employer chooses to offer coverage to dependents.
[(14)]
(17) 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] February 17, 2009.
(18) A small employer health
benefit plan may not impose annual or lifetime limits on the dollar amount of
the essential health benefits prescribed by the United States Secretary of Health
and Human Services pursuant to 42 U.S.C. 300gg-11, except as permitted by
federal law.
(19) This section does not require a
carrier to actively market, offer, issue or accept applications for a
grandfathered health plan or from a small employer not eligible for coverage
under such a plan as provided by the Patient Protection and Affordable Care Act
(P.L. 111-148) as amended by the Health Care and Education Reconciliation Act
(P.L. 111-152).
SECTION 16. ORS 743.745 is amended to
read:
743.745. (1) The Director of
the Department of Consumer and Business Services shall [appoint a Health Insurance Reform Advisory Committee. This committee
shall consist of at least one insurance producer, one representative of a
health maintenance organization, one representative of a health care service
contractor, one representative of a domestic insurer, one representative of a
labor organization and one representative of consumer interests and shall have
representation from the broad range of interests involved in the small employer
and individual market and shall include members with the technical expertise
necessary to carry out the following duties:]
[(1)(a)
Subject to approval by the director, the committee shall recommend]
determine the form and level of coverages under the basic health benefit
plans pursuant to ORS 743.736 to be made available by [small employer] carriers and the portability health benefit plans
to be made available pursuant to ORS 743.760 or 743.761. The [committee shall] director may
take into consideration the levels of health benefit plans provided in Oregon
and the appropriate medical and economic factors and shall establish benefit
levels, cost sharing, exclusions and limitations. The health benefit plans
described in this section may include cost containment features including, but
not limited to:
[(A)]
(a) Preferred provider provisions;
[(B)]
(b) Utilization review of health care services including review of medical
necessity of hospital and physician services;
[(C)]
(c) Case management benefit alternatives;
[(D)]
(d) Other managed care provisions;
[(E)]
(e) Selective contracting with hospitals, physicians and other health care
providers; and
[(F)]
(f) Reasonable benefit differentials applicable to participating and
nonparticipating providers.
[(b)
The committee shall submit the basic and portability health benefit plans and
other recommendations to the director within the time period established by the
director. The health benefit plans and other recommendations shall be deemed
approved unless expressly disapproved by the director within 30 days after the
date the director receives the plans.]
(2) In order to ensure the broadest
availability of small employer, portability and individual health
benefit plans, [the committee shall
recommend for approval by] the director may approve market conduct
and other requirements for carriers and insurance producers, including [requirements developed as a result of a
request by the director, relating to the following]:
(a) Registration by each carrier with
the Department of Consumer and Business Services of [its] the carrier’s intention to [be a small employer carrier] offer group health benefit plans under
ORS 743.733 to 743.737 or [a carrier
offering] individual health benefit plans, or both.
[(b)
Publication by the department of Consumer and Business Services or the
committee of a list of all small employer carriers and carriers offering
individual health benefit plans, including a potential requirement applicable
to insurance producers and carriers that no health benefit plan be sold to a
small employer or individual by a carrier not so identified as a small employer
carrier or carrier offering individual health benefit plans.]
[(c)]
(b) To the extent deemed necessary by the [committee] director to ensure the fair distribution of
high-risk individuals and groups among carriers, periodic reports by carriers
and insurance producers concerning small employer, portability and individual
health benefit plans issued, provided that reporting requirements shall be
limited to information concerning case characteristics and numbers of health
benefit plans in various categories marketed or issued[, or both,] to small employers and individuals.
[(d)]
(c) Methods concerning periodic demonstration by [small employer carriers,] carriers offering [individual] health benefit plans to individuals or small
employers and insurance producers that the [small employer and individual] carriers and insurance producers
are marketing or issuing[, or both,]
health benefit plans [to small employers
or individuals] in fulfillment of the purposes of ORS 743.730 to 743.773.
(3) [Subject to the approval of the director of the Department of Consumer
and Business Services, the committee] The director shall develop a
standard health statement to be used for all late enrollees and by all carriers
offering individual policies of health insurance.
(4) [Subject to the approval of] The director[, the committee] shall develop a list of the specified services for
small employer and portability plans for which carriers may impose an exclusion
period, the duration of the allowable exclusion period for each specified
service and the manner in which credit will be given for exclusion periods
imposed pursuant to prior health insurance coverage.
SECTION 17. ORS 743.748 is amended to
read:
743.748. (1) Each carrier offering a
health benefit plan shall submit to the Director of the Department of Consumer
and Business Services on or before April 1 of each year a report that contains:
(a) The following information for the
preceding year that is derived from the exhibit of premiums, enrollment and
utilization included in the carrier’s annual report:
(A) The total number of members;
(B) The total amount of premiums;
(C) The total amount of costs for
claims;
(D) The medical loss ratio;
(E) The average amount of premiums per
member per month; and
(F) The percentage change in the
average premium per member per month, measured from the previous year.
(b) The following aggregate financial
information for the preceding year that is derived from the carrier’s annual
report:
(A) The total amount of general
administrative expenses, including identification of the five largest
nonmedical administrative expenses and the assessment against the carrier for the
Oregon Medical Insurance Pool;
(B) The total amount of the surplus
maintained;
(C) The total amount of the reserves
maintained for unpaid claims;
(D) The total net underwriting gain or
loss; and
(E) The carrier’s net income after
taxes.
(c) The retention rate and claims
experience of employer groups within the plan for the preceding year for
association health plans as described in ORS 743.734 (7). This information is
not subject to public disclosure under ORS chapter 192.
(2) A carrier shall electronically
submit the information described in subsection (1) of this section in a format
and according to instructions prescribed by the Department of Consumer and
Business Services by rule [after
obtaining a recommendation from the Health Insurance Reform Advisory Committee].
(3) The [advisory committee] department shall evaluate the reporting
requirements under subsection (1)(a) of this section by the following market
segments:
(a) Individual health benefit plans;
(b) Health benefit plans for small employers;
(c) Health benefit plans for employers
described in ORS 743.733;
(d) Health benefit plans for employers
with more than 50 employees; and
(e) Association health plans described
in ORS 743.734 (7).
(4) The department shall make the
information reported under this section available to the public through a
searchable public website on the Internet.
SECTION 18. ORS 743.748, as amended
by section 10, chapter 752, Oregon Laws 2007, is amended to read:
743.748. (1) Each carrier offering a
health benefit plan shall submit to the Director of the Department of Consumer
and Business Services on or before April 1 of each year a report that contains:
(a) The following information for the
preceding year that is derived from the exhibit of premiums, enrollment and
utilization included in the carrier’s annual report:
(A) The total number of members;
(B) The total amount of premiums;
(C) The total amount of costs for
claims;
(D) The medical loss ratio;
(E) The average amount of premiums per
member per month; and
(F) The percentage change in the
average premium per member per month, measured from the previous year.
(b) The following aggregate financial
information for the preceding year that is derived from the carrier’s annual
report:
(A) The total amount of general
administrative expenses, including identification of the five largest
nonmedical administrative expenses and the assessment against the carrier for
the Oregon Medical Insurance Pool;
(B) The total amount of the surplus
maintained;
(C) The total amount of the reserves
maintained for unpaid claims;
(D) The total net underwriting gain or
loss; and
(E) The carrier’s net income after
taxes.
(2) A carrier shall electronically
submit the information described in subsection (1) of this section in a format
and according to instructions prescribed by the Department of Consumer and
Business Services by rule [after
obtaining a recommendation from the Health Insurance Reform Advisory Committee].
(3) The [advisory committee] department shall evaluate the reporting
requirements under subsection (1)(a) of this section by the following market
segments:
(a) Individual health benefit plans;
(b) Health benefit plans for small
employers;
(c) Health benefit plans for employers
described in ORS 743.733; and
(d) Health benefit plans for employers
with more than 50 employees.
(4) The department shall make the
information reported under this section available to the public through a
searchable public website on the Internet.
SECTION 19. ORS 743.751 is amended to
read:
743.751. (1) Except to determine the
application of a preexisting [conditions
provision] condition exclusion for a late enrollee who is 19
years of age or older or as prescribed by the Department of Consumer and
Business Services by rule, a carrier offering group health benefit plans
shall not use health statements when offering such plans to a group of two or
more prospective certificate holders and shall not use any other method to
determine the actual or expected health status of eligible prospective
enrollees. Nothing in this section shall prevent a carrier from using health
statements or other information after enrollment for the purpose of providing
services or arranging for the provision of services under a health benefit plan
or from obtaining aggregate group information related to historical medical
claims expenses and health behavior surveys for rating purposes.
(2) Subsection (1) of this section
applies only to group health benefit plans that are not small employer health
benefit plans.
SECTION 20. ORS 743.754 is amended to
read:
743.754. The following requirements
apply to all group health benefit plans other than small employer health
benefit plans covering two or more certificate holders:
(1) A preexisting [conditions provision in a group health
benefit plan] condition exclusion 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 group health
benefit plan] condition exclusion may not apply to a person under 19
years of age and shall [terminate its
effect] expire as follows:
(a) For an enrollee, on the earlier
of [not later than the first of]
the following dates:
(A) Six months [following] after the enrollee’s effective date of coverage;
or
(B) Twelve months [following] after the start of any
required group eligibility waiting period.
(b) For a late enrollee, not later
than 12 months [following] after
the late enrollee’s effective date of coverage.
(3) In applying a preexisting [conditions provision] condition
exclusion to an enrollee or late enrollee who is 19 years of age or
older, except as provided in this subsection, all [group 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] after
the enrollment date in the new [group
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 [group 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 applicable to all individuals enrolling for the first time in
the [group health benefit] plan.
(4) Late enrollees may be [excluded from coverage for] subjected
to a group eligibility waiting period of up to 12 months or, if 19 years
of age or older, may be subjected to a preexisting [conditions provision] condition exclusion for up to 12
months. If both [an exclusion from
coverage period] a waiting period and a preexisting [conditions provision] condition
exclusion are applicable to a late enrollee, the combined period shall not
exceed 12 months.
(5) [All group health benefit plans shall contain special enrollment periods]
Each plan shall contain a special enrollment period 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] February 17, 2009.
(6) Each [group health benefit] plan shall be renewable with respect to all
eligible enrollees at the option of the policyholder [except] unless:
(a) [For nonpayment of] The policyholder fails to pay the
required premiums [by the policyholder].
(b) [For fraud or misrepresentation of] The policyholder or, with
respect to coverage of individual enrollees, [the enrollees or their representatives] an enrollee or a
representative of an enrollee engages in fraud or makes an intentional
misrepresentation of a material fact as prohibited by the terms of the plan.
(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 carrier’s employer] The policyholder
fails to comply with the contribution requirements under the [health benefit] plan.
(e) [When] The carrier discontinues offering or renewing, or offering
and renewing, all of its group [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 group market in this state or
in the specified service area.
(f) [When] The carrier discontinues offering and renewing a group [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 of the decision
to the [director] department
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
policyholder covered by the plan, all other group health benefit plans that the
carrier offers in the specified service area. 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, other than a grandfathered health plan,
for all groups in this state or in a specified service area within this state,
other than a plan discontinued under paragraph (f) of this subsection.
(h) The carrier discontinues
renewing or offering and renewing a grandfathered health plan for all groups in
this state or in a specified service are within this state, other than a plan
discontinued under paragraph (f) of this subsection.
(i) With
respect to plans that are being discontinued under paragraph (g) or (h) of
this subsection, the carrier must:
(A) Offer in writing to each
policyholder covered by the plan, one or more health benefit plans that the
carrier offers in the specified service area.
(B) Offer the plans at least 90 days
prior to discontinuation.
(C) Act uniformly without regard to
the claims experience of the affected policyholders or the health status of any
current or prospective enrollee.
[(h)]
(j) [When] The Director of the
Department of Consumer and Business Services 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)]
(k) [When,] In the case of a [group 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)]
(L) [When,] In the case of a [health benefit] plan that is offered in
the group 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)]
(7) A carrier may modify a [group
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)(e), (g) and (h) of this section.
[(7)]
(8) Notwithstanding any provision of subsection (6) of this section to the
contrary, [a group health benefit plan
may be rescinded by a carrier for fraud, material misrepresentation or concealment
by a policyholder and the coverage of an enrollee may be rescinded for fraud,
material misrepresentation or concealment by the enrollee.] a carrier
may not rescind the coverage of an enrollee under the plan unless:
(a) The enrollee:
(A) Performs an act, practice or
omission that constitutes fraud; or
(B) Makes an intentional
misrepresentation of a material fact as prohibited by the terms of the plan;
(b) The carrier provides at least 30
days’ advance written notice, in the form and manner prescribed by the
department, to the enrollee; and
(c) The carrier provides notice of the
rescission to the department in the form, manner and time frame prescribed by
the department by rule.
(9) Notwithstanding any provision of
subsection (6) of this section to the contrary, a carrier may not rescind a
plan unless:
(a) The plan sponsor or a
representative of the plan sponsor:
(A) Performs an act, practice or
omission that constitutes fraud; or
(B) Makes an intentional
misrepresentation of a material fact as prohibited by the terms of the plan;
(b) The carrier provides at least 30
days’ advance written notice, in the form and manner prescribed by the
department, to each plan enrollee who would be affected by the rescission of
coverage; and
(c) The carrier provides notice of the
rescission to the department in the form, manner and time frame prescribed by
the department by rule.
[(8)]
(10) A carrier that continues to offer coverage in the group market in this
state is not required to offer coverage in all of the carrier’s group [health benefit] plans. If a carrier,
however, elects to continue a plan that is closed to new policyholders instead
of offering alternative coverage in its other group [health benefit] plans, the coverage for all existing policyholders
in the closed plan is renewable in accordance with subsection (6) of this
section.
[(9)
This section applies only to group health benefit plans that are not small
employer health benefit plans.]
(11) A group health benefit plan
may not impose annual or lifetime limits on the dollar amount of the essential
health benefits prescribed by the United States Secretary of Health and Human
Services pursuant to 42 U.S.C. 300gg-11, except as permitted by federal law.
(12) This section does not require a
carrier to actively market, offer, issue or accept applications for a
grandfathered health plan or from a group not eligible for coverage under such
a plan as provided by the Patient Protection and Affordable Care Act (P.L.
111-148) as amended by the Health Care and Education Reconciliation Act (P.L.
111-152).
SECTION 21. ORS 743.758 is amended to
read:
743.758. The Department of Consumer
and Business Services may adopt rules incorporating, implementing and
administering the Health Insurance Portability and Accountability Act of 1996
(P.L. 104-191), the Patient Protection and Affordable Care Act (P.L.
111-148) as amended by the Health Care and Education Reconciliation Act (P.L.
111-152) and federal regulations that are issued in conjunction with the [Act] Acts [, to the extent that such federal law and regulations are not
inconsistent with any provision of Oregon law].
SECTION 22. 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 Oregon
carrier and is an Oregon resident at the time of such application.
(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 shall develop 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 shall establish standards for:
(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 state 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] standards for portability health
benefit plans [if] established by
the director under subsection (2) of this section must [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 established by the director under subsection (2) of this section.
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] No later than 180 days after [approval by] the director [of
the] establishes standards for 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] after 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]
the carrier’s initial geographic average rate and any changes in the geographic
average rate with respect to each portability health benefit plan issued by the
carrier.
(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] a policyholder 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] policyholder.
The percentage increase in the premium rate charged to [an enrollee] a policyholder 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] A portability [plans]
plan under this section may not contain preexisting [conditions provisions, exclusion periods]
condition exclusions, 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] unless:
(a) [For nonpayment of the required premiums by] The policyholder
fails to pay the required premiums;
(b) [For fraud or misrepresentation by] The policyholder or a
representative of the policyholder engages in fraud or makes an intentional
misrepresentation of a material fact as prohibited by the terms of the policy;
(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] A carrier offering a group health benefit [plans] plan 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] A carrier offering a group health benefit plan
shall file with the [director]
Department of Consumer and Business Services 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]
department. A copy of [such]
each certification shall be retained by the carrier at its principal place
of business.
(c) [Each such] A carrier offering a group health benefit plan
shall make the information and documentation described in paragraph (a) of this
subsection available to the [director]
department 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 a group
health benefit [plans] plan
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.
(13) Subject to the provisions of
section 4 (2) and (4) of this 2011 Act, a carrier may rescind a portability
health benefit plan issued to a policyholder only if the policyholder or a
representative of the policyholder:
(a) Performs an act, practice or
omission that constitutes fraud; or
(b) Makes an intentional
misrepresentation of a material fact as prohibited by the terms of the policy.
SECTION 23. ORS 743.761 is amended to
read:
743.761. (1) A carrier approved
pursuant to subsection (4) of this section that offers individual health
benefit plans may satisfy the requirements of ORS 743.760 by issuing any
individual health benefit plan offered by the carrier to any eligible
individual as defined in ORS 743.760 who:
(a) Is leaving or has left a group
health benefit plan provided by that carrier;
(b) Applies for the policy; and
(c) Agrees to make the required
premium payments and to satisfy the other provisions of the plan.
(2) All health benefit plans issued
pursuant to subsection (1) of this section shall:
(a) Comply with ORS 743.767 and
743.769; and
(b) Contain no preexisting [conditions provisions, exclusion periods]
condition exclusions, waiting periods or other similar limitations on
coverage.
(3) A carrier offering plans pursuant
to this section shall offer plans that meet the standards and requirements
described in ORS 743.760 (2).
(4) The Director of the Department of
Consumer and Business Services shall adopt standards for minimum participation
in the individual market necessary for a carrier to offer policies under this
section and shall develop a program for approval of carriers under this
section.
SECTION 24. ORS 743.766 is amended to
read:
743.766. (1) All carriers [who] that offer an
individual health benefit [plans]
plan and evaluate the health status of individuals for purposes of
eligibility shall use the standard health statement established [by the Health Insurance Reform Advisory
Committee] under ORS 743.745 and may not use any other method to
determine the health status of an individual. Nothing in this subsection shall
prevent a carrier from using health information after enrollment for the
purpose of providing services or arranging for the provision of services under
a health benefit plan.
(2)(a) If an individual is accepted
for coverage under an individual health benefit plan, the carrier shall not
impose exclusions or limitations [on
coverage greater] other than:
(A) A preexisting [conditions provision] condition exclusion
that complies with the following requirements:
(i) The [provision shall apply] exclusion applies only to a condition
for which medical advice, diagnosis, care or treatment was recommended or
received during the six-month period immediately preceding the individual’s
effective date of coverage; [and]
(ii) The [provision shall terminate its effect] exclusion expires no
later than six months [following]
after the individual’s effective date of coverage; and
(iii) Except for grandfathered health
plans, the exclusion does not apply to individuals who are under 19 years of
age;
(B) An individual coverage waiting
period of 90 days; or
(C) An exclusion period for specified
covered services applicable to all individuals enrolling for the first time in
the individual health benefit plan.
(b) Except for grandfathered health
plans, pregnancy of individuals who are under 19 years of age may not
constitute a preexisting condition for purposes of this section.
(3) If the carrier elects to restrict
coverage through the application of a preexisting [conditions provision] condition exclusion or an individual
coverage waiting period provision, the carrier shall reduce the duration of the
provision by an amount equal to the individual’s aggregate periods of
creditable coverage if the most recent period of creditable coverage is ongoing
or ended within 63 days [of] after
the effective date of coverage in the new individual 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.
(4) If an eligible prospective
enrollee is rejected for coverage under an individual health benefit plan, the
prospective enrollee shall be eligible to apply for coverage under the Oregon
Medical Insurance Pool.
(5) If a carrier accepts an individual
for coverage under an individual health benefit plan, the carrier shall renew
the policy [except] unless:
(a) [For nonpayment of the required premiums by] The policyholder
fails to pay the required premiums.
(b) [For fraud or misrepresentation by] The policyholder or a
representative of the policyholder engages in fraud or makes an intentional
misrepresentation of a material fact as prohibited by the terms of the policy.
(c) [When] The carrier discontinues offering or renewing, or offering
and renewing, all of its individual health benefit plans in this state or in a
specified service area within this state. In order to discontinue the 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 individual market in this state or in the specified service
area.
(d) [When] The carrier discontinues offering and renewing an individual
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 of the decision
to the [director] department
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
policyholder covered by the plan, all other individual health benefit plans
that the carrier offers in the specified service area. The carrier shall offer
the plans at least 90 days prior to discontinuation.
(e) [When] The carrier discontinues offering or renewing, or offering
and renewing, an individual health benefit plan, other than a grandfathered
health plan, for all individuals in this state or in a specified service
area within this state, other than a plan discontinued under paragraph (d) of
this subsection.
(f) The carrier discontinues
renewing or offering and renewing a grandfathered health plan for all
individuals in this state or in a specified service area within this state,
other than a plan discontinued under paragraph (d) of this subsection.
(g) With
respect to plans that are being discontinued under paragraph (e) or (f) of
this subsection, the carrier must:
(A) Offer in writing to each
policyholder covered by the plan, [one or
more individual] all health benefit plans that the carrier offers to
individuals in the specified service area.
(B) Offer the plans at least 90 days
prior to discontinuation.
(C) Act uniformly without regard to
the claims experience of the affected policyholders or the health status of any
current or prospective enrollee.
[(f)]
(h) [When] The Director of the
Department of Consumer and Business Services 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 enrollee; or
(B) Impair the carrier’s ability to
meet its contractual obligations.
[(g)]
(i) [When,] In the case of an
individual health benefit plan that delivers covered services through a
specified network of health care providers, the enrollee no longer lives, resides
or works in the service area of the provider network and the termination of
coverage is not related to the health status of any enrollee.
[(h)]
(j) [When,] In the case of a
health benefit plan that is offered in the individual market only through one or
more bona fide associations, the membership of an individual in the association
ceases and the termination of coverage is not related to the health status of
any enrollee.
[(i)
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 service to an enrollee. An enrollee under
this paragraph retains the rights of an enrollee under ORS 743.804.]
[(j)]
(6) A carrier may modify an individual health benefit plan at the time of
coverage renewal. The modification is not a discontinuation of the plan under [paragraphs (c) and (e) of this]
subsection (5)(c), (e) and (f) of this section.
[(6)]
(7) Notwithstanding any other provision of this section, and subject to
the provisions of section 4 (2) and (4) of this 2011 Act, a carrier may rescind
an individual health benefit plan [for
fraud, material misrepresentation or concealment by an enrollee.] if the
policyholder or a representative of the policyholder:
(a) Performs an act, practice or
omission that constitutes fraud; or
(b) Makes an intentional
misrepresentation of a material fact as prohibited by the terms of the policy.
[(7)]
(8) A carrier that withdraws from the market for individual health benefit
plans must continue to renew its portability health benefit plans that have
been approved pursuant to ORS 743.761.
[(8)]
(9) A carrier that continues to offer coverage in the individual market in
this state is not required to offer coverage in all of the carrier’s individual
health benefit plans. However, if a carrier elects to continue a plan that is
closed to new individual policyholders instead of offering alternative coverage
in its other individual health benefit plans, the coverage for all existing
policyholders in the closed plan is renewable in accordance with subsection (5)
of this section.
(10) An individual health benefit
plan may not impose lifetime limits on the dollar amount of the essential
health benefits prescribed by the United States Secretary of Health and Human
Services pursuant to 42 U.S.C. 300gg-11, except as permitted by federal law.
(11) This section does not require a
carrier to actively market, offer, issue or accept applications for a
grandfathered health plan or from an individual not eligible for coverage under
such a plan as provided by the Patient Protection and Affordable Care Act (P.L.
111-148) as amended by the Health Care and Education Reconciliation Act (P.L.
111-152).
SECTION 25. ORS 743.767 is amended to
read:
743.767. Premium rates for individual
health benefit plans shall be subject to the following provisions:
(1) Each carrier must file the carrier’s
initial geographic average rate and any changes to the geographic
average rate for its individual health benefit plans [for a rating period] with the Director of the Department of
Consumer and Business Services [on or
before March 15 of each year].
(2) The premium rates charged during a
rating period for individual health benefit plans issued to individuals shall
not vary from the individual geographic average rate, except that the premium
rate may be adjusted to reflect differences in benefit design, family
composition and age. For age adjustments to the individual plans, a carrier
shall apply uniformly its schedule of age adjustments for individual health
benefit plans as approved by the director.
(3) A carrier may not increase the
rates of an individual health benefit plan more than once in a 12-month period
except as approved by the director. Annual rate increases shall be effective on
the anniversary date of the individual health benefit plan’s issuance. The
percentage increase in the premium rate charged for an individual health
benefit plan for a new rating period may not exceed the sum of the following:
(a) The percentage change in the
carrier’s geographic average rate for its individual health benefit plan
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 and differences in benefit design and family composition.
(4) Notwithstanding any other provision
of this section, a carrier that imposes an individual coverage waiting period
pursuant to ORS 743.766 may impose a monthly premium rate surcharge for a
period not to exceed six months and in an amount not to exceed the percentage
by which the rates for coverage under the Oregon Medical Insurance Pool exceed
the rates established by the Oregon Medical Insurance Pool Board as applicable
for individual risks under ORS 735.625. The surcharge shall be approved by the
Director of the Department of Consumer and Business Services and, in
combination with the waiting period, shall not exceed the actuarial value of a
six-month preexisting [conditions
provision] condition exclusion.
SECTION 26. ORS 743.801 is amended to
read:
743.801. As used in this section and
ORS [743.801,] 743.803, 743.804,
743.806, 743.807, 743.808, 743.811, 743.814, 743.817, 743.819, 743.821,
743.823, 743.827, 743.829, 743.831, 743.834, 743.837, 743.839, 743.854,
743.856, 743.857, 743.858, 743.859, 743.861, 743.862, 743.863, 743.864, 743.911,
743.912, 743.913, 743.917[,] and
743.918 [and 743A.012] and section
4 of this 2011 Act:
(1) “Adverse benefit determination”
means an insurer’s denial, reduction or termination of a health care item or
service, or an insurer’s failure or refusal to provide or to make a payment in
whole or in part for a health care item or service, that is based on the
insurer’s:
(a) Denial of eligibility for or
termination of enrollment in a health benefit plan;
(b) Rescission or cancellation of a
policy or certificate;
(c) Imposition of a preexisting
condition exclusion as defined in ORS 743.730, source-of-injury exclusion,
network exclusion, annual benefit limit or other limitation on otherwise
covered items or services;
(d) Determination that a health care
item or service is experimental, investigational or not medically necessary,
effective or appropriate; or
(e) Determination that a course or
plan of treatment that an enrollee is undergoing is an active course of
treatment for purposes of continuity of care under ORS 743.854.
(2) “Authorized representative” means
an individual who by law or by the consent of a person may act on behalf of the
person.
[(1)
“Emergency medical condition” means a medical condition that manifests itself
by acute symptoms of sufficient severity, including severe pain, that a prudent
layperson possessing an average knowledge of health and medicine would
reasonably expect that failure to receive immediate medical attention would
place the health of a person, or a fetus in the case of a pregnant woman, in
serious jeopardy.]
[(2)
“Emergency medical screening exam” means the medical history, examination,
ancillary tests and medical determinations required to ascertain the nature and
extent of an emergency medical condition.]
[(3)
“Emergency services” means those health care items and services furnished in an
emergency department and all ancillary services routinely available to an
emergency department to the extent they are required for the stabilization of a
patient.]
[(4)]
(3) “Enrollee” has the meaning given that term in ORS 743.730.
[(5)]
(4) “Grievance” means [a written
complaint]:
(a) A request
submitted by [or on behalf of] an
enrollee or an authorized representative of an enrollee:
(A) In writing, for an internal appeal
or an external review; or
(B) In writing or orally, for an
expedited response described in ORS 743.804 (2)(d) or an expedited external
review; or
(b) A written complaint submitted by
an enrollee or an authorized representative of an enrollee regarding
the:
[(a)]
(A) Availability, delivery or quality of a health care [services, including a complaint regarding an
adverse determination made pursuant to utilization review] service;
[(b)]
(B) Claims payment, handling or reimbursement for health care services
and, unless the enrollee has not submitted a request for an internal appeal,
the complaint is not disputing an adverse benefit determination; or
[(c)]
(C) Matters pertaining to the contractual relationship between an enrollee
and an insurer.
[(6)]
(5) “Health benefit plan” has the meaning [provided for] given that term in ORS 743.730.
[(7)]
(6) “Independent practice association” means a corporation wholly owned by
providers, or whose membership consists entirely of providers, formed for the
sole purpose of contracting with insurers for the provision of health care
services to enrollees, or with employers for the provision of health care
services to employees, or with a group, as described in ORS 743.522, to provide
health care services to group members.
[(8)]
(7) “Insurer” [has the meaning
provided for that term in ORS 731.106. For purposes of ORS 743.801, 743.803,
743.804, 743.806, 743.807, 743.808, 743.811, 743.814, 743.817, 743.819,
743.821, 743.823, 743.827, 743.829, 743.831, 743.834, 743.837, 743.839, 743.854,
743.856, 743.857, 743.858, 743.859, 743.861, 743.862, 743.863, 743.864,
743.911, 743.912, 743.913, 743.917, 743A.012, 750.055 and 750.333, “insurer”
also] includes a health care service contractor as defined in ORS 750.005.
(8) “Internal appeal” means a
review by an insurer of an adverse benefit determination made by the insurer.
(9) “Managed health insurance” means
any health benefit plan that:
(a) Requires an enrollee to use a
specified network or networks of providers managed, owned, under contract with
or employed by the insurer in order to receive benefits under the plan, except
for emergency or other specified limited service; or
(b) In addition to the requirements of
paragraph (a) of this subsection, offers a point-of-service provision that allows
an enrollee to use providers outside of the specified network or networks at
the option of the enrollee and receive a reduced level of benefits.
(10) “Medical services contract” means
a contract between an insurer and an independent practice association, between
an insurer and a provider, between an independent practice association and a
provider or organization of providers, between medical or mental health
clinics, and between a medical or mental health clinic and a provider to
provide medical or mental health services. “Medical services contract” does not
include a contract of employment or a contract creating legal entities and
ownership thereof that are authorized under ORS chapter 58, 60 or 70, or other
similar professional organizations permitted by statute.
(11)(a) “Preferred provider
organization insurance” means any health benefit plan that:
(A) Specifies a preferred network of
providers managed, owned or under contract with or employed by an insurer;
(B) Does not require an enrollee to
use the preferred network of providers in order to receive benefits under the
plan; and
(C) Creates financial incentives for
an enrollee to use the preferred network of providers by providing an increased
level of benefits.
(b) “Preferred provider organization
insurance” does not mean a health benefit plan that has as its sole financial
incentive a hold harmless provision under which providers in the preferred
network agree to accept as payment in full the maximum allowable amounts that
are specified in the medical services contracts.
(12) “Prior authorization” means a
determination by an insurer prior to provision of services that the insurer
will provide reimbursement for the services. “Prior authorization” does not
include referral approval for evaluation and management services between
providers.
(13) “Provider” means a person
licensed, certified or otherwise authorized or permitted by laws of this state
to administer medical or mental health services in the ordinary course of
business or practice of a profession.
[(14)
“Stabilization” means that, within reasonable medical probability, no material
deterioration of an emergency medical condition is likely to occur.]
[(15)]
(14) “Utilization review” means a set of formal techniques used by an
insurer or delegated by the insurer designed to monitor the use of or evaluate
the medical necessity, appropriateness, efficacy or efficiency of health care
services, procedures or settings.
SECTION 27. ORS 743.804 is amended to
read:
743.804. All insurers offering a
health benefit plan in this state shall:
[(1)
Have a written policy that recognizes the rights of enrollees:]
[(a)
To voice grievances about the organization or health care provided;]
[(b)
To be provided with information about the organization, its services and the
providers providing care;]
[(c)
To participate in decision making regarding their health care; and]
[(d)
To be treated with respect and recognition of their dignity and need for
privacy.]
[(2)
Provide a summary of policies on enrollees’ rights and responsibilities to all
participating providers upon request and to all enrollees either directly or,
in the case of group coverage, to the employer or other policyholder for
distribution to enrollees.]
[(3)
Have a timely and organized system for resolving grievances and appeals. The
system shall include:]
[(a)
A systematic method for recording all grievances and appeals, including the
nature of the grievances, and significant actions taken;]
[(b)
Written procedures explaining the grievance and appeal process, including a
procedure to assist enrollees in filing written grievances;]
[(c)
Written decisions in plain language justifying grievance determinations,
including appropriate references to relevant policies, procedures and contract
terms;]
[(d)
Standards for timeliness in responding to grievances or appeals that
accommodate the clinical urgency of the situation;]
[(e)
Notice in all written decisions prepared pursuant to this subsection that the
enrollee may file a complaint with the Director of the Department of Consumer
and Business Services; and]
[(f)
An appeal process for grievances that includes at least the following:]
[(A)
Three levels of review, the second of which shall be by persons not previously
involved in the dispute and the third of which shall provide external review
pursuant to an external review program meeting the requirements of ORS 743.857,
743.859 and 743.861;]
[(B)
Opportunity for enrollees and any representatives of the enrollees to appear
before a review panel at either the first or second level of review.
Representatives may include health care providers or any other persons chosen
by the enrollee. The enrollee and insurer shall each provide advance
notification of the number of representatives who will appear before the panel
and the relationship of the representatives to the enrollee or insurer; and]
[(C)
Written decisions in plain language justifying appeal determinations, including
specific references to relevant provisions of the health benefit plan and
related written corporate practices.]
[(4)
If the insurer has a prescription drug formulary, have:]
[(a)
A written procedure by which a provider with authority to prescribe drugs and
medications may prescribe drugs and medications not included in the formulary.
The procedure shall include the circumstances when a drug or medication not
included in the formulary will be considered a covered benefit; and]
[(b)
A written procedure to provide full disclosure to enrollees of any cost sharing
or other requirements to obtain drugs and medications not included in the
formulary.]
[(5)
Furnish to all enrollees either directly or, in the case of a group policy, to
the employer or other policyholder for distribution to enrollees written
general information informing enrollees about services provided, access to
services, charges and scheduling applicable to each enrollee’s coverage,
including:]
[(a)
Benefits and services included and how to obtain them, including any
restrictions that apply to services obtained outside the insurer’s network or
outside the insurer’s service area, and the availability of continuity of care
as required by ORS 743.854;]
[(b)
Provisions for referrals, if any, for specialty care, behavioral health
services and hospital services and how enrollees may obtain the care or
services;]
[(c)
Provisions for after-hours and emergency care and how enrollees may obtain that
care, including the insurer’s policy, if any, on when enrollees should directly
access emergency care and use 9-1-1 services;]
[(d)
Charges to enrollees, if applicable, including any policy on cost sharing for
which the enrollee is responsible;]
[(e)
Procedures for notifying enrollees of:]
[(A)
A change in or termination of any benefit;]
[(B)
If applicable, termination of a primary care delivery office or site; and]
[(C)
If applicable, assistance available to enrollees affected by the termination of
a primary care delivery office or site in selecting a new primary care delivery
office or site;]
[(f)
Procedures for appealing decisions adversely affecting the enrollee’s benefits
or enrollment status;]
[(g)
Procedures, if any, for changing providers;]
[(h)
Procedures for voicing grievances, including the option of obtaining external
review under the insurer’s program established pursuant to ORS 743.857, 743.859
and 743.861;]
[(i)
A description of the procedures, if any, by which enrollees and their
representatives may participate in the development of the insurer’s corporate
policies and practices;]
[(j)
Summary information on how the insurer makes decisions regarding coverage and
payment for treatment or services, including a general description of any prior
authorization and utilization review requirements that affect coverage or
payment;]
[(k)
A summary of criteria used to determine if a service or drug is considered
experimental or investigational;]
[(L)
Information about provider, clinic and hospital networks, if any, including a
list of network providers and information about how the enrollee may obtain
current information about the availability of individual providers, the hours
the providers are available and a description of any limitations on the ability
of enrollees to select primary and specialty care providers;]
[(m)
A general disclosure of any risk-sharing arrangements the insurer has with
physicians and other providers;]
[(n)
A summary of the insurer’s procedures for protecting the confidentiality of
medical records and other enrollee information;]
[(o)
A description of any assistance provided to non-English-speaking enrollees;]
[(p)
A summary of the insurer’s policies, if any, on drug prescriptions, including
any drug formularies, cost sharing differentials or other restrictions that
affect coverage of drug prescriptions;]
[(q)
Notice of the enrollee’s right to file a complaint or seek other assistance
from the Director of the Department of Consumer and Business Services; and]
[(r)
Notice of the information that is available upon request pursuant to subsection
(6) of this section and information that is available from the Department of
Consumer and Business Services pursuant to ORS 743.804, 743.807, 743.814 and
743.817.]
[(6)
Provide the following information upon the request of an enrollee or
prospective enrollee:]
[(a)
Rules related to the insurer’s drug formulary, if any, including information on
whether a particular drug is included or excluded from the formulary;]
[(b)
Provisions for referrals, if any, for specialty care, behavioral health
services and hospital services and how enrollees may obtain the care or services;]
[(c)
A copy of the insurer’s annual report on grievances and appeals as submitted to
the department under subsection (9) of this section;]
[(d)
A description of the insurer’s risk-sharing arrangements with physicians and
other providers consistent with risk-sharing information required by the
federal Health Care Financing Administration pursuant to 42 C.F.R. 417.124
(3)(b) as in effect on June 18, 1997;]
[(e)
A description of the insurer’s efforts, if any, to monitor and improve the
quality of health services;]
[(f)
Information about any insurer procedures for credentialing network providers
and how to obtain the names, qualifications and titles of the providers
responsible for an enrollee’s care; and]
[(g)
A description of the insurer’s external review program established pursuant to
ORS 743.857, 743.859 and 743.861.]
[(7)
Except as otherwise provided in this subsection, provide to enrollees, upon
request, a written summary of information that the insurer may consider in its
utilization review of a particular condition or disease to the extent the
insurer maintains such criteria. Nothing in this section shall require an
insurer to advise an enrollee how the insurer would cover or treat that
particular enrollee’s disease or condition. Utilization review criteria that is
proprietary shall be subject to verbal disclosure only.]
[(8)
Provide the following information to an enrollee when the enrollee has filed a
grievance:]
[(a)
Detailed information on the insurer’s grievance and appeal procedures and how
to use them;]
[(b)
Information on how to access the complaint line of the Department of Consumer
and Business Services; and]
[(c)
Information explaining how an enrollee applies for external review of the
insurer’s actions under the external review program established by the insurer
pursuant to ORS 743.857.]
[(9)
Provide annual summaries to the Department of Consumer and Business Services of
the insurer’s aggregate data regarding grievances, appeals and applications for
external review in a format prescribed by the department to ensure consistent
reporting on the number, nature and disposition of grievances, appeals and
applications for external review.]
[(10)
Ensure that the confidentiality of specified patient information and records is
protected, and to that end:]
[(a)
Adopt and implement written confidentiality policies and procedures;]
[(b)
State the insurer’s expectations about the confidentiality of enrollee
information and records in medical service contracts; and]
[(c)
Afford enrollees the opportunity to approve or deny the release of identifiable
medical personal information by the insurer, except as otherwise permitted or
required by law.]
[(11)
Notify an enrollee of the enrollee’s rights under the health benefit plan at
the time that the insurer notifies the enrollee of an adverse decision. The
notification shall include:]
[(a)
Notice of the right of the enrollee to apply for internal and external review
of the adverse decision;]
[(b)
A statement whether a decision by an independent review organization is binding
on the insurer and enrollee;]
[(c)
A statement that if the decision is not binding on the insurer and if the
insurer does not comply with the decision, the enrollee may sue the insurer as
provided in ORS 743.864; and]
[(d)
Information on filing a complaint with the Director of the Department of
Consumer and Business Services.]
(1) Provide to all enrollees
directly or in the case of a group policy to the employer or other policyholder
for distribution to enrollees, to all applicants, and to prospective applicants
upon request, the following information:
(a) The insurer’s written policy on
the rights of enrollees, including the right:
(A) To participate in decision making
regarding the enrollee’s health care.
(B) To be treated with respect and
with recognition of the enrollee’s dignity and need for privacy.
(C) To have grievances handled in
accordance with this section.
(D) To be provided with the
information described in this section.
(b) An explanation of the procedures
described in subsection (2) of this section for making coverage determinations
and resolving grievances. The explanation must be culturally and linguistically
appropriate, as prescribed by the department by rule, and must include:
(A) The procedures for requesting an
expedited response to an internal appeal under subsection (2)(d) of this
section or for requesting an expedited external review of an adverse benefit
determination;
(B) A statement that if an insurer
does not comply with the decision of an independent review organization under
ORS 743.862, the enrollee may sue the insurer under ORS 743.864;
(C) The procedure to obtain assistance
available from the insurer, if any, and from the Department of Consumer and
Business Services in filing grievances; and
(D) A description of the process for
filing a complaint with the department.
(c) A summary of benefits and an
explanation of coverage in a form and manner prescribed by the department by
rule.
(d) A summary of the insurer’s
policies on prescription drugs, including:
(A) Cost-sharing differentials;
(B) Restrictions on coverage;
(C) Prescription drug formularies;
(D) Procedures by which a provider
with prescribing authority may prescribe drugs not included on the formulary;
(E) Procedures for the coverage of
prescription drugs not included on the formulary; and
(F) A summary of the criteria for
determining whether a drug is experimental or investigational.
(e) A list of network providers and
how the enrollee can obtain current information about the availability of
providers and how to access and schedule services with providers, including
clinic and hospital networks.
(f) Notice of the enrollee’s right to
select a primary care provider and specialty care providers.
(g) How to obtain referrals for
specialty care in accordance with ORS 743.856.
(h) Restrictions on services obtained
outside of the insurer’s network or service area.
(i) The availability of continuity of
care as required by ORS 743.854.
(j) Procedures for accessing
after-hours care and emergency services as required by ORS 743A.012.
(k) Cost-sharing requirements and
other charges to enrollees.
(L) Procedures, if any, for changing
providers.
(m) Procedures, if any, by which
enrollees may participate in the development of the insurer’s corporate
policies.
(n) A summary of how the insurer makes
decisions regarding coverage and payment for treatment or services, including a
general description of any prior authorization and utilization control
requirements that affect coverage or payment.
(o) Disclosure of any risk-sharing
arrangement the insurer has with physicians or other providers.
(p) A summary of the insurer’s
procedures for protecting the confidentiality of medical records and other
enrollee information.
(q) An explanation of assistance
provided to non-English-speaking enrollees.
(r) Notice of the information
available from the department that is filed by insurers as required under ORS
743.807, 743.814 and 743.817.
(2) Establish procedures for making
coverage determinations and resolving grievances that provide for all of the
following:
(a) Timely notice of adverse benefit
determinations in a form and manner approved by the department or prescribed by
the department by rule.
(b) A method for recording all
grievances, including the nature of the grievance and significant action taken.
(c) Written decisions meeting criteria
established by the Director of the Department of Consumer and Business Services
by rule.
(d) An expedited response to a request
for an internal appeal that accommodates the clinical urgency of the situation.
(e) At least one but not more than two
levels of internal appeal for group health benefit plans and one level of
internal appeal for individual and portability health benefit plans. If an
insurer provides:
(A) Two levels of internal appeal, a
person who was involved in the consideration of the initial denial or the first
level of internal appeal may not be involved in the second level of internal
appeal; and
(B) No more than one level of internal
appeal, a person who was involved in the consideration of the initial denial
may not be involved in the internal appeal.
(f)(A) An external review that meets
the requirements of ORS 743.857, 743.859 and 743.861 and is conducted in a
manner approved by the department or prescribed by the department by rule,
after the enrollee has exhausted internal appeals or after the enrollee has
been deemed to have exhausted internal appeals.
(B) An enrollee shall be deemed to
have exhausted internal appeals if an insurer fails to strictly comply with
this section and federal requirements for internal appeals.
(g) The opportunity for the enrollee
to receive continued coverage under the health benefit plan pending the
conclusion of the internal appeal process.
(h) The opportunity for the enrollee
or any authorized representative chosen by the enrollee to:
(A) Submit for consideration by the
insurer any written comments, documents, records and other materials relating
to the adverse benefit determination; and
(B) Receive from the insurer, upon
request and free of charge, reasonable access to and copies of all documents,
records and other information relevant to the adverse benefit determination.
(3) Establish procedures for notifying
affected enrollees of:
(a) A change in or termination of any
benefit; and
(b)(A) The termination of a primary
care delivery office or site; and
(B) Assistance available to enrollees
in selecting a new primary care delivery office or site.
(4) Provide the information described
in subsection (2) of this section and ORS 743.859 at each level of internal
appeal to an enrollee who is notified of an adverse benefit determination or to
an enrollee who files a grievance.
(5) Upon the request of an enrollee,
applicant or prospective applicant, provide:
(a) The insurer’s annual report on
grievances and internal appeals submitted to the department under subsection
(8) of this section.
(b) A description of the insurer’s
efforts, if any, to monitor and improve the quality of health services.
(c) Information about the insurer’s
procedures for credentialing network providers.
(6) Provide, upon the request of an
enrollee, a written summary of information that the insurer may consider in its
utilization review of a particular condition or disease, to the extent the
insurer maintains such criteria. Nothing in this subsection requires an insurer
to advise an enrollee how the insurer would cover or treat that particular
enrollee’s disease or condition. Utilization review criteria that are
proprietary shall be subject to oral disclosure only.
(7) Maintain for a period of at least
six years written records that document all grievances described in ORS 743.801
(4)(a) and make the written records available for examination by the department
or by an enrollee or authorized representative of an enrollee with respect to a
grievance made by the enrollee. The written records must include but are not
limited to the following:
(a) Notices and claims associated with
each grievance.
(b) A general description of the reason
for the grievance.
(c) The date the grievance was
received by the insurer.
(d) The date of the internal appeal or
the date of any internal appeal meeting held concerning the appeal.
(e) The result of the internal appeal
at each level of appeal.
(f) The name of the covered person for
whom the grievance was submitted.
(8) Provide an annual summary to the
department of the insurer’s aggregate data regarding grievances, internal
appeals and requests for external review in a format prescribed by the department
to ensure consistent reporting on the number, nature and disposition of
grievances, internal appeals and requests for external review.
(9) Allow the exercise of any rights
described in this section by an authorized representative.
SECTION 28. ORS 743.806 is amended to
read:
743.806. All utilization review
performed pursuant to a medical services contract to which an insurer is not a
party shall comply with the following:
(1) The criteria used in the review
process and the method of development of the criteria shall be made available
for review to a party to such medical services contract upon request.
(2) A doctor of medicine or osteopathy
licensed under ORS chapter 677 shall be responsible for all final
recommendations regarding the necessity or appropriateness of services or the
site at which the services are provided and shall consult as appropriate with
medical and mental health specialists in making such recommendations.
(3) Any [patient or] provider who has had a request for treatment or payment
for services denied as not medically necessary or as experimental shall be
provided an opportunity for a timely appeal before an appropriate medical
consultant or peer review committee.
(4) A provider request for prior
authorization of nonemergency service must be answered within two business
days, and qualified health care personnel must be available for same-day
telephone responses to inquiries concerning certification of continued length
of stay.
SECTION 29. ORS 743.807 is amended to
read:
743.807. (1) All insurers offering a
health benefit plan in this state that provide utilization review or have
utilization review provided on their behalf shall file an annual summary with
the Department of Consumer and Business Services that describes all utilization
review policies, including delegated utilization review functions, and
documents the insurer’s procedures for monitoring of utilization review
activities.
(2) All utilization review activities
conducted pursuant to subsection (1) of this section shall comply with the
following:
(a) The criteria used in the
utilization review process and the method of development of the criteria shall
be made available for review to contracting providers upon request.
(b) A doctor of medicine or osteopathy
licensed under ORS chapter 677 shall be responsible for all final
recommendations regarding the necessity or appropriateness of services or the
site at which the services are provided and shall consult as appropriate with
medical and mental health specialists in making such recommendations.
(c) Any [patient or] provider who has had a request for treatment or payment
for services denied as not medically necessary or as experimental shall be
provided an opportunity for a timely appeal before an appropriate medical
consultant or peer review committee.
(d) A provider request for prior
authorization of nonemergency service must be answered within two business
days, and qualified health care personnel must be available for same-day
telephone responses to inquiries concerning certification of continued length
of stay.
SECTION 30. ORS 743.845 is amended to
read:
743.845. (1) [For purposes of this section:]
[(a)
“Pregnancy care” means the care necessary to support a healthy pregnancy and
care related to labor and delivery.]
[(b)]
As used in this section, “women’s health care provider” means an
obstetrician or gynecologist, physician assistant specializing in women’s
health, advanced registered nurse practitioner specialist in women’s health or
certified nurse midwife, practicing within the applicable lawful scope of
practice.
(2) Every health insurance policy that
covers hospital, medical or surgical expenses and requires an enrollee to
designate a participating primary care provider shall permit a female enrollee
to designate a women’s health care provider as the enrollee’s primary care
provider if:
(a) The women’s health care provider
meets the standards established by the insurer in collaboration with interested
parties, including but not limited to the Oregon section of the American
College of Obstetricians and Gynecologists; and
(b) The women’s health care provider
requests that the insurer make the provider available for designation as a
primary care provider.
(3) If a female enrollee has
designated a primary care provider who is not a women’s health care provider,
an insurance policy as described in subsection (2) of this section shall permit
the enrollee to have direct access to a women’s health care provider [for the following services:], without
a referral or prior authorization, for obstetrical or gynecological care by a
participating health care professional who specializes in obstetrics or
gynecology.
[(a)
At least one annual preventative women’s health examination;]
[(b)
Medically necessary follow-up visits resulting from a preventative women’s
health examination. A health plan may require the women’s health care provider
to notify and consult with the enrollee’s primary care provider; and]
[(c)
Pregnancy care.]
(4) The standards established by the
insurer under subsection (2) of this section shall not prohibit an insurer from
establishing the maximum number of participating primary care providers and
participating women’s health care providers necessary to serve a defined
population or geographic service area.
SECTION 31. ORS 743.857 is amended to
read:
743.857. (1) An insurer offering
health benefit plans in this state shall have an external review program that
meets the requirements of this section and ORS [743.859 and] 743.861 and rules adopted by the Director of the
Department of Consumer and Business Services to carry out the provisions of
this section and ORS 743.861. Each insurer shall provide the external
review through an independent review organization that is under contract with
the director [of the Department of
Consumer and Business Services] to provide external review. Each health
benefit plan must allow an enrollee, by applying to the insurer or the
director, to obtain review by an independent review organization of a
dispute relating to an adverse [decision]
benefit determination by the insurer on one or more of the following:
(a) Whether a course or plan of
treatment is medically necessary.
(b) Whether a course or plan of
treatment is experimental or investigational.
(c) Whether a course or plan of
treatment that an enrollee is undergoing is an active course of treatment for
purposes of continuity of care under ORS 743.854.
(d) Whether a course or plan of
treatment is delivered in an appropriate health care setting and with the appropriate
level of care.
(2) An insurer shall incur all costs
of its external review program. The insurer may not establish or charge a fee
payable by enrollees for conducting external review.
(3) When an enrollee applies for
external review, the [insurer shall
request the director to] director shall appoint an independent
review organization. When an independent review organization is appointed, the
insurer shall forward all medical records and other relevant materials to the
independent review organization [and]
no later than five business days after the appointment. The insurer shall
produce additional information as requested by the independent review
organization to the extent that the information is reasonably available to the
insurer. [The insurer shall furnish all
such records, materials and information in a timely manner in order to enable a
timely decision by the independent review organization. The director may
establish timelines for the purpose of this subsection.] An independent
review organization may reverse the adverse benefit determination if the
insurer fails to furnish records, information and materials to the independent
review organization in a timely manner.
(4) An enrollee may submit additional
information to the independent review organization no later than five business
days after the enrollee’s receipt of notification of the appointment of the
independent review organization and the organization must consider the
information in its review.
(5) The insurer and the director shall
expedite the external review:
(a) If the adverse benefit
determination concerns an admission, the availability of care, a continued stay
or a health care service for a medical condition for which the enrollee
received emergency services, as defined in ORS 743A.012, and has not been
discharged from a health care facility; or
[(4)]
(b) [An insurer shall expedite an
enrollee’s case] If a provider with an established clinical relationship to
the enrollee certifies in writing and provides supporting documentation that
the ordinary time period for external review would seriously jeopardize the
life or health of the enrollee or the enrollee’s ability to regain maximum
function.
SECTION 32. ORS 743.859 is amended to
read:
743.859. [(1)] An insurer of a health benefit plan shall include in the plan
the following statements, in boldfaced type or otherwise emphasized:
[(a)]
(1) A statement of the right of enrollees to apply for external review by
an independent review organization; and
[(b)
A statement of whether the insurer agrees to be bound by decisions of
independent review organizations.]
[(2)
If an insurer states in the health benefit plan as provided in subsection (1)
of this section that the insurer is not bound by the decisions of independent
review organizations, the plan and the written information provided by the plan
must prominently disclose that:]
[(a)
The insurer is not bound by the decisions of independent review organizations;]
[(b)
The insurer may follow nonetheless a decision by an independent review
organization; and]
[(c)]
(2) A statement that if the insurer does not follow a decision of an
independent review organization, the enrollee has the right to sue the insurer.
[(3)
If an insurer states in the health benefit plan as provided in subsection (1)
of this section that the insurer is bound by the decisions of independent
review organizations, the plan must prominently disclose that fact. The plan
must also state that the insurer agrees to act in accordance with the decision
of the independent review organization notwithstanding the definition of
medical necessity in the plan.]
SECTION 33. ORS 743.861 is amended to
read:
743.861. (1) An enrollee shall apply
in writing for external review of an adverse [decision] benefit determination by the insurer of a health
benefit plan not later than the 180th day after receipt of the insurer’s final
written decision following its grievance and internal [review through its grievance and] appeal
process under ORS 743.804. An enrollee is eligible for external review only if
the enrollee has satisfied the following requirements:
(a) The enrollee must have signed a
waiver granting the independent review organization access to the medical
records of the enrollee.
(b) The enrollee must have exhausted
the plan’s internal [grievance]
appeal procedures established pursuant to ORS 743.804or be deemed to
have exhausted the plan’s internal appeal procedures. The insurer may waive
the requirement of compliance with the internal [grievance] appeal procedures and have a dispute referred
directly to external review upon the enrollee’s consent. An enrollee is
deemed to have exhausted the internal appeal procedures if the insurer fails to
strictly comply with ORS 743.804 and federal requirements for internal appeals.
(2) An enrollee who applies for
external review of an adverse [decision]
benefit determination shall provide complete and accurate information to
the independent review organization [in a
timely manner] as provided in ORS 743.857.
SECTION 34. ORS 743.862 is amended to
read:
743.862. (1) An independent review
organization shall perform the following duties when appointed under ORS
743.857 to review a dispute under a health benefit plan between an insurer and
an enrollee:
(a) Decide whether the dispute [is covered by the conditions established in
ORS 743.857 for external review] pertains to an adverse benefit
determination and notify the enrollee and insurer in writing of the
decision. If the decision is against the enrollee, the independent review
organization shall notify the enrollee of the right to file a complaint with or
seek other assistance from the [Director
of the] Department of Consumer and Business Services and the availability
of other assistance as specified by the [director]
department.
(b) Appoint a reviewer or reviewers as
determined appropriate by the independent review organization.
(c) Notify the enrollee of information
that the enrollee is required to provide and any additional information the
enrollee may provide, and when the information must be submitted as provided
in ORS 743.857.
(d) Notify the insurer of additional
information the independent review organization requires and when the
information must be submitted as provided in ORS 743.857.
(e) Decide the dispute relating to the
adverse [decision] benefit
determination of the insurer [under
ORS 743.857 (1)] and issue the decision in writing.
(2) A decision by an independent
review organization shall be based on expert medical judgment after
consideration of the enrollee’s medical record, the recommendations of each of
the enrollee’s providers, relevant medical, scientific and cost-effectiveness
evidence and standards of medical practice in the United States. An independent
review organization must make its decision in accordance with the coverage
described in the health benefit plan, except that the independent review
organization may override the insurer’s standards for medically necessary or
experimental or investigational treatment if the independent review
organization determines that the standards of the insurer are unreasonable or
are inconsistent with sound medical practice.
(3) When review is expedited, the
independent review organization shall issue a decision not later than the third
day after the date on which the enrollee applies to the insurer for an
expedited review or the Director of the Department of Consumer and Business
Services orders an expedited review.
(4) When a review is not expedited,
the independent review organization shall issue a decision not later than the
30th day after the enrollee applies to the insurer for a review or the
director orders a review.
(5) An independent review organization
shall file synopses of its decisions with the director according to the format
and other requirements established by the director. The synopses shall exclude
information that is confidential, that is otherwise exempt from disclosure
under ORS 192.501 and 192.502 or that may otherwise allow identification of an
enrollee. The director shall make the synopses public.
SECTION 35. ORS 743.863 is amended to
read:
743.863. (1) An insurer shall
comply in a timely manner with a decision of an independent review organization
under ORS 743.862 that reverses, in whole or in part, an adverse benefit
determination. If an insurer [has
agreed under the provisions of a health benefit plan to be bound by the
decision of an independent review organization and the insurer fails to comply
with such a decision] fails to comply with the decision, the
Director of the Department of Consumer and Business Services [shall] may impose on the insurer
a civil penalty of [not less than
$100,000 and] not more than $1 million.
(2) A decision of an independent
review organization is admissible in any legal proceeding involving the insurer
or the enrollee and involving the disputed issues subject to external review.
(3) The sanctions under subsection (1)
of this section and the remedies under subsection (2) of this section are in
addition to and not in lieu of other sanctions, rights and remedies provided by
law or contract.
SECTION 36. ORS 743.864 is amended to
read:
743.864. (1) An enrollee who is the
subject of a decision of an independent review organization has a private right
of action against the insurer for damages arising from an adverse [decision] benefit determination
by the insurer that is subject to external review if[:]
[(a)
The insurer states in the health benefit plan in which the enrollee is enrolled
that the insurer is not bound by the decisions of an independent review
organization; and]
[(b)]
the insurer fails to comply with the decision.
(2) The Legislative Assembly intends
that there is no private right of action under subsection (1) of this section
if a court finds [either subsection
(1)(a) or (b)] subsection (1) of this section to be unconstitutional
or otherwise void.
SECTION 37. ORS 743.878 is amended to
read:
743.878. [(1)] An insurer offering a health benefit plan as defined in ORS
743.730 must submit to the Director of the Department of Consumer and Business
Services:
[(a)]
(1) Upon request by the director, the methodology used to determine the
insurer’s allowable charges for out-of-network procedures and services or, if
the insurer uses a third party to determine the charges, the methodology used
by the third party to determine allowable charges;
[(b)]
(2) For approval, a written explanation of the method used by the insurer
to determine the allowable charge, that is in plain language and that must be
provided upon request to enrollees directly, or, in the case of group coverage,
to the employer or other policyholder for distribution to enrollees; and
[(c)]
(3) Information prescribed by the director as necessary to assess the
effect of the disclosure requirements in ORS 743.874 and 743.876 on the
individual and group health insurance markets.
[(2)
The director shall consider the recommendations of the Health Insurance Reform
Advisory Committee in prescribing the information required for submission under
subsection (1)(c) of this section.]
SECTION 38. ORS 743A.012 is amended
to read:
743A.012. (1) As used in this
section:
(a) “Emergency medical condition”
means a medical condition:
(A) That manifests itself by acute
symptoms of sufficient severity, including severe pain, that a prudent
layperson possessing an average knowledge of health and medicine would
reasonably expect that failure to receive immediate medical attention would:
(i) Place the health of a person, or
an unborn child in the case of a pregnant woman, in serious jeopardy;
(ii) Result in serious impairment to
bodily functions; or
(iii) Result in serious dysfunction of
any bodily organ or part; or
(B) With respect to a pregnant woman
who is having contractions, for which there is inadequate time to effect a safe
transfer to another hospital before delivery or for which a transfer may pose a
threat to the health or safety of the woman or the unborn child.
(b) “Emergency medical screening exam”
means the medical history, examination, ancillary tests and medical
determinations required to ascertain the nature and extent of an emergency
medical condition.
(c) “Emergency services” means, with
respect to an emergency medical condition:
(A) An emergency medical screening
exam that is within the capability of the emergency department of a hospital,
including ancillary services routinely available to the emergency department to
evaluate such emergency medical condition; and
(B) Such further medical examination
and treatment as are required under 42 U.S.C. 1395dd to stabilize a patient, to
the extent the examination and treatment are within the capability of the staff
and facilities available at a hospital.
(d) “Grandfathered health plan” has
the meaning given that term in ORS 743.730.
(e) “Health benefit plan” has the
meaning given that term in ORS 743.730.
(f) “Prior authorization” has the
meaning given that term in ORS 743.801.
(g) “Stabilize” means to provide
medical treatment as necessary to:
(A) Ensure that, within reasonable
medical probability, no material deterioration of an emergency medical condition
is likely to occur during or to result from the transfer of the patient from a
facility; and
(B) With respect to a pregnant women
who is in active labor, to perform the delivery, including the delivery of the
placenta.
[(1)]
(2) All insurers offering a health benefit plan shall provide coverage
without prior authorization for[:]
[(a)]
emergency [medical screening exams;]
services.
(3) A health benefit plan, other than
a grandfathered health plan, must provide coverage required by subsection (2)
of this section:
(a) For the services of participating
providers,
without regard
to any term or condition of coverage other than:
(A) The coordination of benefits;
(B) An affiliation period or waiting
period permitted under part 7 of the Employee Retirement Income Security Act,
part A of Title XXVII of the Public Health Service Act or chapter 100 of the
Internal Revenue Code;
(C) An exclusion other than an
exclusion of emergency services; or
(D) Applicable cost-sharing; and
[(b)
Stabilization of an emergency medical condition; and]
[(c)
Emergency services provided by a nonparticipating provider if a prudent
layperson possessing an average knowledge of health and medicine would
reasonably believe that the time required to go to a participating provider would
place the health of the person, or a fetus in the case of a pregnant woman, in
serious jeopardy.]
(b) For the services of a
nonparticipating provider:
(A) Without imposing any
administrative requirement or limitation on coverage that is more restrictive
than requirements or limitations that apply to participating providers;
(B) Without imposing a copayment
amount or coinsurance rate that exceeds the amount or rate for participating
providers;
(C) Without imposing a deductible,
unless the deductible applies generally to nonparticipating providers; and
(D) Subject only to an out-of-pocket
maximum that applies to all services from nonparticipating providers.
[(2)]
(4) All insurers [described in
subsection (1) of this section] offering a health benefit plan shall
provide information to enrollees in plain language regarding:
(a) What constitutes an emergency
medical condition;
(b) The coverage provided for
emergency services;
(c) How and where to obtain emergency
services; and
(d) The appropriate use of 9-1-1.
[(3)]
(5) An insurer offering a health benefit plan may not discourage
appropriate use of 9-1-1 and [shall]
may not deny coverage for emergency services solely because 9-1-1 was used.
[(4)]
(6) This section is exempt from ORS 743A.001.
SECTION 39. ORS 743A.080 is amended
to read:
743A.080. (1) As used in this
section, “pregnancy care” means the care necessary to support a healthy
pregnancy and care related to labor and delivery.
(2) All
health benefit plans as defined in ORS 743.730 must provide payment or
reimbursement for expenses associated with pregnancy care[, as defined by ORS 743.845,] and childbirth. Benefits provided
under this section shall be extended to all enrollees, enrolled spouses and
enrolled dependents.
SECTION 40. ORS 743A.090 is amended
to read:
743A.090. (1) All individual and group
health [insurance policies providing
hospital, medical or surgical expense benefits] benefit plans, as
defined in ORS 743.730, 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] 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] natural and adopted
children required by subsection (1) of this section shall consist of coverage of
preventive health services and treatment of injury or sickness, including
the necessary care and treatment of medically diagnosed congenital defects and
birth abnormalities.
(3) If payment of [a specific] an additional 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 to the insurer within 31 days
after the date of birth or date of placement in order to effectuate the
coverage required by this section and 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, the policy shall provide benefits to dependent
children placed with participants or beneficiaries for adoption under the same
terms and conditions as apply to the natural, dependent children of the
participants and beneficiaries, 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, or placed with a participant or beneficiary 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 is eligible for coverage under the plan.]
(5) This section does not prohibit
an insurer from denying or limiting coverage based on a preexisting condition
of a child who is 19 years of age or older.
[(5)]
(6) 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.]
(a) “Child” means an individual who
is under 26 years of age.
(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 41. ORS 743A.110 is amended
to read:
743A.110. (1) All insurers offering a
health benefit plan as defined in ORS 743.730 shall provide payment, coverage
or reimbursement for the following mastectomy-related services as determined by
the attending physician and enrollee to be part of the enrollee’s course or
plan of treatment:
(a) All stages of reconstruction of
the breast on which a mastectomy was performed, including but not limited to
nipple reconstruction, skin grafts and stippling of the nipple and areola;
(b) Surgery and reconstruction of the
other breast to produce a symmetrical appearance;
(c) Prostheses;
(d) Treatment of physical
complications of the mastectomy, including lymphedemas; and
(e) Inpatient care related to the
mastectomy and post-mastectomy services.
(2) An insurer providing coverage
under subsection (1) of this section shall provide written notice describing
the coverage to the enrollee at the time of enrollment in the health benefit
plan and annually thereafter.
(3) A health benefit plan must provide
a single determination of prior authorization for all mastectomy-related
services covered under subsection (1) of this section that are part of the
enrollee’s course or plan of treatment.
(4) When an enrollee requests an
external review of an adverse [decision]
benefit determination as defined in ORS 743.801by the insurer regarding
services described in subsection (1) of this section, the insurer or the
Director of the Department of Consumer and Business Services must expedite
the enrollee’s case pursuant to ORS 743.857 [(4)] (5).
(5) The coverage required under
subsection (1) of this section is subject to the same terms and conditions in
the plan that apply to other benefits under the plan.
(6) This section is exempt from ORS
743A.001.
SECTION 42. ORS 746.650 is amended to
read:
746.650. Except as otherwise
provided in ORS 743.804, 743.806, 743.857 and 743.861:
(1) In the event of an adverse
underwriting decision, the insurer or insurance producer responsible for the
decision must:
(a) Either provide the consumer proposed
for coverage with the specific reason or reasons for the adverse underwriting
decision in writing or advise the consumer that upon written request the
consumer may receive the specific reason or reasons in writing; and
(b) Provide the consumer proposed for
coverage with a summary of the rights established under subsection (2) of this
section and ORS 746.640 and 746.645.
(2) Upon receipt of a written request
within 90 business days from the date of the mailing of notice or other
communication of an adverse underwriting decision to a consumer proposed for
coverage, the insurer or insurance producer shall furnish to the consumer
within 21 business days from the date of receipt of the written request:
(a) The specific reason or reasons for
the adverse underwriting decision, in writing, if this information was not
initially furnished in writing pursuant to subsection (1) of this section;
(b) The specific items of personal
information and privileged information that support these reasons, subject to
the following:
(A) The insurer or insurance producer
is not required to furnish specific items of privileged information if the
insurer or insurance producer has a reasonable suspicion, based upon specific
information available for review by the Director of the Department of Consumer
and Business Services, that the consumer proposed for coverage has engaged in
criminal activity, fraud, material misrepresentation or material nondisclosure;
and
(B) Specific items of individually
identifiable health information supplied by a health care provider shall be
disclosed either directly to the consumer about whom the information relates or
to a health care provider designated by the consumer and licensed to provide
health care with respect to the condition to which the information relates,
whichever the insurer or insurance producer prefers; and
(c) The names and addresses of the
institutional sources that supplied the specific items of information described
in paragraph (b) of this subsection. However, the identity of any health care
provider must be disclosed either directly to the consumer or to the designated
health care provider, whichever the insurer or insurance producer prefers.
(3) The obligations imposed by this
section upon an insurer or insurance producer may be satisfied by another
insurer or insurance producer authorized to act on its behalf.
(4) When an adverse underwriting
decision results solely from an oral request or inquiry, the explanation of
reasons and summary of rights required by subsection (1) of this section may be
given orally.
(5) Notwithstanding subsection (1) of
this section, when an adverse underwriting decision is based in whole or in
part on credit history or insurance score, the insurer or insurance producer
responsible for the decision must provide the consumer proposed for coverage
with the specific reason or reasons for the adverse underwriting decision in
writing. The notice must include the following:
(a) A summary of no more than four of
the most significant credit reasons for the adverse underwriting decision,
listed in decreasing order of importance, that clearly identifies the specific
credit history or insurance score used to make the adverse underwriting
decision. An insurer or insurance producer may not use “poor credit history” or
a similar phrase as a reason for an adverse underwriting decision.
(b) The name, address and telephone
number, including a toll-free telephone number, of the consumer reporting
agency that provided the information for the consumer report.
(c) A statement that the consumer
reporting agency used by the insurer or insurance producer to obtain the credit
history of the consumer did not make the adverse underwriting decision and is
unable to provide the consumer with specific reasons why the insurer or
insurance producer made an adverse underwriting decision.
(d) Information on the right of the
consumer:
(A) To obtain a free copy of the
consumer’s consumer report from the consumer reporting agency described in
paragraph (b) of this subsection, including the deadline, if any, for obtaining
a copy; and
(B) To dispute the accuracy or
completeness of any information in a consumer report furnished by the consumer
reporting agency.
(6) Notwithstanding subsection (1) of
this section, an insurer or insurance producer responsible for an adverse
underwriting decision that is based in whole or in part on credit history or
insurance score must provide the notice required by subsection (5) of this
section only when the insurer or insurance producer makes the initial adverse
underwriting decision regarding a consumer.
(7) Notwithstanding subsection (1) of
this section, when an adverse underwriting decision relating to homeowner
insurance is based in whole or in part on a loss history report, the insurer or
insurance producer responsible for the decision must provide the consumer
proposed for coverage with the specific reason or reasons for the adverse
underwriting decision in writing. The notice must include the following:
(a) A description of a specific claim
or claims that are the basis for the specific loss history report used to make
the adverse underwriting decision.
(b) The name, address and telephone
number, including a toll-free telephone number, of the consumer reporting
agency that provided the information for the loss history report.
(c) A statement that the consumer
reporting agency used by the insurer or insurance producer to obtain the loss
history report of the consumer did not make the adverse underwriting decision
and is unable to provide the consumer with specific reasons why the insurer or
insurance producer made an adverse underwriting decision.
(d) Information on the right of the
consumer:
(A) To obtain a free copy of the
consumer’s loss history report from the consumer reporting agency described in
paragraph (b) of this subsection, including the deadline, if any, for obtaining
a copy; and
(B) To dispute the accuracy or
completeness of any information in a loss history report furnished by the
consumer reporting agency.
(8) When an adverse underwriting
decision relating to homeowner insurance is based in part on credit history and
in part on a loss history report, the insurer or insurance producer responsible
for the adverse underwriting decision may provide the notices required by
subsections (5) and (7) of this section in a single notice.
SECTION 42a. ORS 743A.141 is amended
to read:
743A.141. (1) As used in this section,
“hearing aid” means any nondisposable, wearable instrument or device designed
to aid or compensate for impaired human hearing and any necessary ear mold,
part, attachments or accessory for the instrument or device, except batteries
and cords.
(2) A health benefit plan, as defined
in ORS 743.730, shall provide payment, coverage or reimbursement for one
hearing aid per hearing impaired ear if:
(a) Prescribed, fitted and dispensed
by a licensed audiologist with the approval of a licensed physician; and
(b) Necessary for the treatment of
hearing loss in an enrollee in the plan who is:
(A) [Under] 18 years of age or younger; or
(B) [18 years of age or older, eligible as a dependent under the plan]
19 to 25 years of age and enrolled in a secondary school or an
accredited educational institution.
(3)(a) The maximum benefit amount
required by this section is $4,000 every 48 months, but a health benefit plan
may offer a benefit that is more favorable to the enrollee. The benefit amount
shall be adjusted on January 1 of each year to reflect the increase since
January 1, 2010, in the U.S. City Average Consumer Price Index for All Urban
Consumers for medical care as published by the Bureau of Labor Statistics of
the United States Department of Labor.
(b) A health benefit plan may not
impose any financial or contractual penalty upon an audiologist if an enrollee
elects to purchase a hearing aid priced higher than the benefit amount by
paying the difference between the benefit amount and the price of the hearing
aid.
(4) A health benefit plan may subject
the payment, coverage or reimbursement required under this section to
provisions of the plan that apply to other durable medical equipment benefits
covered by the plan, including but not limited to provisions relating to
deductibles, coinsurance and prior authorization.
(5) This section is exempt from ORS
743A.001.
SECTION 43. ORS 750.055 is amended to
read:
750.055. (1) The following provisions
of the Insurance Code apply to health care service contractors to the extent
not inconsistent with the express provisions of ORS 750.005 to 750.095:
(a) ORS 705.137, 705.139, 731.004 to
731.150, 731.162, 731.216 to 731.362, 731.382, 731.385, 731.386, 731.390,
731.398 to 731.430, 731.428, 731.450, 731.454, 731.488, 731.504, 731.508,
731.509, 731.510, 731.511, 731.512, 731.574 to 731.620, 731.592, 731.594,
731.640 to 731.652, 731.730, 731.731, 731.735, 731.737, 731.750, 731.752,
731.804, 731.844 to 731.992 and 731.870.
(b) ORS 732.215, 732.220, 732.230,
732.245, 732.250, 732.320, 732.325 and 732.517 to 732.592, not including ORS
732.582.
(c) ORS 733.010 to 733.050, 733.080,
733.140 to 733.170, 733.210, 733.510 to 733.680 and 733.695 to 733.780.
(d) ORS chapter 734.
(e) ORS 742.001 to 742.009, 742.013,
742.061, 742.065, 742.150 to 742.162, 742.400, 742.520 to 742.540, 743.010,
743.013, 743.018 to 743.030, 743.050, 743.100 to 743.109, 743.402, 743.472,
743.492, 743.495, 743.498, 743.522, 743.523, 743.524, 743.526, 743.527,
743.528, 743.529, 743.549 to 743.552, 743.560, 743.600 to 743.610, 743.650 to
743.656, 743.804, 743.807, 743.808, 743.814 to 743.839, 743.842, 743.845,
743.847, 743.854, 743.856, 743.857, 743.858, 743.859, 743.861, 743.862,
743.863, 743.864, 743.911, 743.912, 743.913, 743.917, 743A.010, 743A.012,
743A.020, 743A.036, 743A.048, 743A.058, 743A.062, 743A.064, 743A.066, 743A.068,
743A.070, 743A.080, 743A.084, 743A.088, 743A.090, 743A.100, 743A.104, 743A.105,
743A.110, 743A.140, 743A.141, 743A.144, 743A.148, 743A.160, 743A.164, 743A.168,
743A.170, 743A.175, 743A.184, 743A.188, 743A.190 and 743A.192 and sections
2, 4 and 4a of this 2011 Act.
(f) The provisions of ORS chapter 744
relating to the regulation of insurance producers.
(g) ORS 746.005 to 746.140, 746.160,
746.220 to 746.370, 746.600, 746.605, 746.607, 746.608, 746.610, 746.615,
746.625, 746.635, 746.650, 746.655, 746.660, 746.668, 746.670, 746.675, 746.680
and 746.690.
(h) ORS 743A.024, except in the case
of group practice health maintenance organizations that are federally qualified
pursuant to Title XIII of the Public Health Service Act unless the patient is
referred by a physician associated with a group practice health maintenance
organization.
(i) ORS 735.600 to 735.650.
(j) ORS 743.680 to 743.689.
(k) ORS 744.700 to 744.740.
(L) ORS 743.730 to 743.773.
(m) ORS 731.485, except in the case of
a group practice health maintenance organization that is federally qualified
pursuant to Title XIII of the Public Health Service Act and that wholly owns
and operates an in-house drug outlet.
(2) For the purposes of this section,
health care service contractors shall be deemed insurers.
(3) Any for-profit health care service
contractor organized under the laws of any other state that is not governed by
the insurance laws of the other state is subject to all requirements of ORS
chapter 732.
(4) The Director of the Department of
Consumer and Business Services may, after notice and hearing, adopt reasonable
rules not inconsistent with this section and ORS 750.003, 750.005, 750.025 and
750.045 that are deemed necessary for the proper administration of these
provisions.
SECTION 44. ORS 750.333 is amended to
read:
750.333. (1) The following provisions
of the Insurance Code apply to trusts carrying out a multiple employer welfare
arrangement:
(a) ORS 731.004 to 731.150, 731.162,
731.216 to 731.268, 731.296 to 731.316, 731.324, 731.328, 731.378, 731.386,
731.390, 731.398, 731.406, 731.410, 731.414, 731.418 to 731.434, 731.454,
731.484, 731.486, 731.488, 731.512, 731.574 to 731.620, 731.640 to 731.652 and
731.804 to 731.992.
(b) ORS 733.010 to 733.050, 733.140 to
733.170, 733.210, 733.510 to 733.680 and 733.695 to 733.780.
(c) ORS chapter 734.
(d) ORS 742.001 to 742.009, 742.013,
742.061 and 742.400.
(e) ORS 743.028, 743.053, 743.524,
743.526, 743.527, 743.528, 743.529, 743.530, 743.560, 743.562, 743.600,
743.601, 743.602, 743.610, 743.730 to 743.773 (except 743.760 to 743.773), 743.801,
743.804, 743.807, 743.808, 743.814 to 743.839, 743.842, 743.845, 743.847,
743.854, 743.856, 743.857, 743.858, 743.859, 743.861, 743.862, 743.863,
743.864, 743.912, 743.917, 743A.012, 743A.020, 743A.052, 743A.064, 743A.080,
743A.100, 743A.104, 743A.110, 743A.144, 743A.170, 743A.175, 743A.184 and
743A.192 and sections 2, 4 and 4a of this 2011 Act.
(f) ORS 743A.010, 743A.014, 743A.024,
743A.028, 743A.032, 743A.036, 743A.040, 743A.048, 743A.058, 743A.066, 743A.068,
743A.070, 743A.084, 743A.088, 743A.090, 743A.105, 743A.140, 743A.141, 743A.148,
743A.168, 743A.180, 743A.188 and 743A.190. Multiple employer welfare
arrangements to which ORS 743.730 to 743.773 apply are subject to the sections
referred to in this paragraph only as provided in ORS 743.730 to 743.773.
(g) Provisions of ORS chapter 744
relating to the regulation of insurance producers and insurance consultants,
and ORS 744.700 to 744.740.
(h) ORS 746.005 to 746.140, 746.160
and 746.220 to 746.370.
(i) ORS 731.592 and 731.594.
(j) ORS 731.870.
(2) For the purposes of this section:
(a) A trust carrying out a multiple
employer welfare arrangement shall be considered an insurer.
(b) References to certificates of
authority shall be considered references to certificates of multiple employer
welfare arrangement.
(c) Contributions shall be considered
premiums.
(3) The provision of health benefits
under ORS 750.301 to 750.341 shall be considered to be the transaction of
health insurance.
SECTION 45. Section 4, chapter 75,
Oregon Laws 2010, is amended to read:
Sec. 4. (1) An insurer who
elects to offer discounted rates for a health insurance plan utilizing
electronic administration shall include the schedule of discounts for
utilization of electronic administration as part of a small employer group
health insurance or individual health insurance rate filing. The rate discounts
may be graduated and must be proportionate to the amount of administrative cost
savings the insurer anticipates as a result of the use of electronic
transactions described in section 3, chapter 75, Oregon Laws 2010 [3 of this 2010 Act].
(2) Discounted rates allowed under
this section shall be applied uniformly to all similarly situated small
employer group or individual health insurance purchasers of an insurer.
(3) Discounts in premium rates under
this section are not premium rate variations for purposes of ORS 743.737 [(8)] (11) or 743.767.
SECTION 46. The Health Insurance
Reform Advisory Committee is abolished.
SECTION 47. (1) Sections 2 and 4
of this 2011 Act and the amendments to statutes and session laws by sections 5,
6, 7 to 9, 12, 14 to 17 and 19 to 45 of this 2011 Act apply to policies or
certificates issued or renewed on or after September 23, 2010, and in effect on
or after the effective date of this 2011 Act.
(2) Section 4a of this 2011 Act
applies to health benefit plans issued or renewed on or after the effective
date of this 2011 Act.
(3) The amendments to ORS 743.610 by
sections 6b and 6c of this 2011 Act apply to group health insurance policies
issued or renewed before, on or after the effective date of this 2011 Act.
SECTION 48. (1) Section 5, chapter
73, Oregon Laws 2009, is repealed.
(2) Section 2, chapter 73, Oregon Laws
2009, as amended by section 6d of this 2011 Act, is repealed on January 2, 2012.
SECTION 49. If Senate Bill 91
becomes law, section 5, chapter 322, Oregon Laws 2011 (Enrolled Senate Bill 91)
(amending ORS 743.730), is repealed and ORS 743.730, as amended by section 7 of
this 2011 Act, 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 condition exclusion;
(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 that provides bronze plan coverage and that is
approved by the Department of Consumer and Business Services under ORS 743.736.
(5) “Bona fide association” means an
association that meets the requirements of 42 U.S.C. 300gg-91 as amended and in
effect on March 23, 2010.
(6) “Bronze plan” means a health
benefit plan that meets the criteria for a bronze plan prescribed by the
director by rule pursuant to section 2, chapter 322, Oregon Laws 2011 (Enrolled
Senate Bill 91).
[(6)]
(7) “Carrier,” except as provided in ORS 743.760, means any person who
provides health benefit plans in this state, including:
(a) A licensed insurance company;
(b) A health care service contractor;
(c) A health maintenance organization;
(d) An association or group of
employers that provides benefits by means of a multiple employer welfare
arrangement and that:
(A) Is subject to ORS 750.301 to
750.341; or
(B) Is fully insured and otherwise
exempt under ORS 750.303 (4) but elects to be governed by ORS 743.733 to
743.737; or
(e) Any other person or corporation
responsible for the payment of benefits or provision of services.
(8) “Catastrophic plan” means a
health benefit plan that meets the requirements for a catastrophic plan under
42 U.S.C. 18022(e) and that is offered through the Oregon Health Insurance
Exchange.
[(7)]
(9) “Creditable coverage” means prior health care coverage as defined in 42
U.S.C. 300gg as amended and in effect on February 17, 2009, and includes coverage
remaining in force at the time the enrollee obtains new coverage.
[(8)]
(10) “Dependent” means the spouse or child of an eligible employee, subject
to applicable terms of the health benefit plan covering the employee.
[(9)]
(11) “Eligible employee” means an employee 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 employer for fewer than 90 days are not eligible employees
unless the employer so allows.
[(10)]
(12) “Employee” means any individual employed by an employer.
[(11)]
(13) “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.
(14) “Exchange” means the Oregon
Health Insurance Exchange established pursuant to section 17, chapter 595,
Oregon Laws 2009.
[(12)]
(15) “Exclusion period” means a period during which specified treatments
or services are excluded from coverage.
[(13)]
(16) [“Financially impaired” means
a carrier that] “Financial impairment” means that a carrier is not
insolvent and is:
(a) Considered by the director 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.
[(14)(a)]
(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) Group health benefit plans
offered to small employers;
(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.
[(15)]
(18) “Grandfathered health plan” has the meaning prescribed by the
United States Secretaries of Labor, Health and Human Services and the Treasury
pursuant to 42 U.S.C. 18011(e).
[(16)]
(19) “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.
[(17)(a)]
(20)(a) “Health benefit plan” means any:
(A) Hospital expense, medical expense
or hospital or medical expense policy or certificate;
(B) Health care service contractor or
health maintenance organization subscriber contract; or
(C) 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, to the
extent that the plan is subject to state regulation.
(b) “Health benefit plan” does not
include:
(A) Coverage for accident only,
specific disease or condition only, credit or disability income;
(B) Coverage of Medicare services
pursuant to contracts with the federal government;
(C) Medicare supplement insurance
policies;
(D) Coverage of TRICARE services
pursuant to contracts with the federal government;
(E) 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;
(F) Separately offered long term care
insurance, including, but not limited to, coverage of nursing home care, home
health care and community-based care;
(G) Independent, noncoordinated,
hospital-only indemnity insurance or other fixed indemnity insurance;
(H) Short term health insurance
policies that are in effect for periods of 12 months or less, including the
term of a renewal of the policy;
(I) Dental only coverage;
(J) Vision only coverage;
(K) Stop-loss coverage that meets the
requirements of ORS 742.065;
(L) Coverage issued as a supplement to
liability insurance;
(M) Insurance arising out of a workers’
compensation or similar law;
(N) 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; or
(O) Any employee welfare benefit plan
that is exempt from state regulation because of the federal Employee Retirement
Income Security Act of 1974, as amended.
(c) For purposes of this subsection,
renewal of a short term health insurance policy includes the issuance of a new
short term health insurance policy by an insurer to a policyholder within 60
days after the expiration of a policy previously issued by the insurer to the
policyholder.
[(18)]
(21) “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 approved by the director under ORS 743.745.
[(19)]
(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.
[(20)]
(23) “Initial enrollment period” means a period of at least 30 days
following commencement of the first eligibility period for an individual.
[(21)]
(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 February 17, 2009;
(b) The individual applies for
coverage during an open enrollment period;
(c) A court issues an order that
coverage be provided for a spouse or minor child under an employee’s employer
sponsored 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 that 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, TRICARE, Indian Health Service or a publicly sponsored or
subsidized health plan, including, but not limited to, the medical assistance
program under ORS chapter 414, has been involuntarily terminated within 63 days
after applying for coverage in a group health benefit plan.
(25) “Minimal essential coverage”
has the meaning given that term in section 5000A(f) of the Internal Revenue
Code.
[(22)]
(26) “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.
[(23)]
(27) “Oregon Medical Insurance Pool” means the pool created under ORS
735.610.
[(24)]
(28) “Preexisting condition exclusion” 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) Except for coverage under an
individual grandfathered health plan, a preexisting condition exclusion may not
exclude coverage for services, charges or expenses incurred by an individual
who is under 19 years of age.
[(25)]
(29) “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.
[(26)]
(30) “Rating period” means the 12-month calendar period for which
premium rates established by a carrier are in effect, as determined by the
carrier.
[(27)]
(31) “Representative” does not include an insurance producer or an
employee or authorized representative of an insurance producer or carrier.
(32) “Silver plan” means an
individual or small group health benefit plan that meets the criteria for a
silver plan prescribed by the director by rule pursuant to section 2, chapter
322, Oregon Laws 2011 (Enrolled Senate Bill 91).
[(28)(a)]
(33) “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 offered by the employer.
(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.
SECTION 50. If Senate Bill 91 becomes
law, section 6, chapter 322, Oregon Laws 2011 (Enrolled Senate Bill 91), is
amended to read:
Sec. 6. Sections 2, 3 and 4,
chapter 322, Oregon Laws 2011 (Enrolled Senate Bill 91), [of this 2011 Act] and the amendments to
ORS 743.730 by [section 5 of this 2011
Act] section 49 of this 2011 Act become operative on January 2,
2014.
SECTION 51. This 2011 Act being
necessary for the immediate preservation of the public peace, health and
safety, an emergency is declared to exist, and this 2011 Act takes effect on
its passage.
Approved by
the Governor June 23, 2011
Filed in the
office of Secretary of State June 23, 2011
Effective date
June 23, 2011
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