76th OREGON LEGISLATIVE ASSEMBLY--2012 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 161
A-Engrossed
House Bill 4164
Ordered by the House March 2
Including House Amendments dated March 2
Introduced and printed pursuant to House Rule 12.00. Presession
filed (at the request of Governor John A. Kitzhaber for Oregon
Health Insurance Exchange Corporation)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure.
Requires Oregon Health Insurance Exchange Corporation to
establish and deposit moneys into accounts in federally insured
depositories. Removes requirement but still permits excess moneys
collected by corporation from insurers and state programs to be
held and invested to offset future net losses. Prescribes
investments to be made with excess charges that are held and
invested. Authorizes corporation to borrow money and give
guarantees under specified conditions.
Specifies applicable provisions of public contracting code.
Authorizes board of directors or executive director of
corporation to contract with carriers to develop innovative
health benefit plans for employees of corporation if plans are
approved by Director of Department of Consumer and Business
Services. Exempts such plans from Insurance Code requirements
for small employer health benefit plans.
Provides legislative approval of corporation business plan for
health insurance exchange by repealing provisions of law enacted
to require legislative approval.
{ + Provides for school district participation in health
insurance exchange. + }
Makes technical corrections.
Declares emergency, effective on passage.
A BILL FOR AN ACT
Relating to the Oregon Health Insurance Exchange; creating new
provisions; amending ORS 243.886, 413.011, 413.033, 741.002,
741.027, 741.101, 741.105, 741.201, 741.220, 741.222, 741.250,
741.310, 741.381, 743.730, 743.822 and 743.826 and section 27,
chapter 415, Oregon Laws 2011; and declaring an emergency.
Whereas the Legislative Assembly of the State of Oregon enacted
Enrolled Senate Bill 99 (2011) establishing the Oregon Health
Insurance Exchange Corporation to operate an exchange to help
improve Oregonians' access to quality, affordable health care
coverage; and
Whereas the Legislative Assembly delayed the operation of the
exchange pending legislative approval of a formal business plan;
and
Whereas the Oregon Health Insurance Exchange Corporation
submitted a formal business plan to the appropriate legislative
committees; and
Whereas the appropriate committees of the Legislative Assembly
have approved the formal business plan; now, therefore,
Be It Enacted by the People of the State of Oregon:
{ +
OREGON HEALTH INSURANCE EXCHANGE CORPORATION + }
SECTION 1. ORS 741.002 is amended to read:
741.002. (1) The duties of the Oregon Health Insurance Exchange
Corporation are to:
(a) Administer a health insurance exchange in accordance with
federal law to make qualified health plans available to
individuals and groups throughout this state.
(b) Provide information in writing, through an Internet-based
clearinghouse and through a toll-free telephone line that will
assist individuals and small businesses in making informed health
insurance decisions, including:
(A) The grade of each health plan as determined by the
corporation and the grading criteria that were used;
(B) Quality and enrollee satisfaction ratings; and
(C) The comparative costs, benefits, provider networks of
health plans and other useful information.
(c) Establish and make available an electronic calculator that
allows individuals and employers to determine the cost of
coverage after deducting any applicable tax credits or
cost-sharing reduction.
(d) Using procedures approved by the corporation's board of
directors and adopted by rule by the corporation under ORS
741.310, screen, certify and recertify health plans as qualified
health plans according to federal and state standards and ensure
that qualified health plans provide choices of coverage.
(e) Decertify or suspend, in accordance with ORS chapter 183,
the certification of health plans that fail to meet federal and
state standards in order to exclude them from participation in
the exchange.
(f) Promote fair competition of carriers participating in the
exchange by certifying multiple health plans as qualified under
ORS 741.310.
(g) Grade health plans in accordance with criteria established
by the United States Secretary of Health and Human Services and
by the corporation.
(h) Establish open and special enrollment periods for all
enrollees, and monthly enrollment periods for Native Americans in
accordance with federal law.
(i) Assist individuals and groups to enroll in qualified health
plans, including defined contribution plans as defined in section
414 of the Internal Revenue Code and, if appropriate, collect and
remit premiums for such individuals or groups.
(j) Facilitate community-based assistance with enrollment in
qualified health plans by awarding grants to entities that are
certified as navigators as described in 42 U.S.C. 18031(i).
(k) Provide information to individuals and employers regarding
the eligibility requirements for state medical assistance
programs and assist eligible individuals and families in applying
for and enrolling in the programs.
(L) Provide employers with the names of employees who end
coverage under a qualified health plan during a plan year.
(m) Certify the eligibility of an individual for an exemption
from the individual responsibility requirement of section 5000A
of the Internal Revenue Code.
(n) Provide information to the federal government necessary for
individuals who are enrolled in qualified health plans through
the exchange to receive tax credits and reduced cost-sharing.
(o) Provide to the federal government:
(A) Information regarding individuals determined to be exempt
from the individual responsibility requirement of section 5000A
of the Internal Revenue Code;
(B) Information regarding employees who have reported a change
in employer;
(C) Information regarding individuals who have ended coverage
during a plan year; and
(D) Any other information necessary to comply with federal
requirements.
(p) Take any other actions necessary and appropriate to comply
with the federal requirements for a health insurance exchange.
(q) Work in coordination with the Oregon Health Authority, the
Oregon Health Policy Board and the Department of Consumer and
Business Services in carrying out its duties.
(2) The corporation may sue and be sued.
(3) The corporation may:
(a) Acquire, lease, rent, own and manage real property.
(b) Construct, equip and furnish buildings or other structures
as are necessary to accommodate the needs of the corporation.
(c) Purchase, rent, lease or otherwise acquire for the
corporation's use all supplies, materials, equipment and services
necessary to carry out the corporation's duties.
(d) Sell or otherwise dispose of any property acquired under
this subsection.
{ + (e) Borrow money and give guarantees to finance its
facilities and operations. + }
(4) Any real property acquired and owned by the corporation
under this section shall be subject to ad valorem taxation.
{ + (5) The corporation may not borrow money or give
guarantees under subsection (3)(e) of this section unless the
obligations of the corporation are payable solely out of the
corporation's own resources and do not constitute a pledge of the
full faith and credit of the State of Oregon or any of the
revenues of this state. The State Treasurer and the State of
Oregon may not pay bond-related costs for an obligation incurred
by the corporation. A holder of an obligation incurred by the
corporation does not have the right to compel the exercise of the
taxing power of the state to pay bond-related costs. + }
{ - (5) - } { + (6) + } The corporation may adopt rules
necessary to carry out its mission, duties and functions.
SECTION 2. ORS 741.101 is amended to read:
741.101. { - The Oregon Health Insurance Exchange Fund is
established in the State Treasury, separate and distinct from the
General Fund. Interest earned by the Oregon Health Insurance
Exchange Fund shall be credited to the fund. The Oregon Health
Insurance Exchange Fund consists of moneys received by the Oregon
Health Insurance Exchange Corporation through premiums or the
imposition of fees under ORS 741.105 and moneys received as
grants under ORS 741.310. Moneys in the fund are continuously
appropriated to the Oregon Health Insurance Exchange Corporation
for carrying out the purposes of ORS 741.001 to 741.540. - }
{ + (1) As used in this section, 'depository' has the meaning
given that term in ORS 295.001.
(2) The Oregon Health Insurance Exchange Corporation shall
establish one or more accounts in one or more depositories
insured by the Federal Deposit Insurance Corporation or the
National Credit Union Share Insurance Fund. In a manner
consistent with the requirements of ORS 295.001 to 295.108, the
corporation shall ensure that sufficient collateral secures any
amount of funds on deposit that exceeds the limits of the
coverage of the Federal Deposit Insurance Corporation or the
National Credit Union Share Insurance Fund. All moneys collected
or received by the corporation or placed to the credit of the
corporation that are not invested under ORS 741.105 must be
deposited to the accounts established under this section,
including, but not limited to, moneys received by the corporation
through premiums or the imposition of fees under ORS 741.105 and
moneys received as grants under ORS 741.310. + }
SECTION 3. All moneys remaining unexpended in the Oregon Health
Insurance Exchange Fund on the effective date of this 2012 Act
shall be deposited to an account established by the Oregon Health
Insurance Exchange Corporation under ORS 741.101.
SECTION 4. ORS 741.105 is amended to read:
741.105. (1) The Oregon Health Insurance Exchange Corporation
board of directors shall establish, and the corporation shall
impose and collect, an administrative charge from all insurers
and state programs participating in the health insurance exchange
in an amount sufficient to cover the costs of grants to
navigators certified under ORS 741.002 and to pay the
administrative and operational expenses of the corporation in
carrying out ORS 741.001 to 741.540. The charge shall be paid in
a manner and at intervals prescribed by the board and shall be
deposited in { - the Oregon Health Insurance Exchange Fund - }
{ + an account + } established in ORS 741.101.
(2) Each insurer's charge shall be based on the number of
individuals, excluding individuals enrolled in state programs,
who are enrolled in health plans offered by the insurer through
the exchange. The assessment on each state program shall be based
on the number of individuals enrolled in state programs offered
through the exchange. The charge may not exceed:
(a) Five percent of the premium or other monthly charge for
each enrollee if the number of enrollees receiving coverage
through the exchange is at or below 175,000;
(b) Four percent of the premium or other monthly charge for
each enrollee if the number of enrollees receiving coverage
through the exchange is above 175,000 and at or below 300,000;
and
(c) Three percent of the premium or other monthly charge for
each enrollee if the number of enrollees receiving coverage
through the exchange is above 300,000.
(3) { + (a) + } If charges collected under subsection (1) of
this section exceed the amounts needed for the administrative and
operational expenses of the corporation, the excess moneys
collected { - shall - } { + may + } be held and invested and,
with the earnings and interest, used by the corporation to offset
future net losses or reduce the administrative costs of the
corporation.
{ + (b) Investments made by the corporation under this
subsection are:
(A) Limited to investments described in ORS 294.035;
(B) Subject to the investment maturity date limitations
described in ORS 294.135; and
(C) Subject to the conduct prohibitions listed in ORS 294.145.
(c) + } The maximum amount of excess moneys that may be held
under this subsection is the total administrative and operational
expenses anticipated by the corporation for a six-month period.
Any moneys received that exceed the maximum shall be applied by
the corporation to reduce the charges imposed by this section.
(4) Charges shall be based on annual statements and other
reports deemed necessary by the corporation and filed by an
insurer or state program with the exchange.
(5) In addition to charges imposed under subsection (1) of this
section, to the extent permitted by federal law the corporation
may impose a fee on insurers and state programs participating in
the exchange to cover the cost of commissions of insurance
producers that are certified by the corporation to facilitate the
participation of individuals and employers in the exchange.
(6) The board shall establish the charges and fees under this
section in accordance with ORS 183.310 to 183.410 and in such a
manner that will reasonably and substantially accomplish the
objective of subsections (1) and (5) of this section.
SECTION 5. ORS 741.201 is amended to read:
741.201. (1) The Oregon Health Insurance Exchange Corporation
is under the supervision of an executive director appointed by
the corporation board of directors. The executive director serves
at the pleasure of the board. The executive director shall be
paid a salary as prescribed by the board.
(2) Before assuming the duties of the office, the executive
director shall:
(a) Give to the state a fidelity bond, with one or more
corporate sureties authorized to do business in this state, in a
penal sum prescribed by the Director of the Oregon Department of
Administrative Services, but not less than $50,000. The premium
for the bond shall be paid from { - the Oregon Health Insurance
Exchange Fund - } { + an account established under ORS
741.101 + }.
(b) Subscribe to an oath that the executive director faithfully
and impartially will discharge the duties of the office and that
the executive director will support the Constitution of the
United States and the Constitution of the State of Oregon. The
executive director shall file a copy of the signed oath with the
Secretary of State.
(3) The executive director { - may establish a line of credit
under ORS 293.214 and - } has such other powers as are necessary
to carry out the duties of the corporation, subject to policy
direction by the board.
(4) The executive director may employ, supervise and terminate
the employment of such staff as the executive director deems
necessary. The executive director shall prescribe their duties
and fix their compensation, in accordance with the personnel
policies adopted by the board. Employees of the corporation may
not be individuals who are:
(a) Employed by, consultants to or members of a board of
directors of:
(A) An insurer or third party administrator;
(B) An insurance producer; or
(C) A health care provider, health care facility or health
clinic;
(b) Members, board members or employees of a trade association
of:
(A) Insurers or third party administrators; or
(B) Health care providers, health care facilities or health
clinics; or
(c) Health care providers, unless they receive no compensation
for rendering services as health care providers and do not have
ownership interests in professional health care practices.
(5) { + (a) + } The board shall adopt personnel policies,
subject to ORS 236.605 to 236.640, for any transferred public
employees. The board may elect to provide for participation in a
health benefit plan available to state employees pursuant to ORS
243.105 to 243.285 and may elect to participate in the state
deferred compensation plan established under ORS 243.401 to
243.507. If the board so elects, employees of the corporation
shall be considered eligible employees for purposes of ORS
243.105 to 243.285 and eligible state employees for purposes of
ORS 243.401 to 243.507.
{ + (b) In order to facilitate the development of innovative
health benefit plans, the board or the executive director may
contract with one or more carriers to offer to employees of the
Oregon Health Insurance Exchange Corporation proof of concept
health benefit plans approved by the Director of the Department
of Consumer and Business Services. A plan offered under this
paragraph is not subject to ORS 743.730 to 743.773. + }
(6) With respect to the Public Employees Retirement System,
employees of the corporation shall be considered employees for
purposes of ORS chapter 238 and eligible employees for purposes
of ORS chapter 238A.
(7) Employees of the corporation may participate in collective
bargaining in accordance with ORS 243.650 to 243.782.
SECTION 6. ORS 741.220 is amended to read:
741.220. (1) The Oregon Health Insurance Exchange Corporation
shall keep an accurate accounting of the operation and all
activities, receipts and expenditures of the corporation and the
health insurance exchange.
(2) Beginning after the first 12 months of the operation of the
exchange and every 12 months thereafter, the Secretary of State
shall conduct a financial audit of the corporation and the
{ - fund - } { + accounts established under ORS 741.101 + }
pursuant to ORS 297.210, which shall include but is not limited
to:
(a) A review of the sources and uses of the moneys in the
{ - fund - } { + accounts + };
(b) A review of charges and fees imposed and collected pursuant
to ORS 741.105; and
(c) A review of premiums collected and remitted.
(3) Beginning after the first 24 months of the operation of the
exchange and every two years thereafter, the Secretary of State
shall conduct a performance audit of the corporation and the
exchange.
(4) The corporation board of directors, the executive director
of the corporation and employees of the corporation shall
cooperate with the Secretary of State in the audits and reviews
conducted under subsections (2) and (3) of this section.
(5) The audits shall be conducted using generally accepted
accounting principles and any financial integrity requirements of
federal authorities.
(6) The cost of the audits required by subsections (2) and (3)
of this section shall be paid by the corporation.
(7) The Secretary of State shall issue a report to the
Governor, the President of the Senate, the Speaker of the House
of Representatives, the Oregon Health Authority, the Oregon
Health Policy Board, the Department of Consumer and Business
Services and appropriate federal authorities on the results of
each audit conducted pursuant to this section, including any
recommendations for corrective actions. The report shall be
available for public inspection, in accordance with the Secretary
of State's established rules and procedures governing public
disclosure of audit documents.
(8) To the extent the audit requirements under this section are
similar to any audit requirements imposed on the corporation by
federal authorities, the Secretary of State and the corporation
shall make reasonable efforts to coordinate with the federal
authorities to promote efficiency and the best use of resources
in the timing and provision of information.
(9) Not later than the 90th day after the Secretary of State
completes and delivers an audit report issued under subsection
(7) of this section, the corporation shall notify the Secretary
of State in writing of the corrective actions taken or to be
taken, if any, in response to any recommendations in the report.
The Secretary of State may extend the 90-day period for good
cause.
SECTION 7. ORS 741.250 is amended to read:
741.250. (1) Except as { - otherwise provided by law - }
{ + provided in subsection (6) of this section + }, the
provisions of ORS 279.835 to 279.855 and ORS chapters 240, 276,
279A, 279B, 279C, 282, 283, 291, 292 and 293 do not apply to the
Oregon Health Insurance Exchange Corporation.
(2) In carrying out the duties, functions and powers imposed by
law upon the corporation, the corporation board of directors or
the executive director of the corporation may contract with any
state agency or other qualified person or entity for the
performance of such duties, functions and powers as the board or
executive director considers appropriate.
(3) ORS 30.210 to 30.250, 30.260 to 30.300, 30.310, 30.312,
30.390 and 30.400 apply to the members of the board, the
executive director and employees of the corporation.
(4) Notwithstanding subsection (1) of this section, ORS
{ - 293.235, - } 293.240 { - , 293.245, 293.260, 293.262,
293.611, 293.625 and 293.630 apply - } { + applies + } to the
accounts of the corporation.
(5) Notwithstanding subsections (1) and (2) of this section,
ORS 243.305, 279A.100 and 659A.012 apply to the members of the
board, executive director and employees of the corporation.
{ + (6) ORS 279B.060 (6) and 279B.400 to 279B.425 apply to
contracts entered into by the corporation. + }
{ +
LEGISLATIVE APPROVAL OF BUSINESS PLAN + }
{ +
FOR OREGON HEALTH INSURANCE EXCHANGE + }
SECTION 8. Section 27, chapter 415, Oregon Laws 2011, is
amended to read:
{ + Sec. 27. + } { - (1) Section 11 of this 2011 Act
becomes operative on the date the Legislative Assembly approves
the formal business plan submitted by the Oregon Health Insurance
Exchange Corporation under section 5 (9) of this 2011 Act. This
subsection does not prohibit the implementation, on or after the
effective date of this 2011 Act, of the responsibilities of the
Oregon Health Authority or the Oregon Health Insurance Exchange
Corporation in administering federal grants received for
planning, administration or information technology for the
exchange. - }
{ - (2) - } The amendments to { - section 11 of this 2011
Act - } { + ORS 741.310 + } by section 12 { - of this 2011
Act - } { + , chapter 415, Oregon Laws 2011, + } become
operative on { - the later of the date the Legislative Assembly
approves the formal business plan submitted by the corporation
under section 5 (9) of this 2011 Act or - } January 1, 2016.
{ +
SCHOOL DISTRICT PARTICIPATION IN HEALTH + }
{ +
INSURANCE EXCHANGE + }
SECTION 9. ORS 243.886 is amended to read:
243.886. (1) Except as provided in subsections (2) { + , + }
{ - and - } (3) { + and (4) + } of this section { + , + }
{ - : - }
{ - (a) - } a district may not provide or contract for a
benefit plan { + and eligible employees of districts may not
participate in a benefit plan + } unless the benefit plan { + :
(a) + } Is provided and administered by the Oregon Educators
Benefit Board under ORS 243.860 to 243.886; { + or + }
{ - and - }
{ - (b) Eligible employees of a district may participate only
in benefit plans provided and administered by the board. - }
{ + (b) On or after October 1, 2015, is offered through the
health insurance exchange under ORS 741.310 (1)(b). + }
(2)(a) Except for community college districts, a district that
was self-insured before January 1, 2007, or a district that had
an independent health insurance trust established and functioning
before January 1, 2007, may provide or contract for benefit plans
other than benefit plans provided and administered by the board
if the premiums for the benefit plans provided or contracted for
by the district are equal to or less than the premiums for
comparable benefit plans provided and administered by the board.
(b) A community college district may provide or contract for
benefit plans other than benefit plans provided and administered
by the board.
(c) In accordance with procedures adopted by the board to
extend benefit plan coverage under ORS 243.864 to 243.874 to
eligible employees of a self-insured district, a district with an
independent health insurance trust or a community college
district, these districts may choose to offer benefit plans that
are provided and administered by the board. Once employees of a
district participate in benefit plans provided and administered
by the board, the district may not thereafter provide or contract
for benefit plans other than those provided and administered by
the board.
(3)(a) A district that has not offered benefit plans provided
and administered by the board before June 23, 2009, may provide
or contract for benefit plans other than benefit plans provided
and administered by the board if the premiums for the benefit
plans provided or contracted for by the district are equal to or
less than the premiums for comparable benefit plans provided and
administered by the board. Once employees of a district or an
employee group within a district participates in benefit plans
provided and administered by the board, the district may not
thereafter provide or contract for benefit plans for those
employees or employee groups other than those provided and
administered by the board.
(b) To maintain the exception created in this subsection, the
board must perform an actuarial analysis of the district at least
once every two years. If requested by the district or a labor
organization representing eligible employees of the district, the
board shall perform the actuarial analysis annually.
(c) As used in this subsection, 'district' does not include a
community college district.
(4) Nothing in ORS 243.860 to 243.886 may be construed to
expand or contract collective bargaining rights or collective
bargaining obligations.
SECTION 10. ORS 741.310 is amended to read:
741.310. (1) The following individuals and groups may purchase
qualified health plans through the health insurance exchange:
(a) Beginning January 1, 2014 { - , individuals and - } { + :
(A) Individuals and families; and
(B) + } Employers with no more than 50 employees.
{ + (b) Beginning October 1, 2015, districts and eligible
employees of districts that are subject to ORS 243.886, unless
their participation is precluded by federal law. + }
{ - (b) - } { + (c) + } Beginning January 1, 2016,
employers with 51 to 100 employees.
(2)(a) Only individuals who purchase health plans through the
exchange may be eligible to receive premium tax credits under
section 36B of the Internal Revenue Code and reduced cost-sharing
under 42 U.S.C. 18071.
(b) Only employers that purchase health plans through the
exchange may be eligible to receive small employer health
insurance credits under section 45R of the Internal Revenue Code.
(3) Only an insurer that has a certificate of authority to
transact insurance in this state and that meets applicable
federal requirements for participating in the exchange may offer
a qualified health plan through the exchange. Any qualified
health plan must be certified under subsection (4) of this
section. Prepaid managed care health services organizations that
do not have a certificate of authority to transact insurance may
serve only medical assistance recipients through the exchange and
may not offer qualified health plans.
(4) { + (a) + } The Oregon Health Insurance Exchange
Corporation shall adopt by rule uniform requirements, standards
and criteria for the certification of qualified health plans,
including requirements that a qualified health plan provide, at a
minimum, essential health benefits and have acceptable consumer
and provider satisfaction ratings.
{ + (b) + } The corporation may limit the number of qualified
health plans that may be offered through the exchange as long as
the same limit applies to all insurers.
{ + (c) The corporation shall consult with stakeholders,
including but not limited to representatives of school
administrators, school board members and school employees,
regarding the plans that may be offered through the exchange to
districts and eligible employees of districts under subsection
(1)(b) of this section. + }
(5) Notwithstanding subsection (4) of this section, the
corporation shall certify as qualified a dental only health plan
as permitted by federal law.
(6) The corporation shall establish one streamlined and
seamless application and enrollment process for both the exchange
and the state medical assistance program.
(7) The corporation, in collaboration with the appropriate
state authorities, may establish risk mediation programs within
the exchange.
(8) The corporation shall establish by rule a process for
certifying insurance producers to facilitate the transaction of
insurance through the exchange, in accordance with federal
standards and policies.
(9) The corporation shall ensure, as required by federal laws,
that an insurer charges the same premiums for plans sold through
the exchange as for identical plans sold outside of the exchange.
(10) The corporation is authorized to enter into contracts for
the performance of duties, functions or operations of the
exchange, including but not limited to contracting with:
(a) All insurers that meet the requirements of subsections (3)
and (4) of this section, to offer qualified health plans through
the exchange; and
(b) Navigators certified by the corporation under ORS 741.002.
(11) The corporation is authorized to apply for and accept
federal grants, other federal funds and grants from
nongovernmental organizations for purposes of developing,
implementing and administering the exchange. Moneys received
under this subsection shall be deposited in { - and credited to
the Oregon Health Insurance Exchange Fund - } { + an
account + } established under ORS 741.101.
SECTION 11. ORS 741.310, as amended by section 12, chapter 415,
Oregon Laws 2011, is amended to read:
741.310. (1) { + The following + } individuals and
{ - employers with no more than 100 employees - } { +
groups + } may purchase qualified health plans through the health
insurance exchange { + :
(a) Individuals and families;
(b) Employers with no more than 100 employees; and
(c) Districts and eligible employees of districts that are
subject to ORS 243.886, unless their participation is precluded
by federal law + }.
(2)(a) Only individuals who purchase health plans through the
exchange may be eligible to receive premium tax credits under
section 36B of the Internal Revenue Code and reduced cost-sharing
under 42 U.S.C. 18071.
(b) Only employers that purchase health plans through the
exchange may be eligible to receive small employer health
insurance credits under section 45R of the Internal Revenue Code.
(3) Only an insurer that has a certificate of authority to
transact insurance in this state and that meets applicable
federal requirements for participating in the exchange may offer
a qualified health plan through the exchange. Any qualified
health plan must be certified under subsection (4) of this
section. Prepaid managed care health services organizations that
do not have a certificate of authority to transact insurance may
serve only medical assistance recipients through the exchange and
may not offer qualified health plans.
(4) { + (a) + } The Oregon Health Insurance Exchange
Corporation shall adopt by rule uniform requirements, standards
and criteria for the certification of qualified health plans,
including requirements that a qualified health plan provide, at a
minimum, essential health benefits and have acceptable consumer
and provider satisfaction ratings.
{ + (b) + } The corporation may limit the number of qualified
health plans that may be offered through the exchange as long as
the same limit applies to all insurers.
{ + (c) The corporation shall consult with stakeholders,
including but not limited to representatives of school
administrators, school board members and school employees,
regarding the plans that may be offered through the exchange to
districts and eligible employees of districts under subsection
(1)(c) of this section. + }
(5) Notwithstanding subsection (4) of this section, the
corporation shall certify as qualified a dental only health plan
as permitted by federal law.
(6) The corporation shall establish one streamlined and
seamless application and enrollment process for both the exchange
and the state medical assistance program.
(7) The corporation, in collaboration with the appropriate
state authorities, may establish risk mediation programs within
the exchange.
(8) The corporation shall establish by rule a process for
certifying insurance producers to facilitate the transaction of
insurance through the exchange, in accordance with federal
standards and policies.
(9) The corporation shall ensure, as required by federal laws,
that an insurer charges the same premiums for plans sold through
the exchange as for identical plans sold outside of the exchange.
(10) The corporation is authorized to enter into contracts for
the performance of duties, functions or operations of the
exchange, including but not limited to contracting with:
(a) Insurers that meet the requirements of subsections (3) and
(4) of this section, to offer qualified health plans through the
exchange; and
(b) Navigators certified by the corporation under ORS 741.002.
(11) The corporation is authorized to apply for and accept
federal grants, other federal funds and grants from
nongovernmental organizations for purposes of developing,
implementing and administering the exchange. Moneys received
under this subsection shall be deposited in { - and credited to
the Oregon Health Insurance Exchange Fund - } { + an
account + } established under ORS 741.101.
SECTION 12. { + The Oregon Health Insurance Exchange
Corporation shall apply for a waiver of federal law or any formal
permission from the appropriate federal agency or agencies that
is necessary to allow districts and eligible employees of
districts to obtain health benefit plans through the health
insurance exchange in accordance with ORS 243.886. + }
{ +
TECHNICAL AND CONFORMING CHANGES + }
SECTION 13. ORS 243.886, as amended by section 9 of this 2012
Act, is amended to read:
243.886. (1) Except as provided in subsections (2), (3) and (4)
of this section, a district may not provide or contract for a
benefit plan and eligible employees of districts may not
participate in a benefit plan unless the benefit plan:
(a) Is provided and administered by the Oregon Educators
Benefit Board under ORS 243.860 to 243.886; or
(b) { - On or after October 1, 2015, - } Is offered through
the health insurance exchange under ORS 741.310 { - (1)(b) - }
{ + (1)(c) + }.
(2)(a) Except for community college districts, a district that
was self-insured before January 1, 2007, or a district that had
an independent health insurance trust established and functioning
before January 1, 2007, may provide or contract for benefit plans
other than benefit plans provided and administered by the board
if the premiums for the benefit plans provided or contracted for
by the district are equal to or less than the premiums for
comparable benefit plans provided and administered by the board.
(b) A community college district may provide or contract for
benefit plans other than benefit plans provided and administered
by the board.
(c) In accordance with procedures adopted by the board to
extend benefit plan coverage under ORS 243.864 to 243.874 to
eligible employees of a self-insured district, a district with an
independent health insurance trust or a community college
district, these districts may choose to offer benefit plans that
are provided and administered by the board. Once employees of a
district participate in benefit plans provided and administered
by the board, the district may not thereafter provide or contract
for benefit plans other than those provided and administered by
the board.
(3)(a) A district that has not offered benefit plans provided
and administered by the board before June 23, 2009, may provide
or contract for benefit plans other than benefit plans provided
and administered by the board if the premiums for the benefit
plans provided or contracted for by the district are equal to or
less than the premiums for comparable benefit plans provided and
administered by the board. Once employees of a district or an
employee group within a district participates in benefit plans
provided and administered by the board, the district may not
thereafter provide or contract for benefit plans for those
employees or employee groups other than those provided and
administered by the board.
(b) To maintain the exception created in this subsection, the
board must perform an actuarial analysis of the district at least
once every two years. If requested by the district or a labor
organization representing eligible employees of the district, the
board shall perform the actuarial analysis annually.
(c) As used in this subsection, 'district' does not include a
community college district.
(4) Nothing in ORS 243.860 to 243.886 may be construed to
expand or contract collective bargaining rights or collective
bargaining obligations.
SECTION 14. { + The amendments to ORS 243.886 by section 13 of
this 2012 Act become operative January 1, 2016. + }
SECTION 15. ORS 413.011 is amended to read:
413.011. (1) The duties of the Oregon Health Policy Board are
to:
(a) Be the policy-making and oversight body for the Oregon
Health Authority established in ORS 413.032 and all of the
authority's departmental divisions { - , including the Oregon
Health Insurance Exchange described in section 17, chapter 595,
Oregon Laws 2009 - } .
(b) Develop and submit a plan to the Legislative Assembly by
December 31, 2010, to provide and fund access to affordable,
quality health care for all Oregonians by 2015.
(c) Develop a program to provide health insurance premium
assistance to all low and moderate income individuals who are
legal residents of Oregon.
(d) Establish and continuously refine uniform, statewide health
care quality standards for use by all purchasers of health care,
third-party payers and health care providers as quality
performance benchmarks.
(e) Establish evidence-based clinical standards and practice
guidelines that may be used by providers.
(f) Approve and monitor community-centered health initiatives
described in ORS 413.032 (1)(i) that are consistent with public
health goals, strategies, programs and performance standards
adopted by the Oregon Health Policy Board to improve the health
of all Oregonians, and shall regularly report to the Legislative
Assembly on the accomplishments and needed changes to the
initiatives.
(g) Establish cost containment mechanisms to reduce health care
costs.
(h) Ensure that Oregon's health care workforce is sufficient in
numbers and training to meet the demand that will be created by
the expansion in health coverage, health care system
transformations, an increasingly diverse population and an aging
workforce.
(i) Work with the Oregon congressional delegation to advance
the adoption of changes in federal law or policy to promote
Oregon's comprehensive health reform plan.
(j) Establish a health benefit package in accordance with ORS
741.340 to be used as the baseline for all health benefit plans
offered through the Oregon Health Insurance Exchange.
{ - (k) Develop and submit a plan to the Legislative Assembly
by December 31, 2010, with recommended policies and procedures
for the Oregon Health Insurance Exchange developed in accordance
with section 17, chapter 595, Oregon Laws 2009. - }
{ - (L) Develop and submit a plan to the Legislative Assembly
by December 31, 2010, with recommendations for the development of
a publicly owned health benefit plan that operates in the
exchange under the same rules and regulations as all health
insurance plans offered through the exchange, including fully
allocated fixed and variable operating and capital costs. - }
{ - (m) - } { + (k) + } By December 31, 2010, investigate
and report to the Legislative Assembly, and annually thereafter,
on the feasibility and advisability of future changes to the
health insurance market in Oregon, including but not limited to
the following:
(A) A requirement for every resident to have health insurance
coverage.
(B) A payroll tax as a means to encourage employers to continue
providing health insurance to their employees.
{ - (C) Expansion of the exchange to include a program of
premium assistance and to advance reforms of the insurance
market. - }
{ - (D) - } { + (C) + } The implementation of a system of
interoperable electronic health records utilized by all health
care providers in this state.
{ - (n) - } { + (L) + } Meet cost-containment goals by
structuring reimbursement rates to reward comprehensive
management of diseases, quality outcomes and the efficient use of
resources by promoting 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.
{ - (o) - } { + (m) + } Oversee the expenditure of moneys
from the Health Care Workforce Strategic Fund to support grants
to primary care providers and rural health practitioners, to
increase the number of primary care educators and to support
efforts to create and develop career ladder opportunities.
{ - (p) - } { + (n) + } Work with the Public Health Benefit
Purchasers Committee, administrators of the medical assistance
program and the Department of Corrections to identify uniform
contracting standards for health benefit plans that achieve
maximum quality and cost outcomes and align the contracting
standards for all state programs to the greatest extent
practicable.
(2) The Oregon Health Policy Board is authorized to:
(a) Subject to the approval of the Governor, organize and
reorganize the authority as the board considers necessary to
properly conduct the work of the authority.
(b) 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 board'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) If the board or the authority is unable to perform, in
whole or in part, any of the duties described in ORS 413.006 to
413.042, 413.101 and 741.340 without federal approval, the
authority is authorized to request, in accordance with ORS
413.072, waivers or other approval necessary to perform those
duties. The authority shall implement any portions of those
duties not requiring legislative authority or federal approval,
to the extent practicable.
(4) 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 the board by ORS 413.006 to
413.042, 413.101 and 741.340 and by other statutes.
(5) The board shall consult with the Department of Consumer and
Business Services in completing the tasks set forth in subsection
(1)(j) { - , (k) and (m)(A) and (C) - } { + and (k)(A) + } of
this section.
SECTION 16. ORS 413.033 is amended to read:
413.033. (1) The Oregon Health Authority is under the
supervision and control of a director, who is responsible for the
performance of the duties, functions and powers of the authority.
(2) The Governor shall appoint the Director of the Oregon
Health Authority, who holds office at the pleasure of the
Governor. The appointment of the director shall be subject to
confirmation by the Senate in the manner provided by ORS 171.562
and 171.565.
(3)(a) In addition to the procurement authority granted by ORS
179.040 and 279A.050, the director shall have all powers
necessary to effectively and expeditiously carry out the duties,
functions and powers vested in the authority by ORS 413.032
{ - and section 19, chapter 595, Oregon Laws 2009 - } , and the
duties, functions and powers that are shared by or delegated to
the authority with respect to the following agencies:
(A) The Oregon Department of Administrative Services;
(B) The Department of Consumer and Business Services; and
(C) The Department of Human Services.
(b) With respect to procurements and contracts that the
authority is authorized to conduct or manage, the director may
make procurements on behalf of, and supervise the procurement,
establishment and administration of contracts entered into by,
the departments described in paragraph (a) of this subsection.
(c) Notwithstanding ORS 279B.085, the director may approve a
special procurement under paragraph (b) of this subsection that:
(A) Describes the proposed contracting procedure and the goods
or services, or the class of goods or services, to be acquired
through the special procurement;
(B) Is unlikely to encourage favoritism in the awarding of
public contracts or to substantially diminish competition for
public contracts; and
(C) Is reasonably expected to result in substantial cost
savings to the authority or to the public.
(d) The director shall give public notice of the approval of a
proposed special procurement as provided by the authority by
rule. The requirements applicable to the Director of the Oregon
Department of Administrative Services under ORS 279B.400 apply to
the Director of the Oregon Health Authority with respect to
special procurements under this subsection.
(e) Notwithstanding ORS 279C.335, the director may exempt a
public improvement contract or a class of public improvement
contracts that the authority is authorized to conduct or manage
from the competitive bidding requirements of ORS 279C.335 (1) if
the director makes the findings described in ORS 279C.335 (2).
The provisions in ORS 279C.335 (3) to (8) with respect to the
Director of the Oregon Department of Administrative Services
apply to the Director of the Oregon Health Authority for
exemptions granted by the director under this subsection.
(4) The director shall have the power to obtain such other
services as the director considers necessary or desirable,
including participation in organizations of state insurance
supervisory officials and appointment of advisory committees. A
member of an advisory committee so appointed shall receive no
compensation for services as a member, but, subject to any other
applicable law regulating travel and other expenses of state
officers, shall receive actual and necessary travel and other
expenses incurred in the performance of official duties.
(5) The director may apply for, receive and accept grants,
gifts or other payments, including property or services from any
governmental or other public or private person and may make
arrangement for the use of the receipts, including the
undertaking of special studies and other projects relating to the
costs of health care, access to health care, public health and
health care reform.
SECTION 17. ORS 741.027 is amended to read:
741.027. (1) The Oregon Health Insurance Exchange Corporation
board of directors shall select one of its members as chairperson
and another as vice chairperson, for such terms and with duties
and powers necessary for the performance of the functions of
those offices as the board determines.
(2) A majority of the members of the board constitutes a quorum
for the transaction of business.
(3) The board shall meet at least once every three months at a
place, day and hour determined by the board. The board shall meet
at such other times and places specified by the call of the
chairperson or of a majority of the members of the board.
(4)(a) Whenever a member of the board has a conflict of
interest on an issue that is before the board, the member shall
declare to the board the nature of the conflict and the
declaration shall be recorded in the official records of the
board. The member may participate in any discussion on the issue
but may not vote on the issue.
(b) As used in this subsection:
(A) 'Business' has the meaning given that term in ORS 244.020.
(B) 'Business with which the member or the member's relative is
associated' has the meaning given the term 'business with which
the person is associated' in ORS 244.020.
(C) 'Conflict of interest' means that by taking any action or
making any decision or recommendation on an issue, the member,
the member's relative, or any business with which the member or
the member's relative is associated, would receive a private
pecuniary benefit or detriment, unless the pecuniary benefit or
detriment would affect to the same degree a class consisting of
all consumers of or payers for health care in this state.
(5) A member of the board is entitled to compensation and
expenses as provided in ORS 292.495, subject to the availability
of funds in { - the Oregon Health Insurance Exchange Fund - }
{ + an account established under ORS 741.101 + }.
(6) ORS 192.610 to 192.690 apply to the board, to the
Individual and Employer Consumer Advisory Committee established
by ORS 741.029 and to any advisory and technical committees
established by the board under ORS 741.031.
SECTION 18. ORS 741.222 is amended to read:
741.222. (1) The executive director of the Oregon Health
Insurance Exchange Corporation shall report to the Legislative
Assembly each calendar quarter on:
(a) The financial condition of the health insurance exchange,
including actual and projected revenues and expenses of the
administrative operations of the exchange and commissions paid to
insurance producers out of fees collected under ORS 741.105 (5);
(b) The implementation of the business plan adopted by the
corporation board of directors;
(c) The development of the information technology system for
the exchange; and
(d) Any other information requested by the leadership of the
Legislative Assembly.
(2) The corporation board of directors shall provide to the
Legislative Assembly, the Governor, the Oregon Health Authority,
the Oregon Health Policy Board and the Department of Consumer and
Business Services, not later than April 15 of each year:
(a) A report covering the activities and operations of the
corporation during the previous year of operations;
(b) A statement of the financial condition { + , + } { - of
the Oregon Health Insurance Exchange Fund - } as of December 31
of the previous year { + , of the accounts established under ORS
741.101 + };
(c) A description of the role of insurance producers in the
exchange; and
(d) Recommendations, if any, for additional groups to be
eligible to purchase qualified health plans through the exchange
under ORS 741.310.
SECTION 19. ORS 741.381 is amended to read:
741.381. The activities of insurers working under the direction
of the Oregon Health Authority { + , the Oregon Health Insurance
Exchange Corporation + } and the Department of Consumer and
Business Services pursuant to ORS 413.011 (1)(j) or participating
in the { - Oregon Health Insurance Exchange created under
section 17, chapter 595, Oregon Laws 2009, - } { + health
insurance exchange administered under ORS 741.002 + } do not
constitute a conspiracy or restraint of trade or an illegal
monopoly, nor are they carried out for the purposes of lessening
competition or fixing prices arbitrarily.
SECTION 20. ORS 743.730, as amended by section 49, chapter 500,
Oregon Laws 2011, 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 ORS 743.822 (2).
(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.
(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.
(10) 'Dependent' means the spouse or child of an eligible
employee, subject to applicable terms of the health benefit plan
covering the employee.
(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.
(12) 'Employee' means any individual employed by an employer.
(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 - } { + health insurance exchange administered by the
Oregon Health Insurance Exchange Corporation in accordance with
ORS 741.310 + }.
(15) 'Exclusion period' means a period during which specified
treatments or services are excluded from coverage.
(16) '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.
(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.
(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).
(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.
(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.
(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.
(22) 'Individual coverage waiting period' means a period in an
individual health benefit plan during which no premiums may be
collected and health benefit plan coverage issued is not
effective.
(23) 'Initial enrollment period' means a period of at least 30
days following commencement of the first eligibility period for
an individual.
(24) 'Late enrollee' means an individual who enrolls in a group
health benefit plan subsequent to the initial enrollment period
during which the individual was eligible for coverage but
declined to enroll. However, an eligible individual shall not be
considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg as amended and in effect on
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.
(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.
(27) 'Oregon Medical Insurance Pool' means the pool created
under ORS 735.610.
(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.
(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.
(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.
(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 ORS 743.822 (2).
(33)(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 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 21. ORS 743.822 is amended to read:
743.822. (1) { - As a condition of transacting business in
the health benefit plan market in this state, - } { + In each
individual or small group market in which a carrier offers a
health benefit plan through the exchange or outside of the
exchange, + } a carrier { - shall - } { + must + } offer to
residents of this state bronze and silver plans approved by the
Department of Consumer and Business Services as meeting the
requirements of subsection (2) of this section { + . + } { - in
each individual and small group market in which the carrier
offers a health benefit plan through the Oregon Health Insurance
Exchange or outside of the exchange. - }
(2) The Director of the Department of Consumer and Business
Services shall prescribe by rule the:
(a) Requirements for a bronze plan to ensure that a bronze plan
offered in this state is actuarially equivalent to 60 percent of
the full actuarial value of benefits included in the essential
health benefits package prescribed by the United States Secretary
of Health and Human Services under 42 U.S.C. 18022(a).
(b) Requirements for a silver plan to ensure that a silver plan
offered in this state is actuarially equivalent to 70 percent of
the full actuarial value of benefits included in the essential
health benefits package prescribed by the United States Secretary
of Health and Human Services under 42 U.S.C. 18022(a).
(c) Form, level of coverage and benefit design for the bronze
and silver plans to be used by carriers in the individual and
small group market in this state.
SECTION 22. ORS 743.826 is amended to read:
743.826. A carrier may offer a catastrophic plan only through
the { - Oregon Health Insurance Exchange - } { + exchange
+ }and only to an individual who:
(1) Is under 30 years of age at the beginning of the plan year;
or
(2) Is exempt from any state or federal penalties imposed for
failing to maintain minimal essential coverage during the plan
year.
SECTION 23. { + (1) Notwithstanding any other provision of
law, ORS 743.822 and 743.826 shall not be considered to have been
added to or made a part of ORS 743.730 to 743.773 for the purpose
of statutory compilation or for the application of definitions,
penalties or administrative provisions applicable to statute
sections in that series.
(2) ORS 743.822 and 743.826 are added to and made a part of the
Insurance Code. + }
{ +
CAPTIONS + }
SECTION 24. { + The unit captions used in this 2012 Act are
provided only for the convenience of the reader and do not become
part of the statutory law of this state or express any
legislative intent in the enactment of this 2012 Act. + }
{ +
EMERGENCY CLAUSE + }
SECTION 25. { + This 2012 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2012 Act takes effect on
its passage. + }
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