Oregon Bulletin
Rule Caption: Changes
to Rates and Form Filing Rules to Reflect Interstate Insurance Product
Regulation Commission Membership.
Adm. Order No.: ID 20-2011
Filed with Sec. of State: 12-16-2011
Certified to be Effective: 1-1-12
Notice Publication Date: 11-1-2011
Rules Amended: 836-010-0000, 836-010-0011
Rules Repealed: 836-010-0012
Subject: This rulemaking is necessary to implement the
requirements of House Bill 2095 (2011 Session) by which the State of Oregon
becomes a member of the Interstate Insurance Product Regulatory Commission
(IIPRC) on January 1, 2012.
This
rulemaking revises the department’s rules to reflect Oregon’s new status as a
member of the IIPRC. The rules remove obsolete references adopted under
previous legislation to life insurance, annuities or disability insurance
products that the director need not separately consider or review if the form
was already approved by the Interstate Insurance Product Regulation Commission.
This rulemaking reflect Oregon’s new status as a member of the Compact. The
rules remove the obsolete references to those earlier approved products and
clarify that rates and forms approved by the IIPRC are not subject to the
department’s rate and form review process.
The
rules will take effect on and apply to products filed after January 1, 2012,
the date Oregon becomes a member of the IIPRC.
Rules Coordinator: Sue Munson—(503) 947-7272
836-010-0000
Statutory
Authority and Implementation
(1) OAR
836-010-0000, 836-010-0011 and 836-010-0021 are adopted under the authority of
ORS 731.244 and 731.296, to aid in giving effect to provisions of ORS Chapters
737, 742 and 743 relating to the filing of rates and policy forms with the
Director. The requirements of OAR 836-010-0000, 836-010-0011 and 836-010-0021
are in addition to any other requirements established by statute or by rule or
bulletin of the Department.
(2) OAR
836-010-0000, 836-010-0011, and 836-010-0021 apply to all filings submitted or
resubmitted to the Director on or after May 1, 2002.
Stat.
Auth.: ORS 731.244
Stats.
Implemented: ORS 731.296, 737.205, 737.207, 742.001, 743.015 & 743.018
Hist.: ID
9-1994, f. 7-1-94, cert. ef. 7-15-94; ID 20-1997(Temp), f. 12-29-97, cert. ef.
12-30-97 thru 6-11-98; ID 11-1998, f. & cert. ef. 8-10-98; ID
11-2002(Temp), f. & cert. ef. 4-18-02 thru 10-11-02; ID 20-2002, f.
10-11-02, cert. ef. 10-12-02; ID 8-2010, f. 3-31-10, cert. ef. 4-1-10; ID
20-2011, f. 12-16-11, cert. ef. 1-1-12
836-010-0011
Filing,
Review of Rates and Forms
(1) Except
as provided in this section, this rule applies to filings of all insurers,
including health care service contractors as defined in ORS 750.005, multiple
employer welfare arrangements as governed by 750.301 to 750.431 and fraternal
benefit societies as governed by ORS Chapter 748. This rule does not apply to:
(a)
Purchasing group insurance filings.
(b)
Negotiated forms as described in ORS 742.003, but only if each of the
negotiated forms is issued only to one policyholder, the insurer has determined
that the forms comply with benefits and coverages mandated by statute and the
forms have a company-assigned form number.
(c) Rates
and forms approved by the Interstate Insurance Product Regulation Commission.
(2) An
insurer must follow the applicable standards set forth on the Oregon Insurance
Division’s website, www.insurance.oregon.gov/insurer/rates_forms/rateform.html,
when making rate and form filings, except that if the insurer files
electronically on SERFF (System for Electronic Rates and Forms Filing), the
insurer must comply with the Oregon standards set forth in SERFF.
(3) An
insurer must submit a completed certificate of compliance as provided in this
section with each filing of a new or revised rate and each filing of a new or
amended form. The insurer must use the certificate of compliance in Exhibit 1
to this rule. The certificate of compliance must certify compliance with the
applicable filing requirements and product standards set forth on the Oregon
Insurance Division’s website,
www.insurance.oregon.gov/docs/serff/filing_requirements.html, or on the SERFF
system for Oregon, if filed electronically. The certificate must be accompanied
by the applicable product standards form. A certificate of compliance must be
completed and signed by:
(a) An
officer of the insurer who is authorized by the insurer to do so; and
(b) Signed
by the filer who is specifically designated by the insurer to prepare and make
the filing.
(4) An
insurer filing changes to a form or forms that were previously approved must
highlight or otherwise visually call attention to the changes in new or revised
forms and must submit a letter explaining the changes.
(5) A
filing received for prior approval by the Department that does not contain a
certificate of compliance and does not comply with the standards referenced in
this rule is incomplete and will be returned to the insurer as disapproved.
[ED. NOTE:
Exhibits referenced are available from the agency.]
Stat.
Auth.: ORS 731.244 & 731.296
Stats.
Implemented: ORS 731.296, 737.205, 737.207, 742.001, 743.015 & 743.018
& 2011 OL Ch. 520, (Enrolled HB 2095)
Hist.: ID
9-1994, f. 7-1-94, cert. ef. 7-15-94; ID 11-1996, f. 6-28-96, cert. ef. 7-1-96;
ID 20-1997(Temp), f. 12-29-97, cert. ef. 12-30-97 thru 6-11-98; ID 11-1998, f.
& cert. ef. 8-10-98; Administrative correction 6-25-99; ID 6-2000, f. &
cert. ef. 7-19-00; ID 3-2001, f. 3-19-01, cert. ef. 5-1-01; ID 11-2002(Temp),
f. & cert. ef. 4-18-02 thru 10-11-02; ID 20-2002, f. 10-11-02, cert. ef.
10-12-02; ID 8-2010, f. 3-31-10, cert. ef. 4-1-10; ID 20-2011, f. 12-16-11,
cert. ef. 1-1-12
Rule Caption: Aligns
Oregon surplus lines laws with federal Nonadmitted and Reinsurance Reform Act
of 2010.
Adm. Order No.: ID 21-2011
Filed with Sec. of State: 12-16-2011
Certified to be Effective: 1-1-12
Notice Publication Date: 11-1-2011
Rules Adopted: 836-071-0501
Rules Amended: 836-071-0500
Subject: This rulemaking implements House Bill 2679 enacted
by the 2011 Legislative Assembly. House Bill 2679 aligns Oregon surplus lines
laws with the federal Nonadmitted and Reinsurance Reform Act of 2010 that is
part of the federal Dodd-Frank Wall Street Reform and Consumer Protection Act.
The rules amend the current surplus lines licensing and filing requirements
rules and provide new insured and surplus lines licensee requirements regarding
reporting of allocation information on Oregon home state risks.
Rules Coordinator: Sue Munson—(503) 947-7272
836-071-0500
Nonresident
Licensing and Placement Requirements
(1) This
rule establishes requirements that a nonresident surplus lines licensee or a
nonresident insurance producer not licensed in this state must satisfy in
connection with placement of a surplus lines insurance policy where Oregon is
determined to be the home state as defined in ORS 735.405(8).
(2) A
person who is licensed as a resident agent or producer in another state must be
licensed in this state as a nonresident surplus lines insurance licensee in
order to place a surplus lines insurance policy on a risk where Oregon is
determined to be the home state.
(3) When a
nonresident surplus lines licensee transacts surplus lines insurance on a risk
where Oregon is determined to be the home state, the nonresident surplus lines
licensee shall comply with the placement requirements in ORS 735.410(1) and (2)
related to an exempt commercial purchaser
Stat.
Auth.: ORS 731.244 & 735.410
Stats.
Implemented: ORS 735.410
Hist.: ID
6-2002, f. & cert. ef. 2-6-02; ID 21-2011, f. 12-16-11, cert. ef. 1-1-12
836-071-0501
Allocation
of Coverage Totals on Multi-state Policies
(1) This
rule establishes requirements that a surplus lines licensee must satisfy in
connection with the reporting of a surplus lines insurance policy where Oregon
is determined to be the home state as defined in ORS 735.405(8), and the
requirements that an insured who obtains independently procured insurance must
satisfy in connection with the reporting of a surplus lines insurance policy in
section 5, chapter 660, Oregon Laws 2011 where Oregon is determined to be the
home state.
(2) For
each surplus lines insurance policy with coverage starting at any time
beginning January 1, 2012 through December 31, 2016 where Oregon is determined
to be the home state, each insured who obtains independently procured insurance
must include in their written report filed with the Director of the Department
of Consumer and Business Services the allocated premium, by coverage for Oregon
and other applicable states in accordance with the filing instructions on the
Surplus Line Association of Oregon Web site in addition to the filing
requirements in section 5, chapter 660, Oregon Laws 2011. Notwithstanding the
January 1, 2012 through December 31, 2016 time period referenced above, on or
after January 1, 2015 the Director may determine that insureds no longer need
to include this allocated premium information in their filed written report.
(3) For
each surplus lines insurance policy with coverage starting at any time
beginning January 1, 2012 through December 31, 2016 where Oregon is determined
to be the home state, a surplus lines licensee must include in their statement
filed with the Director the allocated premium, by coverage for Oregon and other
applicable states in accordance with the filing instructions on the Surplus
Line Association of Oregon Web site in addition to the filing requirements in
ORS 735.425(1) and (2). Notwithstanding the January 1, 2012 through December
31, 2016 time period referenced above, on or after January 1, 2015 the Director
may determine that surplus lines licensees no longer need to include this
allocated premium information in their filed statement.
(4) The written
report required in section 5, chapter 660, Oregon Laws 2011 and the statements
required in ORS 735.425(1) must be filed with the Surplus Line Association of
Oregon.
Stat.
Auth.: ORS 731.244 & 735.425
Stats.
Implemented: ORS 735.425 & OL 2011, Ch. 660 § 5
Hist.: ID
21-2011, f. 12-16-11, cert. ef. 1-1-12
Rule Caption: Requires
vendors to obtain limited license to sell portable electronics insurance.
Adm. Order No.: ID 22-2011
Filed with Sec. of State: 12-16-2011
Certified to be Effective: 1-1-12
Notice Publication Date: 11-1-2011
Rules Adopted: 836-071-0550, 836-071-0560, 836-071-0565, 836-071-0570
Subject: This rulemaking implements House Bill 3411 enacted
by the 2011 Legislative Assembly. House Bill 3411 requires that vendors who
sell or lease portable electronics devices, such as cell phones or electronic
tablets, must obtain a limited insurance producer license from the Department
of Consumer and Business Services before issuing, selling or offering portable
electronics insurance coverage to customers. The rules will establish the
vendor application and renewal requirements, including fees, and training
requirements for a vendor’s employees, agents or authorized representatives.
Rules Coordinator: Sue Munson—(503) 947-7272
836-071-0550
Statutory
Purpose and Authority
(1) OAR
836-071-0550 to 836-071-0570 apply to vendors who sell or lease portable
electronics devices, including but not limited to cell phones or electronic
tablets, and wish to issue, sell or offer for sale portable electronics insurance
coverage.
(2) OAR
836-071-0550 to 836-071-0570 are adopted pursuant to the authority in section
7, chapter 393, Oregon Laws 2011 and ORS 705.135, for the purpose of
implementing sections 1 to 7, chapter 393, Oregon Laws 2011.
Stat. Auth.
: Ch. 393 § 7, OL 2011 & ORS 705.135
Stats.
Implemented: Ch. 393 §§ 1 to 7, OL 2011
Hist.: ID
22-2011, f. 12-16-11, cert. ef. 1-1-12
836-071-0560
Limited
License Application, Portable Electronics Insurance Coverage; Required
Information
(1) An
applicant for a portable electronics limited license shall submit to the
Director of the Department of Consumer and Business Services a portable
electronics limited license application on the form entitled “Portable
Electronics Insurance Vendor.” The form is set forth on the Insurance Division
Web site of the Department of Consumer and Business Services at
www.insurance.oregon.gov.
(2) In
addition to the requirements in section 2(2)(b), chapter 393, Oregon Laws 2011,
the applicant shall include all of the following information in the limited
license application:
(a) The
applicant’s corporate, firm or other business entity name, the business
address, e-mail address and telephone number of the principal place of business
and the business address and telephone number of each additional location at
which the applicant will transact business under the limited license.
(b) All
assumed business names and other names under which the applicant will engage in
business under the limited license.
(c) Whether
any of the following has occurred with respect to the applicant or the
employee, agent or authorized representative of the applicant that the
applicant is designating as being responsible for the applicant’s compliance
with chapter 393, Oregon Laws 2011:
(A)
Conviction of or indictment for a crime, including a felony involving
dishonesty or a breach of trust to which 18 U.S.C. sec. 1033 applies;
(B) A
judgment entered against the applicant or person designated by the applicant as
being responsible for the applicant’s compliance with sections 1 to 7, chapter
393, Oregon Laws 2011, for fraud;
(C) A claim
of indebtedness by an insurer or agent, and the details of any such
indebtedness; or
(D)
Refusal, revocation or suspension of any license to act in any occupational or
professional capacity in this or any other state.
(d) All
states and provinces of Canada in which the applicant currently holds a license
to engage in the transaction of insurance, or has held such a license within
ten years prior to the date of the application.
(e) Whether
the applicant has ever filed for bankruptcy or been adjudged a bankrupt.
(f) The
syllabus for the training program that is developed by the insurer or
supervising entity that issued the portable electronics insurance policy to the
limited licensee.
(g) A
certification by the supervising entity or the applicant that all employees,
agents and authorized representatives to be involved in the issuance, sale or
offering for sale of portable electronics insurance coverage to customers have
completed or will complete the training program under section 5(1)(b), chapter
393, Oregon Laws 2011, prior to issuing, selling or offering for sale portable
electronics insurance coverage.
(h) A
certification by the supervising entity or the applicant that a copy of all
written disclosure materials, as required under section 4, chapter 393, Oregon
Laws 2011, that are currently being made available to prospective customers of
portable electronics or have been made available to prospective customers in
the past, shall be maintained by the supervising entity or the applicant. This
information shall be maintained by the supervising entity or the applicant for
a period of seven years and must be provided to the Director, upon request,
within 21 calendar days.
(i) Any other
information requested by the Director in the license application form.
(3) Each
application shall be accompanied by a $200 fee.
(4) During
the review of an application, the Director may require any other information
that the Director determines will assist consideration of the application.
Stat. Auth.
: Ch. 393 § 7, OL 2011 & ORS 705.135
Stats.
Implemented: Ch. 393 §§ 1 to 7, OL 2011
Hist.: ID
22-2011, f. 12-16-11, cert. ef. 1-1-12
836-071-0565
Limited
License Renewal
(1) A
limited license expires on the last day of the month in which the second
anniversary of the initial issuance date occurs. Thereafter, the limited
license shall expire on the second anniversary following each renewal.
(2) A
limited licensee applying for renewal must submit the following to the
Director:
(a) A
completed renewal application on the form entitled “Renewal Notice for Portable
Electronics Insurance Vendors.” The renewal application will be sent by the
Director to the limited licensee prior to the expiration of the limited license.
If mailed back to the Director, the renewal application must be postmarked by
the United States Postal Service or another nationally recognized delivery
service not later than the limited license expiration date.
(b) An
updated certification by the supervising entity or the limited licensee that
all employees, agents and authorized representatives to be involved in the
issuance, sale or offering for sale of portable electronics insurance coverage
to customers have completed or will complete the training program under section
5(1)(b), chapter 393, Oregon Laws 2011, prior to issuing, selling or offering
for sale portable electronics insurance coverage.
(c) An
updated certification by the supervising entity or the limited licensee that a
copy of all written disclosure materials, as required under section 4, chapter
393, Oregon Laws 2011, that are currently being made available to prospective
customers of portable electronics or have been made available to prospective
customers in the past, shall be maintained by the supervising entity or the
applicant. This information shall be maintained by the supervising entity or
the applicant for a period of seven years and must be provided to the Director,
upon request, within 21 calendar days.
(d) A
renewal fee of $200.
(3) The
Director may allow a limited licensee not more than 30 days after the limited
license expiration date to submit missing information on the renewal
application form if the renewal application, fees, certification and disclosure
materials have been submitted on or before the expiration date.
(4) The
Director may request on the renewal application any information requested on
the original application for a limited license.
(5) An
expired limited license may be renewed up to one year after the limited license
expiration date. The fee to renew an expired limited license is $250.
Stat. Auth.
: Ch. 393 § 7, OL 2011 & ORS 705.135
Stats.
Implemented: Ch. 393 §§ 1 to 7, OL 2011
Hist.: ID
22-2011, f. 12-16-11, cert. ef. 1-1-12
836-071-0570
List of
Employees Selling Coverage; Training Program
(1) A
limited licensee shall maintain at all times standard operating procedures to
assure that all employees, agents and authorized representatives are authorized
to issue, sell or offer for sale portable electronics insurance coverage to a
customer. The limited licensee must provide a description of these procedures,
upon request, to the Director within 21 calendar days.
(2) A limited licensee must ensure that
the information required under section 5(1)(b), chapter 393, Oregon Laws 2011,
is included in any training program for the limited licensee’s employees,
agents and authorized representatives who will be issuing, selling or offering
for sale portable electronics insurance coverage.
Stat. Auth.
: Ch. 393 § 7, OL 2011 & ORS 705.135
Stats.
Implemented: Ch. 393 §§ 1 to 7, OL 2011
Hist.: ID
22-2011, f. 12-16-11, cert. ef. 1-1-12
Rule Caption: Implementation
of Legislation Enacting State and Federal Health Insurance Reforms.
Adm. Order No.: ID 23-2011
Filed with Sec. of State: 12-19-2011
Certified to be Effective: 12-19-11
Notice Publication Date: 11-1-2011
Rules Adopted: 836-053-0415, 836-053-0825, 836-053-0830, 836-053-0857, 836-053-0862,
836-053-1033, 836-053-1035
Rules Amended: 836-053-0410, 836-053-0851, 836-053-1000, 836-053-1030, 836-053-1060,
836-053-1070, 836-053-1080, 836-053-1100, 836-053-1110, 836-053-1140,
836-053-1310, 836-053-1340, 836-053-1342, 836-053-1350
Rules Repealed: 836-053-0856, 836-053-0861, 836-053-0866
Subject: These rules implement provisions of Chapter 500,
Oregon Laws 2011 (Enrolled Senate Bill 89). The rules ensure that the Oregon
Insurance Code is consistent with the federal Affordable Care Act, the federal
health care reform law signed by President Obama on March 23, 2010. The rules
also make changes to Oregon administrative rules to ensure consistency with
other state and federal legislation. The changes are generally in these areas:
•
Revisions to Oregon’s rescission provisions including requirements for the
contents of the notice required to be provided to enrollees whose coverage is
rescinded, and requirements and timelines for notice of rescissions that
insurers must provide to the director of the Department of Consumer and
Business Services Division.
•
Clarifying when notice requirements are triggered when an insurer takes
administrative action to cancel coverage under an individual health benefit
plan.
•
Implementing the changes made to the state continuation laws including
clarifying the requirements of the notice that insurers must send to covered
persons and qualified beneficiaries eligible for state continuation coverage;
defining or clarifying statutory terms and explaining circumstances under which
a person is not considered to be a qualified beneficiary.
•
Defining requirements for cultural and linguistic appropriateness in accordance
with federal law.
•
Implementing changes to Oregon’s internal and external review processes for
adverse benefit determinations in a manner that is consistent with and approved
by federal regulators.
•
A number of changes to clarify and make the rules consistent with the statutory
changes enacted by Senate Bill 89.
Rules Coordinator: Sue Munson—(503) 947-7272
836-053-0410
Purpose;
Statutory Authority; Enforcement
(1) OAR
836-053-0410 to 836-053-0465 are adopted under the authority of ORS 743.769 and
section 4a, chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) for the
purpose of implementing ORS 743.766 to 743.769, and section 4a, chapter 500, Oregon
Laws 2011 (Enrolled Senate Bill 89) relating to individual health benefit
plans.
(2)
Violation of any provision of OAR 836-053-0430 to 836-053-0465 is an unfair
trade practice under ORS 746.240.
Stat.
Auth.: ORS 743.769 & § 4a, Ch. 500, OL 2011 (Enrolled SB 89)
Stats.
Implemented: ORS 743.766 - 743.769 & § 4a, Ch. 500, OL 2011 (Enrolled SB
89)
Hist.: ID
12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID
23-2011, f. & cert. ef. 12-19-11
836-053-0415
Cancellation
of an Individual Health Benefit Plan Coverage
The notice
requirements of section 4a, chapter 500, Oregon Laws 2011 (Enrolled Senate Bill
89), are triggered at the time an insurer takes administrative action to
terminate coverage.
Stat.
Auth.: ORS 743.769 & § 4a, Ch. 500, OL 2011 (Enrolled SB 89)
Stats.
Implemented: ORS 743.766–743.769 & § 4a, Ch. 500, OL 2011 (Enrolled
SB 89)
Hist.: ID
23-2011, f. & cert. ef. 12-19-11
836-053-0825
Rescission
of a Group Health Benefit Plan
(1) For
purposes of ORS 743.737 and 743.754, “representative” means a person who, with
specific authority from the small employer or plan sponsor to do so, binds the
small employer or plan sponsor to a contract for health benefit plan coverage.
(2) The
notice required by ORS 743.737 and 743.754 and section 4(3), chapter 500,
Oregon Laws 2011 (Enrolled Senate Bill 89) to each plan enrollee affected by
the rescission must be in writing and include all of the following:
(a) Clear
identification of the alleged fraudulent act, practice or omission or the
intentional misrepresentation of material fact underlying the rescission.
(b) An
explanation of why the act, practice or omission was fraudulent or was an
intentional misrepresentation of a material fact.
(c) A
statement explaining any rights to grieve or request a review of the decision
to rescind coverage.
(d) A
description of the health carrier’s applicable grievance procedures, including
any time limits applicable to those procedures.
(e) A
statement explaining that complaints relating to the subject matter of the
notice required under ORS 743.737 and 743.754 and section 4(3), chapter 500,
Oregon Laws 2011 (Enrolled Senate Bill 89) may be made with the Insurance
Division of the Department of Consumer and Business Services by writing to the
Insurance Division at PO Box 14480, Salem, OR 97309-0405; by calling (503)
947-7984 or (888) 877-4894; or by email at
http://www.cbs.state.or.us/ins/consumer/consumer.html or cp.ins@state.or.us.
The statement shall also explain that complaints to the Insurance Division do
not constitute grievances under the health benefit plan and may not preserve a
member’s rights under the plan.
(f) The
toll-free customer service number of the insurer.
(g) The
effective date of the rescission and the date back to which the coverage will
be rescinded.
(3) Subject
to section 3, chapter 75, Oregon Laws 2010 (Enrolled House Bill 3666), a health
carrier may provide the required notice for small employer group health
insurance or individual health insurance either by first class mail or
electronically.
(4)(a) An
insurer shall provide to the Department of Consumer and Business Services the
notice required by ORS 743.737(8)(c) and (9)(c), 743.754(8)(c) and (9)(c) and
section 4(4), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89) no later
than February 15 of each calendar year. The insurer shall submit the notice
electronically in accordance with instructions provided by the department. The
notice shall include information related to rescissions for the prior calendar
year, including but not limited to the total number of:
(A)
Rescission reviews started;
(B)
Rescissions completed;
(C) Total
rescissions of an entire insurance policy;
(D) Partial
rescissions;
(E)
Individual policies in force on December 31 of the report year;
(F)
Individual health benefit plans that had either a full or partial rescission;
(G) Group
health benefit plans in force on December 31 of the report year; and
(H) Group
health benefit plans that had either a full or partial rescission.
(b) The
notice required under this section may be combined with the notice required
under OAR 836-053-0830.
Stat.
Auth.: ORS 743.018, 743.019, 743.020 & § 4, Ch. 500, OL 2011 (Enrolled SB
89)
Stats.
Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730,
743.737, 743.754 & 743.767 & § 4, Ch. 500, OL 2011 (Enrolled SB 89)
Hist.: ID
23-2011, f. & cert. ef. 12-19-11
836-053-0830
Rescission
of an Individual’s Group, Individual or Portability Health Benefit Plan, or
Group or Individual Health Insurance Coverage.
(1) Subject
to the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, P.L.
99-272, April 7, 1986, and ORS 743.601 and 743.610, for purposes of rescission
of a group health insurance policy under ORS 743.737 and 743.754 and section
4(2), chapter 500, Oregon Laws 2011 (Enrolled Senate Bill 89), “rescission”
does not include retroactive cancellation or discontinuance of coverage of an
enrollee if:
(a) The
enrollee is no longer eligible for such coverage;
(b) The
enrollee has not paid required premiums or contributed to coverage or any
premiums paid have been refunded; and
(c) The
insurer is not notified of the enrollee’s change in eligibility when the change
occurs.
(2) The
notice required by section 4(2), chapter 500, Oregon Laws 2011 (Enrolled Senate
Bill 89) to the individual whose coverage is rescinded must be in writing and
include all of the following:
(a) Clear
identification of the alleged fraudulent act, practice or omission or the
intentional misrepresentation of material fact underlying the rescission.
(b) An
explanation as to why the act, practice or omission was fraudulent or was an
intentional misrepresentation of a material fact.
(c) A
statement informing the individual of any right the individual has to file a
grievance or to request a review of the decision to rescind coverage.
(d) A
description of the health carrier’s grievance procedures, including any time
limits applicable to those procedures if such procedures are available to the
individual.
(e) A statement
explaining that complaints relating to the subject matter of the notice
required under this section may be made with the Oregon Insurance Division at
PO Box 14480, Salem, OR 97309-0405; (503) 947-7984 or (888) 877-4894;
http://www.cbs.state.or.us/ins/consumer/consumer.html; or cp.ins@state.or.us
and that such complaints do not constitute grievances.
(f) The
toll-free customer service number of the insurer.
(g) The
effective date of the rescission and the date back to which the coverage will
be rescinded.
(3) Subject
to chapter 75, Oregon Laws 2010 (Enrolled House Bill 3666), a health carrier
may provide the notice required under section 4(2), chapter 500, Oregon Laws
2011 (Enrolled Senate Bill 89) for small employer group health insurance or
individual health insurance either by first class mail or electronically.
(4)(a) An
insurer shall provide to the Director of the Department of Consumer and
Business Services the notice required by section 4(4), chapter 500, Oregon Laws
2011 (Enrolled Senate Bill 89) no later than February 15 of each calendar year.
The insurer shall submit the notice electronically in accordance with
instructions provided by the department. The notice shall include information
related to rescissions for the prior calendar year, including but not limited
to the total number of:
(A)
Rescission reviews started;
(B)
Rescissions completed;
(C) Total
rescissions of an entire insurance policy;
(D) Partial
rescissions;
(E)
Individual policies in force on December 31 of the report year;
(F)
Individual health benefit plans that had either a full or partial rescission;
(G) Group
health benefit plans in force on December 31 of the report year; and
(H) Group
health benefit plans that had either a full or partial rescission.
(b) The
notice required under this section may be combined with the notice required
under OAR 836-053-0825.
Stat.
Auth.: ORS 731.244 & § 4, Ch. 500, OL 2011 (Enrolled SB 89)
Stats.
Implemented: ORS 743.731 & § 4, Ch. 500, OL 2011 (Enrolled SB 89)
Hist.: ID
23-2011, f. & cert. ef. 12-19-11
836-053-0851
Purpose;
Authority; Applicability; and Enforcement
OAR
836-053-0851 to 836-053-0862 apply to insurers issuing continuation coverage as
required under ORS 743.610 and are adopted under the authority of ORS 731.244,
743.601 and 743.610 and section 2, chapter 73, Oregon Laws 2009.
Stat.
Auth.: ORS 731.244, 743.610 & 2009 OL Ch. 73 (HB 2433)
Stats.
Implemented: ORS 743.610 & 2009 OL Ch. 73 (HB 2433)
Hist.: ID
12-2010, f. & cert. ef. 6-11-10, ID 23-2011, f. & cert. ef. 12-19-11
836-053-0857
Definitions
(1) As used
in ORS 743.601, “enrollee” has the same meaning as “covered person” as defined
in ORS 743.610.
(2) As used
in ORS 743.610:
(a) “Claim”
means a request for payment of medical treatment, services, drugs, equipment,
or other medical benefit under a health benefit plan.
(b) “Notice”
means the notice provided by an insurer to a covered person or qualified
beneficiary about continuing group coverage after a qualifying event.
(c) “Qualified
beneficiary” does not include:
(A) An individual
eligible for Federal Medicare coverage.
(B) An
individual eligible for any other group health plan. This limitation does not
apply to coverage consisting only of:
(i) Dental,
vision, counseling, or referral services;
(ii)
Coverage under a health flexible spending arrangement as defined in section
106(c)(2) of the Internal Revenue Code of 1986; or
(iii)
Treatment that is furnished in an on-site medical facility maintained by an
employer.
(d) “Similar”
means a plan that provides benefits that are the same or nearly the same as the
coverage provided under the group health benefit plan that is being terminated.
(3) As used
in ORS 743.610(7)(a), “coverage” means the benefits provided under a health
benefit plan continued by a covered person or qualified beneficiary.
(4) As used
in ORS 743.601 and 743.610 “dissolution” includes a separation upon a judgment
of separation granted pursuant to ORS 107.025.
Stat.
Auth.: ORS 731.244, 743.601, & 743.610 & 2009 OL Ch. 73 (HB 2433)
Stats.
Implemented: ORS 743.601 & 743.610 & 2009 OL Ch. 73 (HB 2433)
Hist.: ID
23-2011, f. & cert. ef. 12-19-11
836-053-0862
Notifications
(1) For
purposes of the notice required by ORS 743.610(10):
(a) An
insurer may provide a single notice under ORS 743.610(10) to a covered person
and a qualified beneficiary when:
(A) The
notice is addressed to the covered person or qualified beneficiary at the last
known address of the covered person or qualified beneficiary;
(B) The
covered person and qualified beneficiary are eligible for state continuation
coverage by virtue of the same qualifying event; and
(C) The
covered person and qualified beneficiary have the same last known mailing
address.
(b) An
insurer that does not require a covered person or qualified beneficiary to
complete a form to request continuation of coverage need not include a form in
the notice. However, the insurer must provide sufficient instructions to inform
the covered person or qualified beneficiary how to apply for continuation of
coverage.
(c) An
insurer is not required to include premium rates in the notice. However, an
insurer that does not provide premium rates for continuation of coverage in the
notice must instruct the covered person or qualified beneficiary how and from
whom the premium rates can be obtained.
(d) The
requirement to provide written notice under ORS 743.610(1) may be triggered
either by the notification of a qualifying event received from the covered
person or qualified beneficiary under ORS 743.610(5) or notice of the
qualifying event submitted to the insurer by the group policy holder.
(e) The
enrollment information required to be in the notice under ORS 743.610(10) may
instruct the covered person or qualified beneficiary to contact the employer or
group for information about additional coverage for which the covered person or
qualified beneficiary may be eligible.
(f) The
explanation of appeal rights required to be included in the notice under ORS
743.610(1) may be provided by a statement that continuation coverage constitutes
continued coverage under the group policy and that the covered person or
qualified beneficiary has the same rights to appeal or grieve a decision by the
insurer on a medical claim that exists under the group policy unless the group
policy has been replaced with coverage that provides different appeal or
grievance rights.
(2) Notice
provided under ORS 743.610 must include the following information: “Oregon
Insurance Division, (503) 947-7984 or (888) 877-4894.”
Stat.
Auth.: ORS 731.244, 743.601 & 743.610
Stats.
Implemented: ORS 743.601 & 743.610
Hist.: ID
23-2011, f. & cert. ef. 12-19-11
836-053-1000
Statutory
Authority and Implementation
(1) OAR
836-053-1000 to 836-053-1200 are adopted under the authority of ORS 731.244,
743.814, and 743.819, for the purpose of implementing ORS 743.804, 743.807,
743.814, 743.817, 743.819, 743.821, 743.829, 743.837 and 743A.012. The filing
and reporting requirements in this rule and in OAR 836-053-1070, 836-053-1130,
836-053-1170, and 836-053-1190 apply to all domestic insurers transacting
health benefit plans, including health care service contractors, to all foreign
carriers transacting health benefit plans who transacted $2 million or more in
annual health benefit plan premium in Oregon, and to other carriers transacting
health benefit plans as determined by the Director of the Department of
Consumer and Business Services.
(2) When an
insurer maintains more than one type of health benefit plan, the insurer shall
comply with OAR 836-053-1000 to 836-053-1200 on a plan-by-plan basis.
(3) Not
later than June 30 of each year, each insurer shall file with the director for
the immediately preceding calendar year the following information as required
of the insurer:
(a) An
annual summary of the insurer’s aggregate data relating to grievances, appeals
and applications for external review, required by ORS 743.804of all insurers;
(b) An
annual summary relating to the insurer’s utilization review policies, required
by ORS 743.807(1) of each insurer that provides utilization review or has
utilization review provided on its behalf;
(c) An
annual summary relating to the insurer’s quality assessment activities required
by ORS 743.814(2) of each insurer that offers managed health insurance;
(d) The
results of all publicly available federal Health Care Financing Administration
reports and accreditation surveys by national accreditation organizations
required by ORS 743.814(3)(a) of each insurer that offers managed health
insurance;
(e) The
insurer’s health promotion and disease prevention activities, if any, including
a summary of screening and preventive health care activities covered by the
insurer, required by ORS 743.814(3)(b) of each insurer that offers managed
health insurance. The insurer may submit the summary required in this
subsection in the format of the insurer’s choosing, including a summary
prepared for another purpose. The summary required in this subsection shall
include the following activities, to the extent the insurer engages in them,
and may include any additional information that the insurer deems significant
in describing its health promotion and disease prevention activities:
(A) Tobacco
use and cessation;
(B) Cancer
screening, including mammography;
(C)
Diabetes education and home monitoring;
(D)
Immunizations;
(E)
Childbirth education and parenting support;
(F)
Nutrition;
(G)
Cardiovascular health; and
(H) Injury
prevention; and
(f) An
annual summary relating to the scope of the insurer’s network and to the
accessibility of services, required by ORS 743.817(1) of each insurer that
offers managed health insurance.
(4) In
order to minimize duplicative reporting requirements, an insurer may submit a
copy of a report prepared for a national accreditation organization to meet the
reporting requirements of section (3)(e) of this rule relating to the insurer’s
health promotion and disease prevention activities, OAR 836-053-1130(1)
relating to the insurer’s utilization review policies, OAR 836-053-1170(1)
relating to the insurer’s quality assessment activities and OAR 836-053-1190(1)
relating to the insurer’s provider network and the accessibility of services.
To the extent that a report prepared for a national accreditation organization
does not include information required by the department, the insurer must
submit an addendum to the report that provides this information.
(5) If
information required to be filed annually with the department pursuant to this
rule has not changed since an insurer’s previous annual filing, an insurer may
satisfy the reporting requirements of this rule by indicating that the
information has not changed, or if some but not all information has changed, by
submitting an addendum to the previous annual filing indicating only the
information that has changed since the previous filing. However, every third
year the insurer must file all required information, including information that
may not have changed since the previous filing. For example, if an insurer made
an annual filing in 1998, it is sufficient to indicate in 1999 and 2000 that
certain information has not changed since the previous annual filing or to
submit an addendum indicating the information that has changed, but the filing
in 2001 must contain all information required by the department pursuant to
this rule.
(6) All
filings required in section (3) of this rule must be made electronically.
(7) For
purposes of OAR 836-053-1000 to 836-053-1200, “insurer” also includes a health
care service contractor as defined in ORS 750.005 and a multiple employer
welfare arrangement as defined in ORS 750.301.
(8) OAR
836-053-1000 to 836-053-1200 apply to a self-insured public entity to the
extent provided in ORS 731.036.
(9) An
insurer shall administer the plan in compliance with ORS 743.804, 743.807, 743.814,
743.817, 743.821, 743.829, 743.837 and 743A.012 and OAR 836-053-1000 to
836-053-1200.
(10) An
insurer shall comply with the federal Newborns’ and Mothers’ Health Protection
Act of 1996, as referred to in ORS 743.823 with respect to group health insurance
plans and individual health insurance plans.
Stat.
Auth.: ORS 731.244, 743.814 & 743.819
Stats.
Implemented: ORS 743.804, 743.807, 743.814, 743.817, 743.819, 743.821, 743.829,
743.837 & 743A.012
Hist.: ID
1-1998, f. & cert. ef. 1-15-98; ID 5-2000, f. & cert. ef. 5-11-00; ID
15-2010, f. & cert. 8-19-10; ID 23-2011, f. & cert. ef. 12-19-11
836-053-1030
Written
Information to Enrollees
(1) Each
insurer must furnish the written general information to policyholders that is
required by ORS 743.804, including but not limited to information relating to
enrollee rights and responsibilities, including the right to appeal adverse
benefit determinations, services, access thereto and related charges and
scheduling, and access to external review, as provided in this rule. An
insurer:
(a) Must
furnish the information regarding an individual health insurance policy to each
policyholder; and
(b) Must
furnish the information regarding a group health insurance policy to the group
policyholder for distribution to enrollees of the group policy.
(2)(a) The
written general information referred to in section (1) of this rule must be
included either in the policy or in other evidence of coverage that is
delivered to the individual policyholder by the insurer, or in the case of a
group health insurance policy, that is delivered by the insurer to the group
policyholder for distribution to enrollees.
(b) For
purposes of ORS 743.804(2)(g), “continued coverage under the health benefit
plan” means coverage of an ongoing course of treatment previously approved by
the insurer.
(c) The
information required under subsection (a) of this section must include all of
the following:
(A) A
description of the external review process, including when external review is
available and how to request external review. The description must include the
phone number of the Oregon Insurance Division.
(B) A
disclosure that when filing a request for an external review the enrollee will
be required to authorize the release of any records, including medical records
of the covered person that may be required to be reviewed for the purpose of
reaching a decision on the external review.
(C) A
disclosure that the enrollee is financially responsible for benefits paid to or
on behalf of an enrollee pursuant to ORS 743.804(2)(g) if the insurer’s adverse
benefit determination is upheld on appeal.
(D) A
disclosure that the enrollee may request and receive from the insurer the
information the insurer is required to disclose under ORS 743.804(5).
(3) The
written general information must disclose the following in relation to
referrals for specialty care, behavioral health services, hospital services and
other services, in addition to other relevant information regarding referrals:
(a) If
applicable, how gate keeping or access controls apply to referrals and whether
and how the controls differ for specialty care, behavioral health services and
hospital services; and
(b) Any
limitation on referrals if a plan has a defined network of participating
providers and if referrals for specialty care may be limited to a portion of
the network, such as to those specialists who contract with an enrollee’s
primary care group.
(4) The
written general information must include the information required by ORS
743.699, relating to coverage of emergency medical conditions and obtaining
emergency services, including a statement of the prudent layperson standard for
an emergency medical condition, as that term is defined in 743.801. An insurer
may meet the requirement of providing information in 743.699 by providing
adequate disclosure in the written general information required by 743.804(5)
and this rule. An insurer may use the following statement regarding the use of
the emergency telephone number 9-1-1, or other wording that appropriately
discloses its use:
If you or a
member of your family needs immediate assistance for a medical emergency, call
9-1-1 or go directly to an emergency room.
(5) The
written general information must include information regarding the use of the
insurer’s grievance process, including the assistance available to enrollees in
filing written grievances in accordance with OAR 836-053-1090 and the
utilization review appeal procedures required by ORS 743.807(2)(c). The
information must be contained in a separate section of the written information
and captioned in a manner that clearly indicates that the section addresses
grievances and appeals.
(6) The
written general information must include a notice that states the right to file
a complaint with or seek assistance from the Director of the Department of
Consumer and Business Services. An insurer may use the following statement or
other appropriate wording for this purpose:
You have
the right to file a complaint or seek other assistance from the Oregon
Insurance Division. Assistance is available:
By calling
(503) 947-7984 or the toll free message line at (888) 877-4894.
By writing
to the Oregon Division of Insurance, Consumer Advocacy Unit,
PO Box
14480; Salem, OR 97309-0405.
Through the
Internet at http://www.insurance.oregon.gov/consumer/
consumer.html
By e-mail
at: cp.ins@state.or.us
(7) The
written general information for an insurance policy providing managed health
care must include a description of the procedures by which enrollees,
purchasers and providers may participate in the development and implementation
of insurer policy and operation.
(8) The
portion of the written general information that describes how an insurer makes
decisions regarding coverage and payment for treatment or services must include
a notice to enrollees that they may request an additional written summary of
information that the insurer may consider in its utilization review of a
particular condition to the extent the insurer maintains such criteria. The
notice to enrollees must include the name and telephone number of the
administrative section of the insurer that handles enrollee requests for
information.
(9) If a
plan has a defined network of participating providers, the written general
information must include a list of all primary care providers and direct access
providers, and may also include a list of all specialty care providers. For the
purposes of this section, a primary care provider or direct access provider is
a participating provider under the terms of the plan who an enrollee may designate
as the primary care provider for the enrollee or from whom an enrollee may
obtain services without referral. The list of providers must include for each
provider the provider’s name, professional designation, category of practice
and the city in which the practice of the provider is located. If the
information does not list participating specialty care providers, the
information must state that fact and must disclose the manner in which an
enrollee may obtain information about participating specialty care providers.
(10) If a
plan includes risk-sharing arrangements with physicians or other providers, the
written general information must contain a statement to that effect, including
a brief description of risk-sharing in general, and must notify enrollees that
additional information is available upon request. For the purpose of this
requirement, a risk-sharing arrangement does not include a fee-for-service
arrangement or a discounted fee-for-service arrangement. An insurer may use the
following statement to describe risk-sharing, or other appropriate wording:
This plan
includes “risk-sharing” arrangements with physicians who provide services to
the members of this plan. Under a risk-sharing arrangement, the providers that
are responsible for delivering health care services are subject to some
financial risk or reward for the services they deliver. An example of a risk
sharing arrangement is a contract between an insurer and a group of heart
surgeons in which the surgeons agree to provide all of the heart operations
needed by plan members and the insurer agrees to pay a fixed monthly amount for
those services.
(11) If the
insurer of a plan uses a mandatory closed formulary, the written general
information for that plan must prominently disclose and explain the formulary
provision. The disclosure and explanation must be in boldfaced type or
otherwise emphasized.
(12) The
written general information must include a notice disclosing that additional
information is available to enrollees upon request to the insurer. The notice
must include the name and telephone number of the insurer’s administrative
section that handles enrollee requests for information. For the notice required
in the written general information disclosing information available from the
Department of Consumer and Business Services, an insurer may use the following
statement, or other appropriate wording:
The
following information regarding the health benefit plans of (insurer’s name) is
available from the Oregon agency:
1. An
annual summary of grievances and appeals;
2. (if
applicable) An annual summary of utilization review policies;
3. (if
applicable) An annual summary of quality assessment activities;
4. (if
applicable) The results of all publicly available accreditation surveys;
5. (if
applicable) An annual summary of the insurer’s health promotion and disease
prevention activities;
6. (if
applicable) An annual summary of scope of network and accessibility of
services.
This
information is available:
By calling
(503) 947-7984 or the toll free message line at (888) 877-4894.
By writing
to the Oregon Division of Insurance, Consumer Advocacy Unit,
PO Box
14480; Salem, OR 97309-0405.
Through the
Internet at http://www.insurance.oregon.gov/consumer/
consumer.html
Or by
e-mail at: cp.ins@state.or.us
Stat.
Auth.: ORS 731.244 & 743.857
Stats.
Implemented: ORS 743.699, 743.804 & 743.807
Hist.: ID
1-1998, f. & cert. ef. 1-15-98; ID 5-2000, f. & cert. ef. 5-11-00; ID
11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. &
cert. ef. 12-19-11
836-053-1033
Cultural
and Linguistic Appropriateness
(1) All
notices and communications required to be provided by an insurer to enrollees
under ORS 743.804 and 743.857 must be provided in a manner that is culturally
and linguistically appropriate, as required by ORS 743.804. For purposes of
this section, an insurer is considered to provide relevant notices in a
culturally and linguistically appropriate manner if the plan or issuer meets
all the following requirements with respect to the applicable non-English
languages as described in section (2) of this rule:
(a) The
plan or issuer must provide oral language services (such as a telephone
customer assistance hotline) that include answering questions in any applicable
non-English language and providing assistance with filing claims and appeals
(including external review) in any applicable non-English language.
(b) The
plan or issuer must provide, upon request, a notice in any applicable
non-English language.
(c) The
plan or issuer must include in the English versions of all notices, a statement
prominently displayed in any applicable non-English language clearly indicating
how to access the language services provided by the plan or issuer.
(2) For the
purpose of this rule, “applicable non-English language” means, with respect to
an address in any United States county to which a notice is sent, a non-English
language for which ten percent or more of the population residing in the county
is literate only in the same non-English language.
Stat.
Auth.: ORS 731.244 & 743.804
Stats.
Implemented: ORS 743.804
Hist.: ID
23-2011, f. & cert. ef. 12-19-11
836-053-1035
Summary of
Benefits and Explanation of Coverage
The summary
of benefits and explanations of coverage required by ORS 743.804 must be
provided in a manner and form consistent with the requirements of 45 CFR
147.200 as set forth on August 22, 2011.
Stat.
Auth.: ORS 731.244 & 743.804
Stats.
Implemented: ORS 743.804
Hist.: ID
23-2011, f. & cert. ef. 12-19-11
836-053-1060
Definitions
For
purposes of grievance procedures under OAR 836-053-1000 to 836-053-1200, and
ORS 743.804:
(1) “Complaint”
means an expression of dissatisfaction directly to an insurer that is about a
specific problem encountered by an enrollee or about a decision by an insurer
or by an insurance producer acting on behalf of the insurer and that includes a
request for action to resolve the problem or change the decision. “Complaint”
does not include an inquiry as that term is defined in this rule.
(2) “Inquiry”
means a written request for information or clarification about any subject
matter related to the enrollee’s health benefit plan.
Stat.
Auth.: ORS 731.244 & 743.819
Stats.
Implemented: ORS 743.801 & 743.804
Hist.: ID
1-1998, f. & cert. ef. 1-15-98; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID
23-2011, f. & cert. ef. 12-19-11
836-053-1070
Reporting
of Grievances; Format and Contents
(1) For the
purpose of complying with the requirement in ORS 743.804 that each insurer
provide an annual summary of the insurer’s aggregate data regarding grievances,
appeals and applications for external review, an insurer must report the data
required in section (2) of this rule for grievances closed in the previous
calendar year ending December 31. The data must be reported in a format prescribed
by the Director of the Department of Consumer and Business Services. For
purposes of this rule, a grievance is “closed” if:
(a) The
grievance has been appealed through all available grievance appeal levels; or
(b) The
insurer determines that the complainant is no longer pursuing the grievance.
(2) The
data to be included in the annual summary are as follows:
(a) The
total number of grievances closed in the reporting year;
(b) The
number of grievances closed in each of the categories listed in section (3) of
this rule;
(c) The
number and percentage of grievances in each of the categories listed in section
(3) of this rule in which the insurer’s initial decision is upheld and the
number and percentage in which the initial decision is reversed at closure of
the grievance;
(d) The
number and percentage of all grievances that are closed at the conclusion of
the first level of appeal;
(e) The
number and percentage of all grievances that are closed at the conclusion of
the second level of appeal;
(f) The
number and percentage of all grievances that result in applications for
external review; and
(g) For
each level of appeal listed in subsections (d) and (e) of this section, the
average length of time between the date an enrollee files the appeal and the
date an insurer sends written notice of the insurer’s determination for that
appeal to the enrollee, or person filing the appeal on behalf of the enrollee.
(3) An
insurer must report each grievance according to the nature of the grievance.
The nature of the grievance shall be determined according to the categories
listed in this section. The insurer must report each grievance in one category
only and must have a system that allows the insurer to report accurately in the
specified categories. If a grievance could fit in more than one category, an
insurer shall report the grievance in the category established in this section
that the insurer determines to be most appropriate for the grievance. The
categories of grievances are as follows:
(a) Adverse
benefit determinations based on medical necessity under ORS 743.857;
(b) Adverse
benefit determinations based on an insurer’s determination that a plan or
course of treatment is experimental or investigational under ORS 743.857;
(c)
Continuity of care as defined in ORS 743.854;
(d) Access
and referral problems including timelines and availability of a provider and
quality of clinical care;
(e) Whether
a course or plan of treatment is delivered in an appropriate health care
setting and with the appropriate level of care;
(f) Adverse
benefit determinations of otherwise covered benefits due to imposition of a
preexisting condition exclusion, source-of-injury exclusion, out-of-network or
out-of-plan exclusion, annual benefit limits or other limitations of otherwise
covered benefits;
(g) Adverse
benefit determinations based on general exclusions, not a covered benefit or
other coverage issues not listed in this section;
(h)
Eligibility for, or termination of enrollment, rescission or cancelation of a
policy or certificate;
(i) Quality
of plan services, not including the quality of clinical care as provided in
subsection (d) of this section;
(j)
Emergency services; and
(k)
Administrative issues and issues other than those otherwise listed in this
section.
(4) Nothing
in this rule prohibits an insurer from creating or using its own system to
categorize the nature of grievances in order to collect data if the system
allows the insurer to report grievances accurately according to the categories
in section (3) of this rule and if the system enables the director to track the
grievances accurately.
Stat.
Auth.: ORS 731.244 & 732.819
Stats.
Implemented: ORS 743.804
Hist.: ID
1-1998, f. & cert. ef. 1-15-98; ID 15-2010, f. & cert. 8-19-10; ID
23-2011, f. & cert. ef. 12-19-11
836-053-1080
Tracking
Grievances
An insurer
shall record data relating to all grievances, significant actions taken from
each initial grievance filing through the appeals process, and applications for
external review as required by ORS 743.804, in a manner sufficient for the
insurer to report grievances accurately as required by ORS 743.804 and OAR
836-053-1070, and for the insurer to track individual files in response to a
market conduct examination or other inquiry by the Director of the Department
of Consumer and Business Services under ORS 733.170 and OAR 836-080-0215. In
accordance with ORS 743.804, records documenting grievances must be maintained
for a period of at least six years after the date the record is generated.
Stat.
Auth.: ORS 731.244 & 743.819
Stats.
Implemented: ORS 743.804
Hist.: ID
1-1998, f. & cert. ef. 1-15-98; ID 15-2010, f. & cert. 8-19-10; ID
23-2011, f. & cert. ef. 12-19-11
836-053-1100
Internal
Appeals Process
(1) The
minimum standards for timeliness of response by an insurer to appeals by its
enrollees, for purposes of the system of resolving and appeals required by ORS
743.804 are as follows:
(a) An
insurer shall acknowledge receipt of an appeal from an enrollee not later than
the seventh day after receiving the appeal;
(b) An
insurer shall make a decision on the appeal not later than the 30th day after
receiving notice of the appeal.
(2) An
otherwise applicable standard for timeliness in section (1) of this rule does
not apply when:
(a) The
period of time is too long to accommodate the clinical urgency of the
situation;
(b) The
enrollee does not reasonably cooperate; or
(c)
Circumstances beyond the control of a party prevent that party from complying
with the standard, but only if the party who is unable to comply gives notice
of the specific circumstances to the other party when the circumstances arise.
(3) For
adverse benefit determinations eligible for external review under ORS 743.857,
an insurer may waive its internal appeals process at any time. If the insurer
waives its internal appeals process, the internal appeals process is deemed
exhausted for the purposes of qualifying for external review.
Stat.
Auth.: ORS 731.244
Stats.
Implemented: ORS 743.804
Hist.: ID
1-1998, f. & cert. ef. 1-15-98; ID 5-2000, f. & cert. ef. 5-11-00; ID
11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11; ID 23-2011, f. &
cert. ef. 12-19-11
836-053-1110
Notice of
Complaint Filing with Director
(1) A
written decision by an insurer in response to a grievance, a first appeal and a
second appeal must prominently disclose the following:
You have
the right to file a complaint or seek other assistance from the Oregon agency.
Assistance is available:
By calling
(503) 947-7984 or the toll free message line at (888) 877-4894.
By writing
to the Oregon Division of Insurance, Consumer Advocacy Unit,
PO Box
14480; Salem, OR 97309-0405.
Through the
Internet at http://www.insurance.oregon.gov/consumer/
consumer.html
Or by
e-mail at: cp.ins@state.or.us
(2) The
information stated in section (1) of this section is subject to change upon
notice from the Director of the Department of Consumer and Business Services.
Stat.
Auth.: ORS 731.244
Stats.
Implemented: ORS 743.804
Hist.: ID
1-1998, f. & cert. ef. 1-15-98; ID 23-2011, f. & cert. ef. 12-19-11
836-053-1140
Appeal,
Utilization Review Determinations
(1) When a
provider first appeals the decision of an insurer to deny treatment or payment
for services as not medically necessary or experimental under ORS
743.807(2)(c):
(a) The
insurer shall acknowledge receipt of the notice of appeal not later than the
seventh day after receiving the notice; and
(b) An
appropriate medical consultant or peer review committee shall review the appeal
and decide the issue not later than the 30th day after the insurer receives
notice of the appeal.
(2) A
standard for timeliness in section (1) of this rule does not apply when:
(a) The
period of time is too long to accommodate the clinical urgency of the
situation;
(b) The
provider does not reasonably cooperate; or
(c)
Circumstances beyond the control of a party prevent that party from complying
with the standard, but only if the party who is unable to comply gives notice
of the specific circumstances to the other party when the circumstances arise.
(3) An
insurer shall treat an appeal from a decision by a medical consultant or peer
review committee pursuant to section (1)(b) of this rule as an internal appeal
under the insurer’s grievance procedures under ORS 743.804(3).
(4) Nothing
in this rule shall prevent an enrollee from filing an internal appeal under the
insurer’s regular grievance procedure established pursuant to ORS 743.804 when
the grievance concerns an adverse benefit determination, but this rule does not
entitle a person not otherwise allowed to file a grievance or to appeal a
decision by a medical consultant or peer review committee to file such a
grievance or appeal.
Stat.
Auth.: ORS 731.244
Stats.
Implemented: ORS 743.804, 743.806 & 743.807
Hist.: ID
1-1998, f. & cert. ef. 1-15-98; ID 23-2011, f. & cert. ef. 12-19-11
836-053-1310
Contracting
Requirements
(1) To be
considered for contracting with the Director of the Department of Consumer and
Business Services as an independent review organization under ORS 743.858 for
the purpose of providing independent review under ORS 743.857, an independent
review organization must submit to the director a response to the director’s
request for proposal according to its requirements. The response must include:
(a) For an
independent review organization that is publicly held, the name of each
stockholder or owner of more than five percent of any stock or options;
(b) The
name of any holder of bonds or notes of the independent review organization that
exceed $100,000;
(c) The
name and type of business of each corporation or other organization that the
independent review organization controls or is affiliated with and the nature
and extent of the affiliation or control;
(d) The
name and a biographical sketch of each director, officer and executive of the
independent review organization and any entity listed under subsection (c) of
this section and a description of any relationship the named individual has
with:
(A) An
insurer;
(B) A
utilization review agent;
(C) A
nonprofit or for-profit hospital or other health care corporation;
(D) A
doctor of medicine or osteopathy, a provider or other health care professional;
(E) A drug
or device manufacturer; or
(F) A group
representing any of the entities described by paragraph (A) to (E) of this
subsection;
(e) The
percentage of the independent review organization’s revenues that the
independent review organization anticipates will be derived from reviews
conducted under ORS 743.862;
(f) A
description of the areas of expertise of the medical reviewers making review
determinations for the independent review organization, as well as policies and
standards of the independent review organization that address qualifications,
training and assignment of all types of medical reviewers and that are
compliant with requirements of OAR 836-053-1317;
(g) The
procedures that the independent review organization will use in making review
determinations regarding reviews conducted under ORS 743.862;
(h)
Attestations that all requirements will be met;
(i)
Evidence of accreditation by a nationally recognized private accrediting
organization;
(j) Other
documentation, including but not limited to legal and financial information,
policies and procedures, and data that are pertinent to requirements of ORS
743.862 and OAR 836-053-1315; and
(k) Any
other requirements established by the director that demonstrate the independent
review organization’s ability to meet all requirements for contracting as an
independent review organization in this state.
(2) In
order to enable the director to consider the response of an independent review
organization under section (1) of this rule:
(a) The
independent review organization must authorize release of information from
primary sources, including full reports of site visits, inspections and audits;
and
(b) The
Director may require the independent review organization to indicate which
documents demonstrate compliance with specific statutory requirements under ORS
743.862 and OAR 836-053-1315.
(3) Investigation
and verification activities of the director regarding the independent review
organization may include, but are not limited to:
(a) Review
of the response of the independent review organization to the request for
proposals and its filings for completeness and compliance with standards;
(b) On-site
survey or examination;
(c)
Primary-source verification with accreditation or regulatory bodies of
compliance with requirements that are used to demonstrate compliance with
applicable standards established in ORS 743.862 and OAR 836-053-1315; and
(d) Other
means of determining regulatory and accreditation histories.
Stat.
Auth.: ORS 731.244, 743.857 & 743.858
Stats.
Implemented: ORS 743.858
Hist.: ID
10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02,
cert. ef. 9-28-02; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11;
ID 23-2011, f. & cert. ef. 12-19-11
836-053-1340
Timelines
and Notice for Dispute That is Not Expedited
(1) An
insurer shall give the Director of the Department of Consumer and Business
Services notice of an enrollee’s request for independent review by delivering a
copy of the request to the director not later than the second business day of
the insurer after the insurer receives the request for the independent review.
In the event the enrollee applies to the director rather than to the insurer
for independent review, the director shall provide the insurer notice of the
enrollee’s request for independent review by delivering a copy of the request
to the insurer not later than the next business day of the department after the
director receives the request for independent review.
(2) If an
insurer reverses its final adverse determination before expiration of the
deadline for sending the notice to the director under section (1) of this rule,
the insurer must notify the enrollee not later than the next business day of
the insurer after its reversal. The notice to the enrollee may be given
electronically, by facsimile or by telephone, followed by a written
confirmation.
(3) Not
later than the next business day of the department after the director has
received a request for independent review from an insurer or an enrollee, the
director shall assign the review to one of the independent review organizations
with whom the director has contracted. The director shall notify the insurer in
writing of the name and address of the independent review organization to which
the request for the independent review should be sent. If sending written
notice will unduly delay notification, the director shall give the notice
electronically, by facsimile or by telephone, followed by a written
confirmation.
(4) The
director shall notify the enrollee, not later than the second business day of
the department after the director gave notice under section (3) of this rule of
the assignment of the request. The notice must include a written description of
the independent review organization selected to conduct the independent review
and information explaining how the enrollee may provide the director with
documentation regarding any potential conflict of interest of the independent
review organization as described in OAR 836-053-1320.
(5) Not
later than the third calendar day following receipt of notice from the director
under section (4) of this rule, or the subsequent business day of the
department if any of the days is not a normal business day of the department,
the enrollee may provide the director with documentation regarding a potential
conflict of interest of the independent review organization. The documentation
shall be sent in written form. If sending written documentation will unduly
delay the process, the enrollee shall give the notice electronically, by
facsimile or by telephone, followed by a written confirmation. If the director
determines that the independent review organization presents a conflict of
interest as described in OAR 836-053-1320, the director shall assign another
independent review organization not later than the next business day of the
department. The director shall notify the insurer of the new independent review
organization to which the request for the independent review should be sent.
The director shall also notify the enrollee of the director’s determination regarding
the potential conflict of interest and the name and address of the new
independent review organization.
(6) Not later than the sixth business
day of the insurer after the date on which the insurer received notice from the
director under section (3) of this rule, the insurer shall deliver to the
assigned independent review organization the following documents and
information considered in making the insurer’s final adverse decision,
including the following:
(a)
Information submitted to the insurer by a provider or the enrollee in support
of the request for coverage under the health benefit plan’s procedures.
(b)
Information used by the health benefit plan during the internal appeal process
to determine whether the course or plan of treatment is:
(A) Medically
necessary;
(B)
Experimental or investigational; or
(C) An
active course of treatment for purposes of continuity of care.
(c) A copy
of all denial letters issued by the plan concerning the case under review.
(d) A copy
of the signed waiver form, or a waiver, authorization or consent that is
otherwise permitted under the federal Health Insurance Portability and
Accountability Act or other state or federal law, authorizing the insurer to
disclose protected health information, including medical records, concerning
the enrollee that is pertinent to the independent review.
(e) An
index of all submitted documents.
(7) Not
later than the second business day of the independent review organization after
receiving the material specified in section (6) of this rule, the independent
review organization shall deliver to the enrollee the index of all materials
that the insurer has submitted to the independent review organization. The
insurer shall provide to the enrollee, upon request, all relevant information supplied
to the independent review organization that is not confidential or privileged
under state or federal law concerning the case under review.
(8) After
receipt of the notice from the director under section (4) of this rule, the
enrollee, the insurer or a provider acting on behalf of the enrollee or at the
enrollee’s request may submit additional information to the independent review
organization. In accordance with OAR 836-053-1325(3)(b) the independent review
organization must consider this additional information if the information is
related to the case and relevant to the statutory grounds for external review
contained in ORS 743.857. The independent review organization is not required
to consider this information if the information is submitted after the seventh
calendar day following the receipt of notice from the director under section
(4) of this rule, or the subsequent business day of the independent review
organization if any of the seven days is not a normal business day of the
independent review organization. Upon receiving information under this section
the independent review organization must:
(a) Forward
any information provided by the insurer to the enrollee within one business day
after the independent review organization receives the information.
(b) Forward
any information provided by the enrollee or a provider acting on behalf of the
enrollee or at the enrollee’s request to the insurer within one business day
after the independent review organization receives the information.
(9) The
independent review organization shall notify the enrollee, the provider of the
enrollee and the insurer of any additional medical information required to
conduct the review after receipt of the documentation under section (7) of this
rule. Not later than the fifth business day of such a request, the enrollee or
the provider of the enrollee shall submit the additional information or an
explanation of why the additional information is not being submitted to the
independent review organization. If the enrollee or the provider of the
enrollee fails to provide the additional information or the explanation of why
additional information is not being submitted within the timeline specified in
this subsection, the assigned independent review organization shall make a decision
based on the information submitted by the insurer as required by section (6) of
this rule. Except as provided in this section, failure by the insurer to
provide the documents and information within the time specified in section (6)
of this rule shall not delay the conduct of the independent review.
(10) An
independent review organization must provide notice to enrollees and the
insurer of the result and basis for the determination as provided in OAR
836-053-1325 not later than the fifth day after the independent review
organization makes a determination in a regular, nonexpedited case.
Stat.
Auth.: ORS 731.244, 743.858 & 743.862
Stats.
Implemented: ORS 743.858 & 743.862
Hist.: ID
10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02,
cert. ef. 9-28-02; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11;
ID 23-2011, f. & cert. ef. 12-19-11
836-053-1342
Timelines
and Notice for Expedited Decision-Making
(1) When an
insurer expedites an enrollee’s case under ORS 743.857(5), the insurer shall
inform the Director of the Department of Consumer and Business Services and the
independent review organization that the referral is expedited. If information
on whether a referral is expedited is not provided to the independent review
organization, the independent review organization may presume that the referral
is not an expedited review, but the independent review organization may request
clarification from the insurer.
(2) The
insurer and the director must expedite external review that is required to be
expedited under ORS 743.857(5) when:
(a) An
enrollee requests external review before the enrollee has exhausted all
internal appeals; or
(b) An
enrollee simultaneously requests an expedited internal appeal and an expedited
external review.
(3) An
independent review organization shall make its decision in each expedited case
within a time period that is appropriate for accommodating the clinical urgency
of the particular case, but in any event not exceeding the maximum time period
specified in ORS 743.862(3).
(4) In an
expedited case, an independent review organization shall immediately provide
notice to enrollees and the insurer of the result and basis for the
determination as provided in OAR 836-053-1325.
Stat.
Auth.: ORS 731.244, 743.858 & 743.862
Stats.
Implemented: ORS 743.857, 743.858 & 743.862
Hist.: ID
10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02,
cert. ef. 9-28-02; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11;
ID 23-2011, f. & cert. ef. 12-19-11
836-053-1350
Ongoing
Requirements for Independent Review Organizations
(1) An
independent review organization shall file an annual statistical report with
the Director of the Department of Consumer and Business Services, on a form
specified by the director, that summarizes reviews conducted. The report shall
include, but need not be limited to, volumes, types of cases, compliance with
timelines for expedited and nonexpedited cases, determinations, number and
nature of complaints and compliance with conflict of interests rules.
(2) An
independent review organization shall submit updated information to the
director if at any time there is a material change in the information included
in the response of the independent review organization to the director’s
request for proposals.
(3) An
independent review organization shall maintain records of all materials,
including materials submitted by all parties, notifications, documents relied
upon, and the independent review organization’s ultimate decision for a period
of not less than three years after any review. The independent review
organization shall provide copies of any of these documents to the director at
the director’s request.
Stat.
Auth.: ORS 731.244, 743.857, 743.858 & 743.862
Stats.
Implem ented: ORS 743.858 & 743.862
Hist.: ID
10-2002(Temp), f. & cert. ef. 4-5-02 thru 9-27-02; ID 19-2002, f. 9-27-02,
cert. ef. 9-28-02; ID 11-2011(Temp), f. & cert. ef. 7-7-11 thru 12-21-11;
ID 23-2011, f. & cert. ef. 12-19-11
Rule Caption: Suspension
of Rules for Physician Credentialing and Recredentialing in Connection with
Health Care Service Contractors.
Adm. Order No.: ID 1-2012(Temp)
Filed with Sec. of State: 1-12-2012
Certified to be Effective: 1-13-12 thru 5-1-12
Notice Publication Date:
Rules Suspended: 836-052-0900
Subject: This rulemaking suspends rules adopted by the
Department of Consumer and Business Services related to physician credential
and recredentialing by health care service contractors. During the 2009
Legislative Session, the statutory authority for adopting these rules was
transferred from DCBS to the Oregon Health Authority. The Oregon Health
Authority is proposing to adopt temporary rules that replace this DCBS rule and
that make further changes to these rules, rather than relying on the rules in
force previously adopted by DCBS. To avoid confusion, the DCBS rule will be
suspended until permanent rules are adopted by the Oregon Health Authority, at
which time the DCBS rule will be repealed.
Rules Coordinator: Sue Munson—(503) 947-7272
836-052-0900
Physician
Credentialing, Health Care Service Contractors
(1) The
Oregon Practitioner Credentialing Application and the Oregon Practitioner
Recredentialing Application, both of which were approved by the Advisory
Committee on Physician Credentialing Information (ACPCI) on September 22, 2008,
and both of which carry that date, are adopted with respect to hospitals and
health care service contractors as Exhibits 1 and 2 to this rule.
(2) Each
hospital and health care service contractor shall use the application forms
adopted in section (1) of this rule
(3) This
rule is adopted pursuant to the authority of ORS 442.807 for the purpose of
enabling the collection of uniform information necessary for hospitals and
health care service contractors to credential physicians seeking designation as
a participating practitioner for a health plan, thereby implementing ORS
442.800 to 442.807 with respect to hospitals and health care service
contractors.
Stat.
Auth.: ORS 442.807
Stats.
Implemented: ORS 442.800 - 442.807
Hist.: ID
12-2001, f. & cert. ef. 10-15-01; ID 1-2004, f. & cert. ef. 2-3-04; ID
2-2005, f. & cert. ef. 3-1-05; Renumbered from 836-052-0700, ID 10-2007, f.
12-3-07, cert. ef. 1-1-08; ID 5-2009, f. 7-21-09, cert. ef. 10-1-09; Suspended
by ID 1-2012(Temp), f. 1-12-12, cert. ef. 1-13-12 thru 5-1-12
Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2011.
2.) Copyright 2012 Oregon Secretary of State: Terms and Conditions of Use |