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Oregon Bulletin

February 1, 2012

 

Department of Consumer and Business Services,
Insurance Division
Chapter 836

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Rules Repealed: 836-010-0012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

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