Department of Consumer and Business Services, Insurance Division, Chapter 836
Rule Caption: Clarifying six month guarantee issue period and establishing “birthday rule” for Medicare supplement insurance.
Adm. Order No.: ID 4-2012
Filed with Sec. of State: 2-16-2012
Certified to be Effective: 1-1-13
Notice Publication Date: 12-1-2011
Rules Adopted: 836-052-0143
Rules Amended: 836-052-0138
Subject: These rules were developed in response to numerous complaints received by the Department of Consumer and Business Services regarding open enrollment periods and unexpected rate increases with respect to Medicare supplement policies. To address these complaints, the rules:
• Clarify that for a person who receives “retroactive” eligibility for Medicare as a result of an appeal of an initial denial for eligibility, the six month open enrollment period begins after the person is notified of their enrollment in Medicare, not on the date the person’s enrollment has been backdated to.
• Adopt a “birthday rule” for Medicare supplement policies to allow an individual the opportunity to change Medicare supplement plans (as long as the new policy has the same or lesser benefits) with guaranteed issue and nondiscrimination in rating once per year for a period of thirty days beginning on the individual’s birthday.
Rules Coordinator: Sue Munson—(503) 947-7272
(1)(a) An issuer may not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this state, nor discriminate in the pricing of a policy or certificate because of the health status, claims experience, receipt of health care, or medical condition of an applicant in the case of an application for a Medicare supplement policy or certificate that is submitted to the issuer prior to or during the six month period beginning with the first day of the first month in which an individual is enrolled for benefits under Medicare Part B. Each Medicare supplement policy and certificate currently available from an issuer shall be made available on a guaranteed issue basis to all applicants who qualify under this section without regard to age.
(b) If a person under the age of 65 applies for enrollment under Medicare Part B due to disability and is initially denied as ineligible, but upon conclusion of the person’s appeals process the person is awarded retroactive enrollment, the six month period described in this section begins on the first day of the first month after the person receives written notice of retroactive enrollment.
(2)(a) If an applicant qualifies under section (1) of this rule and submits an application during the time period referenced in section (1) of this rule and, as of the date of application, has had a continuous period of creditable coverage of at least six months, the issuer shall not exclude benefits based on a preexisting condition;
(b) If the applicant qualifies under section (1) of this rule and submits an application during the time period referenced in section (1) of this rule and, as of the date of application, has had a continuous period of creditable coverage that is less than six months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The manner of the reduction under this subsection shall be the manner prescribed in 42 USC 300gg(a)(3) as of the effective date of this rule.
(3) Except as provided in section 2 of this rule and OAR 836-052-0142 and 836-052-0190, section (1) of this rule shall not be construed as preventing the exclusion of benefits under a policy, during the first six months, based on a preexisting condition for which the policyholder or certificate holder received treatment or was otherwise diagnosed during the six months before the coverage became effective.
(4) This section applies to a person who qualifies for Medicare by reason of disability and who obtains a Medicare supplement policy during the six month period described in section (1) of this rule. For the period that a person to whom this section applies is 65 years of age or less, the premium charged the person by the issuer shall not be greater than the premium charged by the issuer for persons who are 65 years of age. Following that period, for issuers who charge rates on policies on the basis of attained age, the rating plan shall not differentiate on the basis of the reason for eligibility for Medicare Part B.
(5) An issuer must comply with section (1) of this rule with respect to a person:
(a) Who qualifies for Medicare by reason of disability, who first enrolls for benefits under Medicare Part B on or after September 1, 1993, and who applies for a Medicare supplement policy or certificate during the period of eligibility described in section (1) of this rule; or
(b) Who enrolled in Medicare Part B before attaining 65 years of age, who applies for a Medicare supplement policy or certificate upon attaining 65 years of age, during the period of eligibility described in section (1) of this rule that would apply if the person first enrolled in Medicare Part B upon attaining 65 years of age.
Stats. Implemented: ORS 743.010 & 743.683
Hist.: ID 7-1992, f. & cert. ef. 5-8-92; ID 5-1993(Temp), f. 8-11-93, cert. ef. 9-1-93; ID 9-1993, f. 9-28-93, cert. ef. 10-1-93; ID 5-1996, f. & cert. ef. 4-26-96; ID 21-1998(Temp), f. 12-8-98, cert. ef. 1-1-99 thru 6-25-99; ID 4-1999, f. & cert. ef. 4-29-99; ID 6-2001, f. & cert. ef. 5-22-01; ID 10-2005, f. & cert. ef. 7-26-05; ID 4-2012, f. 2-16-12, cert. ef. 1-1-13
Annual Opportunity to Select Another Medicare Supplement Policy or Certificate
(1) For the purposes of this rule, for 1990 and 2010 Medicare Supplement Plans, “same or lesser benefits” means a policy or certificate of the same or lower benefit level as indicated on a chart available on the website of the Insurance Division of the Department of Consumer and Business Services.
(2) Beginning on a person’s birthday and for 30 days after the person’s birthday, a person enrolled in a Medicare supplement policy may cancel the person’s existing Medicare supplement policy or certificate and purchase or select another Medicare supplement policy or certificate with the same or lesser benefits to replace the existing Medicare supplement policy or certificate. An issuer may not deny or condition the issuance or effectiveness, nor discriminate in the pricing of the replacement policy or certificate on the basis of health status, claims experience, receipt of health care or medical condition of the applicant.
(3) This rule does not apply to Medicare supplement policies or certificates issued or delivered before January 1, 1990.
ORS 731.244, 743.010, 743.680 - 743.689
Stats. Implemented: ORS 743.010, 743.683, 743.684
Hist.: ID 4-2012, f. 2-16-12, cert. ef. 1-1-13
Rule Caption: Requirements for Health Insurers’ Report on Services Provided by Expanded Practice Dental Hygienists.
Adm. Order No.: ID 5-2012
Filed with Sec. of State: 2-16-2012
Certified to be Effective: 2-16-12
Notice Publication Date: 11-1-2011
Rules Adopted: 836-011-0600
Subject: Enrolled Senate Bill 738 requires a health insurance policy that covers dental health services to cover services provided by an expanded practice dental hygienist if the same services are covered when provided by a licensed dentist and the expanded practice dental hygienist has entered into a provider contract with the insurer. Section 12 of SB 738 (ORS 680.210) requires the Department of Consumer and Business Services (DCBS) to adopt rules requiring health insurers to report to DCBS on the reimbursement of services to expanded practice dental hygienists and requires DCBS to provide the information to the Oregon Board of Dentistry (OBD).
This new rule establishes those reporting requirements and also defines “expanded practice dental hygienist” and “health insurer” for purposes of the reporting requirement. The first report is due on or before August 1, 2012.
Rules Coordinator: Sue Munson—(503) 947-7272
Report on Services Provided by Expanded Practice Dental Hygienists
(1) As used in this rule:
(a) “Expanded practice dental hygienist” has the meaning given in ORS 679.010.
(b) “Health insurer” includes:
(A) An insurer authorized to transact health insurance in Oregon;
(B) A health care service contractor as defined in ORS 750.005;
(C) A multiple employer welfare arrangement as defined in ORS 750.301;
(D) A coordinated care organization as defined in ORS 414.025, or a dental care organization or governed by the Oregon Health Authority;
(E) A third party administrator licensed under ORS 744.702; and
(F) Federally qualified health centers governed by the United States Department of Health and Human Services.
(2) A health insurer authorized to transact health insurance that provides coverage for dental services in Oregon shall, by August 1 of every even-numbered year, report to the Department of Consumer and Business Services information pertaining to reimbursement for those dental services provided by Expanded Practice Dental Hygienists (EPDH) to Oregon residents for the 24-month period ending June 30 of the reporting year. For each dental service provided during the period under review the information shall include:
(a) The Current Dental Terminology code denoting the type of service provided;
(b) The provider’s National Provider Identifier number; and
(c) The following information, which the department will aggregate prior to providing the information to the Board of Dentistry:
(A) The amount billed by the EPDH to the insurer for the service provided;
(B) The amount allowed for the service under the insurance plan;
(C) The amount of benefit paid by the insurer for the dental service (i.e. the amount of the benefit subtracting any deductible, copay, coinsurance or other cost-sharing);
(D) The amount owed by the insured for the service (i.e. deductible, copay, coinsurance or other cost-sharing);
(E) The amount of excluded charges owed by the insured; and
(F) The amount of excluded charges, if any, that the provider is not allowed to collect from the insured due to their provider agreement with the insurer.
(3) A health insurer subject to this rule shall provide the report required in section (2) of this rule electronically, as requested by the Director.
ORS 731.244, 680.210.
Stats. Implemented: ORS 680.210 (Sec. 11 & 12, Ch.716, OL 2011)
Hist.: ID 5-2012, f. & cert. ef. 2-16-12