Oregon Bulletin

October 1, 2012

Oregon Health Insurance Exchange, Chapter 945

Rule Caption: Certification of Plans as Qualified Health Plans.

Adm. Order No.: OHIE 3-2012(Temp)

Filed with Sec. of State: 9-13-2012

Certified to be Effective: 10-1-12 thru 3-13-13

Notice Publication Date:

Rules Adopted: 945-020-0010, 945-020-0020

Subject: In order to participate in the Exchange, the Oregon Health Insurance Exchange is adopting Temporary Rules (and subsequently Permanent Rules) to certify health plans in Oregon as Qualified Health Plans. In developing these rules, the corporation consulted state agency partners, carriers, individual consumers and small businesses. These rules are being filed in accordance with the provisions outlined in the federal Affordable Care Act and SB 99 (2011).

Rules Coordinator: Claudia Grimm—(503) 373-9404


Statutory Authority; Purpose; Applicability

(1) OAR chapter 945, division 20 is adopted pursuant to the general rulemaking authority of the Exchange in ORS 741.002.

(2) The purpose of OAR chapter 945, division 20 is to establish the process for certification of health plans as qualified health plans.

(3) OAR chapter 945, division 20 applies to all qualified health plans offered through the Exchange, except the following:

(a) Multistate plans, as defined in section 1334 of the Affordable Care Act.

(b) Consumer Operated and Oriented Plans (CO-OPs), as defined in section 1322 of the Affordable Care Act.

Stat. Auth.: ORS 741.002

Stats. Implemented: ORS 741.310

Hist.: OHIE 3-2012(Temp), f. 9-13-12, cert. ef. 10-1-12 thru 3-13-13


Certification of Qualified Health Plans

(1) Each health benefit plan offered through the Oregon Health Insurance Exchange (Exchange) must have in effect a certification issued by the Exchange. This certification demonstrates that the health benefit plan is a qualified health plan (QHP).

(2) The Exchange will issue a request for applications (RFA). To be considered for participation and plan certification, a health insurance issuer must submit a completed application to the Exchange in the form and manner, and within the timeframes specified by the Exchange.

(3) Conditional approval to participate in the Exchange will be granted to applicants who

(a) Are licensed and in good standing to offer health insurance in Oregon;

(b) Agree to offer at least one standardized QHP at the bronze, silver, and gold levels of coverage;

(c) Meet any other performance standards that may be adopted by the Exchange; and

(d) Agree to contract with the Exchange to offer QHPs. Contracts will require issuers to comply with Exchange standards and requirements, including but not limited to the following:

(A) Transparency in coverage standards;

(B) Accreditation requirements;

(C) Network adequacy standards;

(D) Exchange administrative fees and assessments;

(E) Quality improvement strategies, quality reporting, and enrollee satisfaction surveys;

(F) Exchange agent management program requirements;

(G) Tribal requirements;

(H) Premium tax credit and cost sharing reductions; and

(I) Exchange processes and procedures, including those related to enrollment, enrollment periods, premium payment, terminations of coverage, customer service, and QHP recertification and decertification.

(4) Issuer approval is conditioned upon certification of their health benefit plans. Issuers will be approved for a two-year period. No new issuers will be approved to participate during those two years unless there is a loss of statewide coverage.

(5) Any health benefit plan an approved issuer wants to offer through the Exchange must be filed with the Oregon Insurance Division and determined to meet applicable benefit design standards and all other insurance regulations as required under state and federal law.

(6) Benefit design standards means coverage that includes, but is not limited to, the following:

(a) The essential health benefits as described in section 1302(b) of the Affordable Care Act;

(b) Cost sharing limits as described in section 1302(c) of the Affordable Care Act; and

(c) A bronze, silver, gold, or platinum level of coverage as described in section 1302(d) of the Affordable Care Act, or is a catastrophic plan as described in section 1302(e) of the Affordable Care Act

(7) Subject to any limitation on the number of plans that may be offered through the Exchange, the Exchange will certify health benefit plans that are submitted by approved carriers and determined by the Oregon Insurance Division to meet all applicable standards.

Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.310
Hist.: OHIE 3-2012(Temp), f. 9-13-12, cert. ef. 10-1-12 thru 3-13-13

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.

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