Loading
The Oregon Administrative Rules contain OARs filed through November 15, 2014
 
QUESTIONS ABOUT THE CONTENT OR MEANING OF THIS AGENCY'S RULES?
CLICK HERE TO ACCESS RULES COORDINATOR CONTACT INFORMATION

 

DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
INSURANCE DIVISION

 

DIVISION 53

HEALTH BENEFIT PLANS

836-053-0000

Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53

(1) Except as provided in section (3) of this rule, the January 1, 2014 amendment to rules in OAR chapter 836, division 53 as amended effective January 1, 2014 apply to health benefit plans issued or renewed on or after January 1, 2014.

(2) Except as provided in section (3) of this rule, the version of rules included in OAR chapter 836, division 53 in effect on December 31, 2013, applies to health benefit plans issued or renewed before January 1, 2014.

(3) Amendments to and repeals of the following rules are effective on January 1, 2014, and apply to all issuers and health benefit plans according to the specified market whether issued or renewed before, on or after January 1, 2014:

(a) OAR 836-053-0700;

(b) OAR 836-053-0710;

(c) OAR 836-053-0750;

(d) OAR 836-053-760;

(e) OAR 836-053-780;

(f) OAR 836-053-0785;

(g) OAR 836-053-0790;

(h) OAR 836-053-0800;

(i) OAR 836-053-0825;

(j) OAR 836-053-083;

(k) OAR 836-053-0835;

(l) OAR 836-053-1000;

(m) OAR 836-053-1035;

(n) OAR 836-053-1070;

(o) OAR 836-053-1130;

(p) OAR 836-053-1170;

(q) OAR 836-053-1180;

(r) OAR 836-053-1190;

(s) OAR 836-053-1315;

(t) OAR 836-053-1320;

(u) OAR 836-053-1325;

(v) OAR 836-053-1330;

(w) OAR 836-053-1335;

(x) OAR 836-053-1340;

(y) OAR 836-053-1342;

(z) OAR 836-053-1345;

(aa) OAR 836-053-1350;

(bb) OAR 836-053-1355;

(cc) OAR 836-053-1360;

(dd) OAR 836-053-1365;

(ee) OAR 836-053-1400;

(ff) OAR 836-053-1401;

(gg) OAR 836-053-1410; and

(hh) OAR 836-053-1415.

Stat. Auth.: ORS 743.018, 743.019, 743.020
Stats. Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730, 743.767
Hist.: ID 5-2010, f. & cert. ef. 2-16-10; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0001

Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements

(1) A modification of a health benefit plan not subject to the levels of coverage defined in 42 U.S.C. 18022(d) is defined in this rule for the purposes of:

(a) ORS 743.737 and 743.754, regarding group health benefit plans; and

(b) ORS 743.766, regarding individual health benefit plans.

(2) One or more decreases or increases described in this section in the services or benefits covered in a health benefit plan are a modification and not a discontinuance when the decrease or decreases, or the increase or increases, or any combination thereof, occur at the time of renewal and the change or changes together alter the actuarial valuation of the health benefit plan by less than ten percent in the aggregate to the policyholder. This section applies to a decrease or increase that:

(a) Eliminates or adds benefits payable under the plan;

(b) Decreases or increases benefits payable under the plan, including a decrease or increase that occurs as a result of a change in formulas, methodologies or schedules that serve as the basis for making benefit determinations;

(c) Increases or decreases deductibles, copayments or other amounts to be paid by an enrollee; or

(d) Establishes new conditions or requirements, such as prior authorization requirements, to obtaining services or benefits under the plan, or eliminates such conditions or requirements.

(3) A carrier must give the policyholder notice of a modification to which this rule applies not later than the 30th day before the date of renewal of the plan to which the modification applies.

(4) A change in a requirement for eligibility is not a modification for purposes of this rule but instead is a discontinuance if the change will result in the exclusion of a class or category of enrollees covered under the current plan.

(5) A decrease or increase described in this section in the services or benefits covered in a health benefit plan is a modification and not a discontinuance, but the decrease or increase is not subject to section (2) of this rule. This section applies to the following:

(a) A carrier's normal and customary administrative changes that do not have an actuarial impact, such as the following:

(A) Formulary changes.

(B) Utilization management protocols.

(C) Changes to pharmacy prior authorization requirements if, at least 48 hours before a change, the insurer prominently posts:

(i) A description of any pharmacy prior authorization requirement change to a page of the insurer’s website that an enrollee or provider can easily locate and access; and

(ii) A link to the website page described in subparagraph (i) of this paragraph on the home page of the insurer’s website.

(D) Changes to non-pharmacy prior authorization requirements that are made other than at renewal only when an insurer does all of the following:

(i) Makes a reasonable and good faith effort to identify all enrollees affected by the changes.

(ii) Makes a reasonable and good faith effort to identify providers who provide a service or treatment affected by the changes.

(iii) Notifies all enrollees and providers identified in subparagraphs (i) and (ii) of this paragraph at least 60 days in advance of the effective date of the change.

(iv) Posts a description of any change to the non-pharmacy prior authorization requirements to a page of the insurer’s website that an enrollee or provider can easily locate and access.

(v) Posts a link to the website page described in subparagraph (iv) of this paragraph on the home page of the insurer’s website.

(vi) Covers to the extent otherwise payable under the terms of the contract, and without penalty, any claim for services or treatment affected by changes to prior authorization requirements of an enrollee to whom the insurer fails to provide notice of the change.

(b) A decrease or increase required by state or federal law.

Stat. Auth.: ORS 731.244, 743.566 & 743.773
Stats Implemented: ORS 743.737, 743.754 & 743.766
Hist.: ID 7-2002, f. & cert. ef. 2-15-02; ID 18-2010, f. 9-14-10, cert. ef. 1-1-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0002

Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements

(1) A modification of a health benefit plan subject to the levels of coverage defined in 42 U.S.C. 18022(d) is defined in this rule for the purposes of:

(a) ORS 743.737, regarding small employer health benefit plans; and

(b) ORS 743.766, regarding individual health benefit plans.

(2) One or more decreases or increases in the services or benefits covered in a health benefit plan are a modification and not a discontinuance when the decrease or decreases, or the increase or increases, or any combination thereof, occur at the time of renewal and the change or changes together do not alter the level of coverage as defined in 42 U.S.C. 18022(d).

(3) One or more decreases or increases in the services or benefits covered in a health benefit plan are a discontinuance when the decrease or decreases, or the increase or increases, or any combination thereof, alter the level of coverage as defined in 42 U.S.C. 18022(d).

Stat. Auth.: ORS 731.244, 743.566 & 743.773
Stats Implemented: ORS 743.737, 743.754 & 743.766
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0003

Prohibition of Exclusion Period for Pregnancy

A carrier may not impose an exclusion period or a waiver in a health benefit plan for pregnancy and childbirth expenses, for which coverage is required by ORS 743A.080.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.737, 743.754, 743.766 & 743A.080
Hist.: ID 9-2006, f. 4-27-06, cert. ef. 5-1-06; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0005

Prescription Drug Identification Cards

(1) This rule establishes minimum standards for prescription drug identification cards or other technologies that are required by ORS 743.788 to be issued by carriers, administrators of health benefit plans, third party administrators for self-insured plans, pharmacy benefits managers and administrators of state administered plans. This rule is adopted pursuant to the rulemaking authority of 743.790 for the purpose of implementing 743.788.

(2) A prescription drug identification card or other technology required by ORS 743.788 must contain the following information:

(a) The data element consistent with the "BIN, "IIN/BIN" or "RxBIN," which is the American National Standards Institute-assigned international identification number identified in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide, and labeled as RxBIN or BIN.

(b) The enrollee's name and identification number.

(c) A telephone number of the carrier or other issuer of the card or technology that a pharmacist may use to contact the carrier or other issuer, and a telephone number for after hour calls from a pharmacist (if that number is different from the first), unless the telephone number or numbers are provided electronically to the pharmacist at the time of processing.

(d) If required by the claims processor of the carrier or other issuer of the card, the processor control number labeled as RxPCN, and the pharmacy group number if different from the medical group number labeled as RxGrp.

(e) Any other information and any other data element of the National Council for Prescription Drug Programs Guide required by the issuer of the card for the processing of claims.

Stat. Auth.: ORS 743.790
Stats. Implemented: ORS 743.788
Hist.: ID 3-2003, f. 4-14-03 cert. ef. 7-1-03; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0007

Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements

(1) Before an insurer may issue coverage to an association, trust, discretionary group or Multiple Employer Welfare Arrangement (MEWA) not already approved by the Director of the Department of Consumer and Business Services as a group policyholder, the insurer must obtain approval from the director to issue coverage to the association, trust, discretionary group or MEWA as the group policyholder.

(2) Annually, or more frequently if required by the director, an insurer must certify that an association, trust, discretionary group or MEWA that is a group policyholder continues to meet the requirements of ORS 743.522 and section 7, chapter 681, Oregon Laws 2013 .

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.522 & Sect. 7, Ch. 681, OL 2013
Hist.: ID 8-2007(Temp), f. 10-24-07, cert. ef. 10-25-07 thru 4-18-08; ID 6-2008, f. & cert. ef. 4-18-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0008

Essential Health Benefits

(1) As used in the Insurance Code:

(a) “Base benchmark health benefit plan” means the PacificSource Health Plans Preferred CoDeduct Value 3000 35 70 small group health benefit plan, including prescription drug benefits, as set forth on the Insurance Division website of the Department of Consumer and Business Services at www.insurance.oregon.gov;

(b) “Essential health benefits” means the following coverage provided in compliance with 45 CFR 156:

(A) The base-benchmark health benefit plan, excluding the 24-month waiting period for transplant benefits;

(B) Pediatric dental benefits;

(C) Pediatric vision benefits; and

(D) Habilitative services.

(c) “Habilitative benefits” means the rehabilitative services provisions of the base benchmark when the services are medically necessary for the maintenance, learning or improving skills and function for daily living.

(d) “Pediatric dental benefits” means the benefits described in the children’s dental provisions of the State Children’s Health Insurance Plan as set forth on the Insurance Division website of the Department of Consumer and Business Services at www.insurance.oregon.gov. Pediatric dental benefits are payable to persons under 19 years of age.

(e) “Pediatric vision benefits” means the benefits described in the vision provisions of the Federal Employee Dental and Vision Insurance Plan Blue Vision High Option as set forth on the Insurance Division website of the Department of Consumer and Business Services at www.insurance.oregon.gov. Pediatric vision benefits are payable to persons under 19 years of age.

(2) An issuer of a plan offering essential health benefits may not include as an essential health benefit:

(a) Routine non-pediatric dental services;

(b) Routine non-pediatric eye exam services;

(c) Long-term care or custodial nursing home care benefits; or

(d) Non-medically necessary orthodontia services.

Stat. Auth.: Sec. 2, Ch. 681, OL 2013
Stats. Implemented: Sec. 2, Ch. 681, OL 2013
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0009

Oregon Standard Bronze and Silver Health Benefit Plans

(1) As used in this rule, “coverage” includes medically necessary benefits, services, prescription drugs and medical devices. “Coverage” does not include coinsurance, copayments, deductibles, other cost sharing, provider networks, out-of-network coverage, wigs or administrative functions related to the provision of coverage, such as eligibility and medical necessity determinations.

(2) For purposes of coverage required under this rule:

(a) “Inpatient” includes but is not limited to:

(A) Surgery;

(B) Intensive care unit, neonatal intensive care unit, maternity and skilled nursing facility services; and

(C) Mental health and substance abuse treatment.

(b) “Outpatient” includes but is not limited to services received from ambulatory surgery centers and physician and anesthesia services and benefits when applicable.

(c) “Habilitation services” are medically necessary services for maintenance, learning or improving skills and function for daily living and are subject to the same cost sharing as rehabilitation services.

(d) A reference to a specific version of a code or manual, including but not limited to references to ICD-9, CPT, Diagnostic and Statistical Manual of Mental Disorders, DSM-IV TR, Fourth Edition; place of service and diagnosis includes a reference to a code with equivalent coverage under the most recent version of the code or manual.

(3) When offering a plan required under ORS 743.822, an issuer must use the following naming convention: “[Name of Issuer] Oregon Standard [Bronze/ Silver] Plan”. For example, “Acme Oregon Standard Bronze Plan”.

(4) Coverage required under ORS 743.822 must be provided in accordance with the requirements of sections (5) to (10) of this rule.

(5) Coverage must be provided in a manner consistent with the requirements of:

(a) 45 CFR 156, except that actuarial substitution of coverage within an essential health benefits category is prohibited;

(b) OAR 836-053-1404 and 836-053-1405; and

(c) The federal Mental Health Parity and Addiction Equity Act of 2008;

(6) Coverage must provide essential health benefits as defined in OAR 836-053-0008.

(7) Except when a specific benefit exclusion applies, or a claim fails to satisfy the issuer’s definition of medical necessity or fails to meet other issuer requirements the following coverage must be provided:

(a) Ambulatory services based on the following Place of Service Codes:

(A) 11 — Office;

(B) 12 — Patient’s home;

(C) 20 — Urgent care facility;

(D) 22 — Outpatient hospital;

(E) 24 — Ambulatory surgical center;

(F) 25 — Birthing center;

(G) 49 — Independent clinic;

(H) 50 — Federally qualified health center;

(I) 71 — State or local public health clinic;

(J) 72 — Rural health clinic;

(b) Emergency services based on Place of Service Code 23 — Emergency;

(c) Hospitalization services based on Place of Service Code 21 — Hospital;

(d) Maternity and newborn services based on the following ICD-9 codes:

(A) V20 to V20.2;

(B) V22 to V39; and

(C) 630-677;

(e) Rehabilitation and habilitation services based the following ICD-9 or CPT codes:

(A) Physical Therapy/Professional: 97001-97002, 97010-97036, 97039, 97110, 97112, 97113-97116, 97122, 97128, 97139, 97140-97530, 97535, 97542, 97703, 97750, 97760, 97761-97762, 97799, and S9090;

(B) Occupational Therapy/Professional: 97003-97004 and G0129 in addition to all physical therapy codes if performed by an occupational therapist;

(C) Speech Therapy/Professional: 92507-92508, 92526, 92609-92610, and 97532 except ICD-9 784.49;

(f) Laboratory services in the CPT code range 8XXXX;

(g) All grade A and B United States Preventive Services Task Force preventive services, Bright Futures recommended medical screenings for children, Institute of Medicine recommended women's guidelines, and Advisory Committee on Immunization Practices recommended immunizations for children coverage must be provided without cost share; and

(h) Prescription drug coverage at the greater of:

(A) At least one drug in every United States Pharmacopeia (USP) category and class as the prescription drug coverage of the plan described in OAR 836-053-0000(1)(a); or

(B) The same number of prescription drugs in each category and class as the prescription drug coverage of the plan described in OAR 836-053-0000(1)(a).

(8) Copays and coinsurance for coverage required under ORS 743.822 must comply with the following:

(a) Non-specialist copays apply to physical therapy, speech therapy, occupational therapy and vision services when these services are provided in connection with an office visit.

(b) Subject to the Mental Health Parity and Addiction Equity Act of 2008, specialist copays apply to specialty providers including, mental health and substance abuse providers, if and when such providers act in a specialist capacity as determined under the terms of the health benefit plan.

(c) Coinsurance for emergency room coverage must be waived if a patient is admitted, at which time the inpatient coinsurance applies.

(9) Deductibles for coverage required under ORS 743.822 must comply with the following:

(a) For a bronze plan, in accordance with the coinsurance, copayment and deductible amounts and coverage requirements for a bronze plan set forth in Exhibit 1 to this rule. The bronze plan deductible must be integrated applicable to prescription drugs and all services except preventive services.

(b) For a silver plan, in accordance with the coinsurance, copayment and deductible amounts and coverage requirements for a silver plan set forth in Exhibit 1 to this rule. The silver plan deductible applies to all services except preventive services, office visits, urgent care, and prescription drugs.

(c) The individual deductible applies to all enrollees, and the family deductible applies when multiple family members incur claims.

(10) Dollar limits for coverage required under ORS 743.822 must comply with the following:

(a) Annual dollar limits must be converted to a non-dollar actuarial equivalent.

(b) Lifetime dollar limits must be converted to a non-dollar actuarial equivalent.

Stat. Auth.: ORS 743.822
Stats. Implemented: ORS 743.822
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0010

Purpose; Statutory Authority; Enforcement

(1) OAR 836-053-0010 to 836-053-0070 are adopted for the purpose of implementing ORS 743.730 to 743.745, pursuant to the authority of ORS 731.244 and 743.730 to 743.745.

(2) Violation of any provision of OAR 836-053-0021 to 836-053-0065 is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244, 743.731(4) & 746.240
Stats. Implemented: ORS 743.730 et seq.
Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 12-1996, f. & cert. e.f 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98

836-053-0021

Plans Offered to Oregon Small Employers

(1) A small employer carrier shall issue a plan to a small employer if the employee eligibility criteria established by the small employer meet the requirements of this section. Except when coverage is obtained through the Oregon Health Insurance Exchange Corporation, a carrier must use the form entitled “Oregon Standardized Group Profile Form” set forth on the website of the Insurance Division of the Department of Consumer and Business Services to collect data to determine the applicable type of group coverage for an employer and to provide disclosure notices as required for small employers. The eligibility criteria must be based solely on weekly work hours and completion of a group eligibility waiting period, if applicable, and those criteria must meet the following standards:

(a) The work hours requirement may range from 17.5 to 40 hours per week, but a single, uniform requirement must apply to all employees of the employer; and

(b) A waiting period requirement may not exceed 90 days and a single, uniform requirement must apply to all employees of the employer.

(2) For purposes of determining whether an employer is a small employer a carrier may not count as an employee:

(a) A sole proprietor;

(b) A partner of a partnership;

(c) The owner of more than two percent of the shares of:

(A) An S corporation; or

(B) Limited liability company;

(d) The owner of a corporation wholly owned by the individual or the individual and the individual’s spouse; or

(e) The spouse of a person described in subsections (a) to (d) of this section.

(3) Employee eligibility criteria must be limited to those described in section (1) of this rule. Impermissible criteria include:

(a) Health status;

(b) Disability; and

(c) A requirement that an employee be actively at work when coverage would otherwise begin.

(4) A small employer carrier may provide different health benefit plans to different categories of employees of an employer, as determined by the employer only if based on bona fide employment-based classifications that are consistent with the employer's usual business practice. The categories may not relate to the actual or expected health status of the employees or their dependents

Stat. Auth.: ORS 731.244 & 743.731(4)
Stats. Implemented: ORS 743.730 et seq.
Hist.: ID 5-1998, f. & cert. ef. 3-9-98; ID 23-2002, f. & cert. ef. 11-27-02; ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08; ID 2-2008, f. & cert. ef. 2-11-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0030

Marketing of a Health Benefit Plan to Small Employers

(1) A carrier may offer different small employer health benefit plans in different geographic areas. The bronze and silver plan required to be offered under ORS 743.822 and a point-of-service plan required under ORS 743.808 must be offered in every geographic area in which the carrier offers or renews its small employer health benefit plans. A carrier may not cease offering or renewing, or offering and renewing, the bronze or silver small group health benefit plan required to be offered under ORS 743.822 or a point-of -service plan required under ORS 743.808 in a geographic area unless the carrier discontinues all plans in the geographic area as provided in 743.737(3)(e).

(2) A carrier must offer all of its approved nongrandfathered small employer health benefit plans and plan options, including small employer health benefit plans offered through an association, to all small employers on a guaranteed issue basis without regard to health status, claims experience or industry except that a carrier may limit enrollment to the period from November 15 to December 15 of each calendar year for small employers that fail to meet the carrier’s reasonable participation or contribution requirements. A carrier may not serve only a portion of the small employer market, such as employers with more than 25 employees, and a carrier may not establish or maintain a closed plan or plan option or a closed book of business in the small employer market. For purposes of this section, a "closed" arrangement is one in which coverage is maintained and renewed for currently enrolled small employers, but the coverage is not offered or issued to other small employers.

(3) A carrier may not require a small employer to purchase or maintain other lines of coverage, such as group life insurance, in order to purchase or maintain a small employer health benefit plan. However, a small group carrier may require reasonable assurance of pediatric dental coverage consistent with Essential Health Benefits, Final Rule, 78 Fed. Reg. 12853 (February 25, 2013).

(4) A carrier must market fairly all of its small employer health benefit plans and plan options and shall not engage in any practice that:

(a) Restricts a small employer's choice of such plans and plan options; or

(b) Has the effect or is intended to influence a small employer's choice of such plans and plan options for reasons of risk selection.

(5) A carrier shall not provide to any insurance producer any financial or other incentive that conflicts with the requirements of section (4) of this rule.

(6) A carrier must use the same sales compensation methodology for all small employer health benefit plans offered by the carrier.

(7) A small employer carrier may not terminate, fail to renew, or limit its contract or agreement of representation with an insurance producer for any reason related to the following: the health status, claims experience, occupation, geographic location of small employer groups, or the type of small employer plans placed by the insurance producer with the carrier.

Stat. Auth.: ORS 731.244 & 743.731
Stats. Implemented: ORS 743.736, 743.737, 743.743, 743.822 & 746.650
Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 12-1996, f. & cert. e.f 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08; ID 2-2008, f. & cert. ef. 2-11-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0050

Trade Practices Relating to Small Employer Health Benefit Plans

(1) When offering plans to small employers, a carrier must briefly describe the variety of small employer plans and plan options that are available from the carrier and must specify that:

(a) Nongrandfathered plans and plan options are available without regard to health status, claims experience or industry and are offered on a guaranteed issue basis; and

(b) Grandfathered plans and plan options are available under limited circumstances to a small employer that has existing grandfathered coverage.

(2) Subject to requirements established by the Oregon Health Insurance Exchange Corporation pursuant to 45 CFR 155.720(b) for small employer health benefit plans offered through the Oregon Health Insurance Exchange Corporation, a small employer health benefit plan must be issued with an effective date no later than 31 days after the carrier actually receives the application, and if required by the carrier, the premium.

(3) Neither a carrier nor an insurance producer may encourage or direct a small employer to seek coverage from another carrier because of the small employer's health status, claims experience, industry occupation or geographic location, if within the carrier's service area.

(4) Neither a carrier nor an insurance producer may induce or otherwise encourage a small employer to separate or otherwise exclude an eligible employee from employment or from health coverage or benefits provided in connection with the employee's employment.

(5) A small employer health benefit plan may specify that an enrolled small employer may replace its current coverage with another small employer plan offered by the carrier only on the anniversary date of the current coverage. This limitation also applies to a small employer that discontinues coverage with a carrier, or forfeits coverage because of non-payment of premiums and then requests new coverage with the same carrier.

(6) A small employer carrier that also issues individual health benefit plans may not include with an invoice for small employer coverage, individual health benefit plan premiums for employees of the employer or otherwise bill a small employer for such premiums.

Stat. Auth.: ORS 731.244 & 746.240
Stats. Implemented: ORS 743.731, 743.734(1), 743.736, 743.737 & 746.240
Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 12-1996, f. & cert. e.f 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 8-2005, f. 5-18-05, cert. ef. 8-1-05; ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08; ID 2-2008, f. & cert. ef. 2-11-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0063

Rating for Nongrandfathered Small Group Plans

The following provisions relating to rating apply to nongrandfathered health benefit plans offered to small employers:

(1) A small employer carrier shall file a single geographic average rate for each nongrandfathered health benefit plan that is offered to small employers within a geographic area and for each category of family composition. The geographic rate must be determined on a pooled basis and the pool shall only include all of the carrier's nongrandfathered business in the small employer market.

(2) There shall be one rating class for each small employer carrier. All nongrandfathered small employer health benefit plans of the carrier shall be rated in that class. A rating of a health benefit plan is subject to adjustments reflecting age, tobacco use and differences in family composition.

(3) The variation in geographic average rates among different nongrandfathered small employer health benefit plans offered by a carrier must be based solely on objective differences in plan design or coverage. The variation shall not include differences based on the risk characteristics or claims experience of the actual or expected enrollees in a particular plan.

(4) A small employer carrier shall file its geographic average rates for nongrandfathered small employer health benefit plans in accordance with the rate filing requirements of OAR 836-053-0910.

(5) A small employer carrier shall assess administrative expenses in a uniform manner to all nongrandfathered small employer health benefit plans. Administrative expenses shall be expressed as a percentage of premium and the percentage may not vary with the size of the small employer.

(6) Nongrandfathered small group plans shall be rated within the following geographic areas comprising counties as follows:

(a) Area 1 shall include: Clackamas, Multnomah, Washington and Yamhill.

(b) Area 2 shall include: Benton, Lane and Linn.

(c) Area 3 shall include: Marion and Polk.

(d) Area 4 shall include: Deschutes, Klamath and Lake.

(e) Area 5 shall include: Clatsop, Columbia, Coos, Curry, Lincoln and Tillamook.

(f) Area 6 shall include: Baker, Crook, Gilliam, Grant, Harney, Hood River, Jefferson, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco and Wheeler.

(g) Area 7 shall include: Douglas, Jackson and Josephine.

(7) For nongrandgathered small group plans, a small employer carrier may use the same geographic average rate for multiple rating areas.

(8) Premium rates for nongrandfathered small employer health benefit plans:

(a) For each group, shall total the sum of the product of the base rate and the applicable factors in section (9) of this rule for each employee and dependent 21 years of age and older and the sum of the product of the base rate and the applicable factors in section (9) of this rule for each of the three oldest dependent children under the age of 21 within each family in the group.

(b) Shall be allocated to an employee by dividing the total premium described in subsection (a) of this section by the sum of the products of the number of employees and the applicable tier factors specified in paragraphs (A) through (D) of this subsection, and multiplying the quotient by the applicable tier factor for the employee as specified in paragraphs (A) through (D) of this subsection. The tier factors are:

(A) 1.00 for an employee only;

(B) 1.85 for an employee and one or more children age 25 or younger;

(C) 2.00 for an employee and spouse; and

(D) 2.85 for an employee and family.

(9) The variations in rates described in this rule may be based on one or more of the following factors as determined by the carrier:

(a) The ages of enrolled employees and their dependents according to Exhibit 1 to this rule. Variations in rates based on age may not exceed a ratio of three to one.

(b) A tobacco use factor of no more than 1.5 times the non-tobacco use rate for persons 18 years or older except that the factor may not be applied when the person is enrolled in a tobacco cessation program.

(c) The level at which enrolled employees and their dependents engage in health promotion, disease prevention or wellness programs.

Stat. Auth.: ORS 731.244 & 743.731 & 743.758
Stats. Implemented: ORS 743.731, 743.734 & 743.737
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0065

Rating for Grandfathered Small Group Plans

The following provisions relating to rating apply to grandfathered health benefit plans offered to small employers:

(1) A small employer carrier shall file a single geographic average rate for each grandfathered health benefit plan that is offered to small employers within a geographic area and for each category of family composition. The geographic average rate must be determined on a pooled basis and the pool shall include all of the carrier's grandfathered business in the small employer market.

(2) There shall be one rating class for each small employer carrier. All grandfathered small employer health benefit plans of the carrier shall be rated in that class. A rating of a grandfathered health benefit plan is subject to adjustments reflecting the level of benefits provided and differences in family composition and age.

(3) The variation in geographic average rates among different grandfathered small employer health benefit plans offered by a carrier must be based solely on objective differences in plan design or coverage. The variation shall not include differences based on the risk characteristics or claims experience of the actual or expected enrollees in a particular plan, except that a carrier may make further adjustment at renewal to reflect the expected claims experience of the covered small employer; however, this adjustment may not exceed five percent of the annual premium otherwise payable by the small employer, is not cumulative year to year, and may be based only on the carrier’s claims experience with the small employer. A variation based on the level of contribution by the small employer or on the level of participation by eligible employees, or on both, must be actuarially sound.

(4) A small employer carrier shall file its geographic average rates for grandfathered small employer health benefit plans in accordance with the rate filing requirements of OAR 836-053-0910.

(5) A small employer carrier shall assess administrative expenses in a uniform manner to all grandfathered small employer health benefit plans. Administrative expenses shall be expressed as a percentage of premium and the percentage may not vary with the size of the small employer.

(6) Grandfathered small employer plans shall be rated within the following geographic areas comprising counties as follows:

(a) Area 1 shall include: Clackamas, Multnomah, Washington and Yamhill.

(b) Area 2 shall include: Benton, Lane and Linn.

(c) Area 3 shall include: Marion and Polk.

(d) Area 4 shall include: Deschutes, Klamath and Lake.

(e) Area 5 shall include: Clatsop, Columbia, Coos, Curry, Lincoln and Tillamook.

(f) Area 6 shall include: Baker, Crook, Gilliam, Grant, Harney, Hood River, Jefferson, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, Wasco and Wheeler.

(g) Area 7 shall include: Douglas, Jackson and Josephine.

(7) For grandfathered small employer plans, a small employer carrier may use five digit zip code groupings to define the carrier's geographic areas. The zip code groupings may vary from the county areas defined in section (6) of this rule by no more than ten percent of the population of a county. The small employer carrier must use either the zip code system or the county system and shall not modify the geographic areas in any other manner.

(8) For grandfathered small employer plans, a small employer carrier may use the same geographic average rate for multiple rating areas.

(9) For grandfathered small employer plans, a small employer carrier may deviate from the variation described in section (1) of this rule for coverage that extends to a geographic area outside the state of Oregon. The carrier must do so in a reasonable fashion and maintain records regarding the basis for the rate charged in the small employer's file.

(10) The premium rates charged during a rating period for a grandfathered health benefit plan issued to a small employer may not vary from the geographic average rate by more than 50 percent

(11) The variations in premium rates described in section (10) of this rule may be based on one or more of the following factors as determined by the carrier:

(a) The ages of enrolled employees and their dependents;

(b) The level at which the small employer contributes to the premiums payable for enrolled employees and their dependents;

(c) The level at which eligible employees participate in the health benefit plan;

(d) The level at which enrolled employees and their dependents engage in tobacco use;

(e) The level at which enrolled employees and their dependents engage in health promotion, disease prevention or wellness programs;

(f) The period of time during which a small employer retains uninterrupted coverage in force with the same small employer carrier; and

(g) Adjustments to reflect the level of benefits provided and differences in family composition.

(12) The premium rate determined in accordance with this rule may be further adjusted to reflect expected claims experience of a small employer but may not exceed five percent of the annual premium rate. The adjustment is not cumulative year to year.

Stat. Auth.: ORS 731.244 & 743.731
Stats. Implemented: ORS 743.731, 743.734 & 743.737
Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 1-1994, f. & cert. ef. 1-26-94; ID 12-1996, f. & cert. ef. 9-23-96; Renumbered from 836-053-0020; ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 5-2007(Temp), f. 8-17-07, cert. ef. 8-20-07 thru 2-15-08; ID 2-2008, f. & cert. ef. 2-11-08; ID 4-2013(Temp), f. & cert. ef. 6-17-13 thru 12-6-13; Administrative correction, 12-19-13; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0066

Rating for Transitional Health Benefit Plans

The following provisions relating to rating apply to transitional health benefit plans offered to individuals or small employers:

(1) A transitional health benefit plan offered to small employers:

(a) Is subject to the requirements of OAR 836-053-0065 that apply to grandfathered health benefit plans offered to small employers; and

(b) Must be pooled with all of the carrier’s grandfathered business in the small employer market to determine its geographic average rate.

(2) An individual transitional health benefit plan:

(a) Is subject to the requirements of OAR 836-053-0465(4)(a) and 836-053-0465(4)(c)(A); and

(b) Must be pooled with all of the carrier’s grandfathered business in the individual market to determine its geographic average rate.

Stat. Auth.: ORS 731.244, 743.731 & 743.737 & 2014 OL Ch. 80, Sec. 5
Stats. Implemented: ORS 743.731 & 746.737 & 2014 OL Ch. 80, Sec. 5
Hist.: ID 6-2014(Temp), f. & cert. ef. 4-11-14 thru 10-8-14; ID 17-2014, f. & cert. ef. 10-6-14

836-053-0070

Multiple Employer Welfare Arrangements

For purposes of determining whether a multiple employer welfare arrangement is exempt from the requirements of the Insurance Code that apply to a small employer carrier, the director must consider the following factors:

(1) Whether all of the benefits that are provided under the arrangement are guaranteed by policies of insurance issued by an authorized insurer.

(2) Whether the arrangement consists of an employee welfare benefit plan for employees of two or more employers or their beneficiaries as defined in ERISA sections 3 (5) and (40).

(3) Whether the arrangement is essentially controlled by an insurer, benefit service organization or individual for the purpose of creating a market for furnishing benefits to diverse individuals or groups rather than a bona fide multiple employer welfare arrangement.

Stat. Auth.: ORS 731.244, 743.731 & 746.240
Stats. Implemented: ORS 743.730(24)
Hist.: ID 17-1992, f. 12-3-92, cert. ef. 12-7-92; ID 12-1996, f. & cert. e.f 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

Work Related Injuries or Disease

836-053-0100

Work Related Injuries or Disease

A carrier may not impose an exclusion or waiver in a health benefit plan for coverage of any service otherwise provided under the plan solely on the basis that the service is provided for a work-related injury or occupational disease.

Stat. Auth: ORS 731.008, 731.016 & 731.244
Stat. Implemented: ORS 656.247, 731.008, 731.016, & 2014 OL Ch. 94, Sec. 2
Hist.: ID 18-2014, f. 10-17-14, cert. ef. 1-1-15

836-053-0105

Coordination of Payment for Interim Medical Services

(1) As used in this section:

(a) “Expedited preauthorization” means a determination by an insurer prior to provision of interim medical services that the insurer will provide reimbursement for the services.

(b) “Health benefit plan” does not include the Oregon Health Plan.

(c) “Interim medical benefits” are those benefits described in OAR 436-009-0035.

(d) “Interim medical services” means those services provided prior to claim acceptance or denial in accordance with ORS 656.247.

(e) “Worker” has the meaning given in ORS 656.005.

(2) A health benefit plan carrier that receives a request for expedited preauthorization under ORS 656.247(4) shall submit the expedited preauthorization to the medical provider who is proposing the treatment. The preauthorization shall be based on the terms, conditions and benefits of the health benefit plan.

(3) A carrier need only preauthorize medical services for which the health benefit plan requires a preauthorization and may exclude from the preauthorization any treatment otherwise provided by the carrier if that treatment is excluded under OAR 436-009-0010(12). A carrier must provide an expedited preauthorization not later than the third day after the date on which the request for expedited preauthorization is submitted to the carrier.

(4) If the workers’ compensation insurer denies a claim and the insurer notifies the medical provider that the initial claim has been denied, the provider must forward a copy of the workers’ compensation denial letter to the health benefit plan. Upon receipt of the denial letter, the health benefit plan carrier shall pay the provider in accordance with the expedited preauthorization issued to the provider at the time the interim medical services were provided. The carrier shall pay the claim in accordance with any other applicable requirements for payment of claims under the Insurance Code.

(5) For purposes of complying with ORS 743.911 and OAR 836-080-0080, payment for medical services under ORS 656.247 shall be considered a particular circumstance requiring special treatment that requires special handling and the claim will not be considered a clean claim until after the workers compensation insurer makes the determination to accept or deny the claim.

Stat. Auth: ORS 731.244
Stat. Implemented: ORS 656.247, 743.911 & 2014 OL Ch. 94, Sec. 2
Hist.: ID 18-2014, f. 10-17-14, cert. ef. 1-1-15

Group Health Benefit Plans

836-053-0211

Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan

(1) As used in this rule, an “enrollee” includes an employee covered under a group health benefit plan and a dependent of an employee covered under a group health benefit plan.

(2) A carrier issuing a group health plan may not:

(a) Modify health insurance with respect to an employee or any eligible dependent of an employee by means of a rider, endorsement or otherwise, for the purpose of restricting or excluding coverage for certain diseases or medical conditions otherwise covered by the health benefit plan;

(b) Decline to offer coverage to any eligible member of a group;

(c) Delay enrollment for an otherwise eligible member of the group or dependent for reasons related to actual or expected health status, race, color, national origin, sex, sexual orientation as defined in ORS 174.100, age or disability; or

(d) Use a health statement when offering a group health benefit plan.

(3) Unless otherwise required by law. a modification to an existing group health benefit plan that is required by ORS 743.730 to 743.754 must be implemented for each policyholder on the next renewal date. As used in this rule, “the next renewal date” means the first renewal date of the policy issued to the policyholder that occurs on or after January 1, 2014.

(4) A carrier must enroll a person who is eligible in a small group health benefit plan during the plan’s open enrollment period and when a person is eligible or becomes eligible as a result of the occurrence of an event described in this section, if:

(a) The person applies for coverage within at least 30 calendar days after:

(A) An event described in section 603 of the Employee Retirement Income Security Act of 1974, as amended;

(B) An event described in 45 CFR 146.117(a)(3) if the person is eligible for special enrollment under 45 CFR 146.117(a)(2), except for an event described in 45 CFR 146.117(a)(3)(D) a carrier must enroll a person who applies for coverage within 30 days, or later if allowed by the carrier, after the first denial of a claim due to the operation of a lifetime limit on all benefits; or

(C) Gaining a dependent, including a spouse, or becoming a dependent through marriage, birth, adoption or placement for adoption if the person is eligible for special enrollment under 45 CFR 146.117(b)(2); or

(b) The person applies for coverage within 60 calendar days after:

(A) Loss of eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a state child health plan under title XXI of the Social Security Act; or

(B) An event described in 45 CFR 155.725(j)(2)(iii).

(5) The following effective dates apply to coverage for enrollment under section (4) of this rule:

(a) For section (4)(a)(A), coverage must be effective by the applicable date described in 45 CFR 155.420(b)(1).

(b) For section (4)(a)(B) coverage must be effective no later than the first day of the first calendar month following the date the plan or issuer receives the request for special enrollment.

(c) For section (4)(a)(C) coverage must be effective:

(A) In the case of marriage, no later than the first day of the first calendar month following the date the carrier receives the request for special enrollment.

(B) In the case of birth, on the date of birth.

(C) In the case of adoption or placement for adoption, no later than the date of adoption or placement for adoption.

(e) For section (4)(b)(A) coverage must be effective by the applicable date described in 45 CFR 155.420(b)(1).

(f) For section (8)(b)(B) coverage must be effective no later than the first day of the first calendar month following the date the plan or issuer receives the request for special enrollment.

(6) At or before enrollment, a carrier must provide notice to an enrollee that complies with the requirements of 45 CFR 146.117(c).

(7) An enrollee under section (4) of this rule may not be considered a late enrollee.

(8) Violation of this rule is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244 & 743.731
Stats. Implemented: Sec. 7, ch. 681, OL 2013, ORS 743.522, 743.730–743.754 & 746.240
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0221

Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans

(1) For every group health benefit plan, a carrier that chooses to enforce participation, contribution or eligibility requirements must:

(a) Specify in the plan all of participation, contribution and eligibility requirements that have been agreed upon by the carrier and the group; and

(b) Apply the participation and eligibility requirements uniformly to all categories of eligible members and their dependents.

(2) For a small group health benefit plan, a carrier:

(a) May establish and apply contribution requirements for different categories of members and dependents that exceed the minimum contribution;

(b) Must apply participation requirements on an aggregate basis in which all categories of eligible employees of a small employer are combined;

(c) Must apply participation and eligibility requirements uniformly to all small employers with the same number of eligible employees;

(d) If a carrier requires 100 percent participation of eligible employees in a small group health benefit plan, the carrier may not impose a contribution requirement upon the employer that exceeds 50 percent of the premium of an employee-only benefit plan; and

(e) Except as provided in this subsection, a carrier may not increase any requirement for minimum employee participation or any requirement for minimum employer contribution applicable to a small employer except at plan anniversary. At plan anniversary, the carrier may increase the requirements only to the extent those requirements are applicable to all other small employer groups of the same size. At the anniversary of a plan or at any time other than the anniversary, a small employer carrier may consider the existing small group as a new group for purposes of coverage if the eligibility requirements applicable to the group are changed by the employer.

(3) Violation of this rule is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244 & 743.751
Stats. Implemented: Sec. 7, Ch. 681, OL 2013, ORS 743.522, 743.730– 743.754 & 746.240
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0230

Underwriting

(1) Every group health benefit plan issued by a carrier must specify all of the participation, contribution and eligibility requirements that have been agreed upon by the carrier and the covered group, and the carrier must apply those requirements uniformly within each category of eligible members.

(2) A carrier offering a group health benefit plan shall not use health statements, except for late enrollees as provided in ORS 743.751. A health statement used for a late enrollee must comply with the requirements of OAR 836-053-0510. After enrollment, health statements or other information may be used by a carrier for the purpose of providing services or arranging for the provision of services under a group health benefit plan.

(3) A carrier offering a group health benefit plan shall not use health statements or other information revealing individual health status to determine the acceptance or rejection of a group that has applied for coverage. Impermissible other information includes claim records that identify individual claimants. Permissible criteria for the declination of a group include such factors as:

(a) The risk status or claims experience of the group as a whole; and

(b) The financial condition of the group as a whole.

(4) When a group health benefit plan is issued to a collection of eligible subgroups or individuals, as may occur with an association, trust or fully insured multiple employer welfare arrangement, a carrier may determine the acceptance or rejection of coverage for each eligible subgroup or individual. The determination of the carrier, however, must be made in accordance with section (3) of this rule.

(5) If a carrier accepts a group for coverage, the carrier shall not:

(a) Decline to offer coverage to any eligible member;

(b) Impose any terms or conditions on the coverage of an eligible member that are based on the actual or expected health status of the member, except as provided in ORS 743.754; or

(c) Delay enrollment for an otherwise eligible employee or dependent who is disabled when enrollment would normally occur.

(6) The crediting of prior coverage, as specified in ORS 743.754, shall be applied in either of the following cases:

(a) If creditable coverage remains in effect on the enrollment date, as specified in ORS 743.754(1); or

(b) If creditable coverage terminated no more than 62 days prior to the enrollment date, as specified in ORS 743.754(1).

(7) All policy forms and enrollee summaries for group health benefit plans that contain a preexisting conditions provision must clearly disclose how prior creditable coverage will be applied. A carrier may use the following statement, or other similar disclosure, for this purpose:

The duration of the preexisting conditions provision in this policy will be reduced by the amount of your prior “creditable coverage” if:

(a) Your creditable coverage is still in effect on your date of enrollment in this policy; or

(b) Your creditable coverage ended no more than 62 days beforeyour date of enrollment in this policy. Creditable coverage means any of the following coverages: Group coverage (including FEHBP and Peace Corps); Individual coverage (including student health plans); Medicaid; Medicare; CHAMPUS; Indian Health Service or tribal organization coverage; state high risk pool coverage; and public health plans. Creditable coverage does not include coverage only for a specified disease or illness or hospital indemnity (income) insurance.

(8) To expedite the accurate crediting of prior coverage, in accordance with section (6) of this rule, a carrier shall:

(a) Include a question about potential creditable coverage in all enrollment forms that are used in conjunction with any group health benefit plan containing a preexisting conditions provision; and

(b) Include a notice about potential creditable coverage whenever the carrier notifies an enrollee that a claim has been denied because of a preexisting conditions provision. The notice of claim denial shall also include a telephone number at the carrier that the enrollee may use for additional information regarding the denied claim.

(9) A late enrollee, as defined in ORS 743.730, must be accepted for coverage in a group health benefit plan, but may be subject to the coverage limitations specified in 743.754. A health statement may be used to determine a late enrollee’s preexisting conditions, but not to determine a late enrollee’s eligibility to enroll or enrollment date. If a late enrollee is subject to a preexisting conditions provision, credit for prior creditable coverage must be applied to the preexisting condition period applicable to the enrollee.

(10) An enrollee who qualifies under a special enrollment period, as specified in ORS 743.754, must be accepted for coverage in a group health benefit plan and shall not be considered a late enrollee. Such an enrollee, however, is subject to the preexisting conditions provision, if any, and the creditable coverage requirements that apply to regular enrollees.

(11) A modification to an existing group health benefit plan that is required by ORS 743.751 to 743.754 or by OAR 836-053-0210 to 836-053-0250 shall be implemented for each policyholder on the next renewal date. For the purposes of this subsection, the next renewal date means the first renewal date of the policy issued to the policyholder that occurs on or after the operative date of the governing statutory provision (i.e., October 1, 1996, for SB 152 (1995); August 1, 1997, for SB 98 (1997)). In addition:

(a) Any existing rider or endorsement in effect for a certificate holder or dependent that was based on the actual or expected health status of the certificate holder or dependent and that excludes coverage for a disease or medical condition otherwise covered by the plan shall be eliminated and deemed ineffective as of the next renewal date;

(b) A person who was previously eligible to enroll in a plan, but who was denied enrollment on the basis of the actual or expected health status of the person, shall be offered enrollment in the plan as of the next renewal date, if the person is still eligible as of that date; and

(c) If a certificate holder or dependent has limited coverage because of late enrollment in a plan, credit shall be granted for the time so enrolled against the maximum exclusion or limitation specified in ORS 743.754 and such crediting of time shall be effective as of the next renewal date.

(12) A group health benefit plan shall be renewable at the option of the policyholder and shall not be discontinued by the carrier during or at the termination of the contract period except in the circumstances specified in ORS 743.754 and consistent with the requirements of HIPAA (42 U.S.C. 300gg-12).

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.522 & 743.751 - 743.754
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98

Individual Health Benefit Plans

836-053-0410

Purpose; Statutory Authority; Enforcement

(1) OAR 836-053-0410 to 836-053-0465 are adopted under the authority of ORS 743.499, 743.769 and 743.894 for the purpose of implementing ORS 743.766 to 743.769and 743.894 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 743.499, 743.769 & 743.894
Stats. Implemented: ORS 743.499, 743.766–743.769 & 743.894
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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0415

Cancellation of an Individual Health Benefit Plan Coverage

The notice requirements of ORS 743.499 and 743.894 are triggered at the time an insurer takes administrative action to terminate coverage.

Stat. Auth.: ORS 743.499, 743.769 & 743.894
Stats. Implemented: ORS 743.499, 743.766–743.769 & 743.894
Hist.: ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0431

Underwriting, Enrollment and Benefit Design

(1) A carrier must offer all of its approved nongrandfathered individual health benefit plans and plan options, including individual plans offered through associations, to all individuals eligible for such plans on a guaranteed issue basis without regard to health status, age, immigration status or lawful presence in the United States. Except as provided in section (2) of this rule:

(a) For individual health benefit plans approved by October 1 of each calendar year for sale in the following calendar year, a carrier may limit enrollment to:

(A) October 1, 2013 to March 31, 2014 for coverage effective in 2014;

(B) November 15, 2014 through January 15, 2015 for coverage effective in 2015; and

(C) October 15 to December 7 of each preceding calendar year for coverage effective on or after January 1, 2016; and

(b) Coverage must be effective consistent with the dates described in 45 CFR 155.410(c) and (f).

(2)(a) Notwithstanding section (1) of this rule, a carrier must deny enrollment under the following circumstances:

(A) To an individual who is not lawfully present in the United States in a plan provided through the Oregon Health Insurance Exchange Corporation.

(B) To an individual entitled to benefits under a Medicare plan under part A or B or a Medicare Choice or Medicare Advantage plan described in 42 USC 1395W–21, if and only if the individual is enrolled in such a plan.

(b) A carrier must enroll an individual who, within 60 days before application for coverage with the carrier:

(A) Loses minimum essential coverage. Loss of minimum essential coverage does not include termination or loss due to failure to pay premiums or rescission as specified in 45 CFR 147.128. The effective date of coverage for the loss of minimum essential must be consistent with the requirements of 45 CFR 155.420(b)(1).

(B) Gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption or foster care. The effective date for coverage for enrollment under this paragraph must be:

(i) In the case of marriage, no later than the first day of the first calendar month following the date the carrier receives the request for special enrollment.

(ii) In the case of birth, on the date of birth.

(iii) In the case of adoption or placement for adoption or foster care, no later than the date of adoption or placement for adoption or foster care.

(C) Experiences a qualifying event as defined under section 603 of the Employee Retirement Income Security Act of 1974, as amended.

(D) Experiences an event described in 45 CFR 155.420(d)(4), (5), (6), or (7). The effective date of coverage for enrollment under this paragraph must be:

(i) For 45 CFR 155.420(d)(4) or (d)(5), consistent with the requirements of 45 CFR 155.420(b)(2)(iii).

(ii) For 45 CFR 155.420(d)(6) or (d)(7), consistent with the requirements of 45 CFR 155.420(b)(1).

(E) Loses eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a state child health plan under title XXI of the Social Security Act. The effective date of coverage for enrollment under this paragraph must be consistent with the requirements of 45 CFR 155.420(b)(1).

(c) During the month of April 2014, a carrier must allow special enrollment on the basis that an individual who applies during April 2014 has experienced an event described in 45 CFR 155.420(d)(9), if no other basis for special enrollment exists. The effective date of coverage for enrollment under this paragraph must be no less restrictive than those described in 45 CFR 155.420(b)(2)(iii)(B).

(3) Notwithstanding section (1)(a)(A) of this rule, a carrier must enroll an individual who is enrolled in an individual health benefit plan with a policy year that terminates after March 31, 2014 if the individual applies for coverage within 30 calendar days before the end of the individual’s individual health benefit plan policy year. This subsection does not require a carrier to enroll an individual enrolled in an individual health benefit plan with a policy year that ends after December 31, 2014 if enrollment is not otherwise required under section (1) or (2) of this rule. The effective date of coverage for enrollment under this subsection must be effective consistent with the requirements of 45 CFR 155.420(b)(1).

(4) Except as permitted under a preexisting condition provision of a grandfathered individual plan, a carrier may not modify the benefit provisions of an individual health benefit plan for any enrollee by means of a rider, endorsement or otherwise for the purpose of restricting or excluding coverage for medical services or conditions that are otherwise covered by the plan.

(5) A carrier may offer wrap-around occupational coverage to an accepted individual health benefit plan applicant.

(6) A carrier may impose an individual coverage waiting period on the coverage of certain new enrollees in a grandfathered individual health benefit plan in accordance with ORS 743.766. The terms of the waiting period must be specified in the policy form and enrollee summary. The waiting period may apply only when the carrier has determined that the enrollee has a preexisting health condition warranting the application of a waiting period through evaluation of the form entitled “Oregon Individual Standard Health Statement” as set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov.

(7) A carrier may treat a request by an enrollee in an individual health benefit plan to enroll in another individual plan as a new application for coverage.

(8) Unless otherwise required by law and except as provided in section (9) of this rule, a carrier must implement a modification of a nongrandfathered individual health benefit plan required by statute on the next anniversary or fixed renewal date of the plan that occurs on or after the operative date of the statutory provision requiring the modification.

(9) For a grandfathered individual health benefit plan:

(a) Unless otherwise required by law, a carrier must implement a modification required by statute on the first day of the calendar year that occurs on or after the operative date of the statutory provision requiring the modification.

(b) A carrier must eliminate and deem ineffective a rider or endorsement in effect for an enrollee based on the actual or expected health status of the enrollee and that excludes coverage for diseases or medical conditions otherwise covered by the plan as of the next renewal date;

(c) If an enrollee who is subject to a preexisting condition provision has a rider or endorsement eliminated in accordance with subsection (a) of this section, the enrollee's medical condition that is subject to the rider or endorsement may be subject to the preexisting conditions provision of the plan, including the prior coverage credit provisions;

(10) In accordance with applicable federal law, a carrier may not deny continuation or renewal of an individual health benefit plan based on Medicare eligibility of an individual but an individual health benefit plan may contain a Medicare non-duplication provision.

(11) Violation of this rule is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244, 743.745 & 743.769
Stats. Implemented: ORS 743.745 & 743.766 - 743.769
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 2-2014(Temp), f. & cert. ef. 2-4-14 thru 7-31-14; ID 5-2014(Temp), f. & cert. ef. 4-2-14 thru 9-24-14; ID 7-2014(Temp), f. & cert. ef. 4-16-14 thru 9-24-14; ID 14-2014, f. & cert. ef. 7-30-14; ID 17-2014, f. & cert. ef. 10-6-14

836-053-0465

Rating for Individual Health Benefit Plans

(1) Individual health benefit plans must be rated in accordance with the geographic areas specified in OAR 836-053-0065. A carrier must file a single geographic average rate for each health benefit plan that is offered to individuals within a geographic area. The geographic average rate must be determined on a pooled basis, and the pool shall include all of the carrier's business in the Oregon individual health benefit plan market, except for grandfathered health benefit plans, student health benefit plans and transitional health benefit plans.

(2) The variation in geographic average rates among different individual health benefit plans offered by a carrier must be based solely on objective differences in plan design or coverage. The variation shall not include differences based on the risk characteristics or claims experience of the actual or expected enrollees in a particular plan.

(3) A carrier may use the same geographic average rate for multiple rating areas.

(4) For a nongrandfathered health benefit plan:

(a) A carrier must implement premium rate increases on a fixed schedule that applies concurrently to all enrollees in a plan. A carrier may adjust an enrollee's premium during the rating period if the enrollee has a change in family composition.

(b) Premium rates must total the sum of the product of the applicable factors in subsection (c) of this section for each enrollee and dependent 21 years of age and older and the sum of the product of the applicable factors in section (7) of this rule for each of the three oldest dependent children under the age of 21.

(c) As determined by a carrier, variations in rates may be based on one or both of the following factors:

(A) The ages of enrollees and their dependents according to Exhibit 1 to this rule. Variations in rates based on age may not exceed a ratio of three to one; or

(B) A tobacco use factor of no more than one and one-half times the non-tobacco use rate for persons 18 years of age or older except that the factor may not be applied when the person is enrolled in a tobacco cessation program.

(5) For a grandfathered health benefit plan, a carrier must implement premium rate increases in a consistent manner for all enrollees in a plan. A carrier may use either of the following methods to schedule premium rate increases for all enrollees in a grandfathered health benefit plan:

(a) A rolling schedule that is based on the anniversary of the date of coverage issued to each enrollee or on another anniversary date established by the carrier; or

(b) A fixed schedule that applies concurrently to all enrollees in a plan. If a fixed schedule is used, a carrier may adjust the premium of an enrollee during the rating period if the enrollee moves into a higher age bracket or has a change in family composition.

(6) In addition to other bases offered by a carrier, an enrollee of an individual health benefit plan must be offered the opportunity to pay premium on a monthly basis.

Stat. Auth.: ORS 731.244, 743.019, 743.020, 743.769 & 2014 OL Ch. 80, Sec. 5
Stats. Implemented: ORS 743.766 - 743.769, 746.015, 746.240 & 2014 OL Ch. 80, Sec. 5
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; Renumbered from 836-053-0420, ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 7-2001(Temp), f. 5-30-01, cert. ef. 5-31-01 thru 11-16-01; ID 14-2001, f. & cert. ef. 11-20-01; ID 5-2010, f. & cert. ef. 2-16-10; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 6-2014(Temp), f. & cert. ef. 4-11-14 thru 10-8-14; ID 17-2014, f. & cert. ef. 10-6-14

836-053-0472

Statutory Authority and Implementation

(1) OAR 836-053-0473 and 836-053-0475 are adopted under the authority of ORS 731.244, 743.018, 743.019, and 743.020 to aid in giving effect to provisions of ORS Chapters 742 and 743 relating to the filing of rates and policy forms with the Director. The requirements of OAR 836-053-0473 and 836-053-0475 are in addition to any other requirements established by statute or by rule or bulletin of the Department.

(2) OAR 836-053-0473 and 836-053-0475 apply to the following rate filings submitted or resubmitted to the Director on or after April 1, 2010:

(a) Health benefit plans for small employers;

(b) Individual health benefit plans.

Stat. Auth.: ORS 743.018, 743.019 & 743.020
Stats. Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730 & 743.767
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0473

Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans

(1) Every insurer that offers a health benefit plan for small employers or an individual health benefit plan must file the information specified in section (2) of this rule when the insurer files with the director a schedule or table of premium rates for approval.

(2) A schedule or table of base premium rates filed under section (1) of this rule must include sufficient information and data to allow the director to consider the factors set forth in ORS 743.018(4) and (5). The filing must include all of the following separately set forth and labeled as indicated:

(a) A filing description labeled “Filing Description.” The filing description must:

(A) Be submitted in the form of a cover letter;

(B) Provide a summary of the reasons an insurer is requesting a rate change and the minimum and maximum rate impact to all groups or members affected by the rate change, including the anticipated change in number of enrollees if the proposed premium rate is approved;

(C) Explain the rate change in a manner understandable to the average consumer; and

(D) Include a description of any significant changes the insurer is making to the following:

(i) Rating factor changes; and

(ii) Benefit or administration changes.

(b) Rate tables and factors labeled “Rate Tables and Factors.” The rate tables and factors must:

(A) Include base and geographic average rate tables;

(B) Identify factors used by the insurer in developing the rates;

(C) Explain how the information is used in the development of rates;

(D) Include a table of rating factors reflecting ages of employees and dependents and geographic area.

(E) Include rate tier tables if base rates are not provided by rating tier;

(F) Indicate whether the rate increases are the same for all policies;

(G) Explain how the rate increases apply to different policies;

(H) Provide the entire distribution of rate changes and the average of the highest and lowest rates resulting from the application of other rating factors;

(I) Within the geographic average rate table, include family type, geographic area and the average of the highest and lowest rates resulting from the application of other rating factors;

(J) Within the base rate table, include the base rates for each available plan and sufficient information for determination of rates for each health benefit plan, including but not limited to:

(i) Each age bracket;

(ii) Each geographic area;

(iii) Each rate tier;

(iv) Any other variable used to determine rates; and

(v) If the rates vary more frequently than annually, separate rates for each effective date of change or sufficient information to permit the determination of the rates and the justification for the variation in the rates;

(K) For a grandfathered small group health benefit plan, include the following factors if applied by the insurer:

(i) Contribution;

(ii) Level of participation;

(iii)Family composition;

(iv) The level at which enrollees or dependents engage in health promotion, disease prevention or wellness programs;

(v) Duration of coverage in force;

(vi) Any adjustment to reflect expected claims experience; and

(vii) Age.

(L) For a grandfathered individual health benefit plan, include the following factors to the extent applied by the insurer:

(i) Family composition; and

(iv) Age; and

(M) For a nongrandfathered health benefit plan, include the following factors if applied by the insurer:

(i) Tobacco usage; and

(ii) The level at which enrollees or dependents engage in health promotion, disease prevention, or wellness programs.

(c) An actuarial memorandum consistent with the requirements of both state and federal law labeled “Actuarial Memorandum.” The actuarial memorandum must include all of the following:

(A) A description of the benefit plan and a quantification of any changes to the benefit plan as set forth in subsection (e) of this section;

(B) A discussion of assumptions, factors, calculations, rate tables and any other information pertinent to the proposed rate, including an explanation of the impact of risk corridors, risk adjustment and state and federal reinsurance on the proposed rate;

(C) A description of any changes in rating methodology supported by sufficient detail to permit the department to evaluate the effect on rates and the rationale for the change;

(D) The range of rate impact to groups or members including the distribution of the impact on members;

(E) A cross-reference of all supporting documentation in the filing in the form of an index and citations;

(F) The dated signature of the qualified actuary or actuaries who reviewed and authorized the rate filing; and

(G) The contact information of the filer.

(d) A description of the development of the proposed rate change or base rate that is included as an exhibit to the filing and labeled “Exhibit 1: Development of Rate Change.” The development of rate change is the core of the rate filing and must:

(A) Explain how the proposed rate or rate change was calculated using generally accepted actuarial rating principles for rating blocks of business;

(B) Include actual or expected membership information;

(C) Identify a proposed loss ratio for the rating period;

(D) Include a rate renewal calculation that:

(i) Begins with an assumed experience period of at least one year and ends within the immediately preceding year; or

(ii) If more recent data is available, uses the one-year period that ends with the most recent period for which data is available;

(E) Show adjustments to total premium earned during the experience period to yield premium adjusted to current rates;

(F) Include a projection of premiums and claims for the period during which the proposed rates are to be effective; and

(G) Provide a renewal projection using claims underlying the projection that reflect an assumed medical trend rate and other expected changes in claims cost, including but not limited to, the impact of benefit changes or provider reimbursement.

(e) A description of changes to covered benefits or health benefit plan design that is included as an exhibit to the rate filing and labeled “Exhibit 2: Covered Benefit or Plan Design Changes.” The covered benefit or plan design changes must:

(A) Explain all applicable benefit and administrative changes with a rating impact, including but not limited to:

(i) Covered benefit level changes;

(ii) Member cost-sharing changes;

(iii) Elimination of plans;

(iv) Implementation of new plan designs;

(v) Provider network changes;

(vi) New utilization or prior authorization programs;

(vii) Changes to eligibility requirements; and

(viii) Changes to exclusions; and

(B) Show any change in the plan offerings that impacts costs or coverage provided not otherwise provided pursuant to subsection (e)(A) of this section.

(f) The average annual rate change included as an exhibit to the filing and labeled “Exhibit 3: Average Annual Rate Change.” The average annual rate change must:

(A) Provide the average, maximum and minimum annual rate changes for each effective date in the filing;

(B) Include a meaningful distribution of rate changes; and

(C) Provide an estimate of contributing factors to the annual rate change.

(g) Trend information and projection included as an exhibit to the filing and labeled “Exhibit 4: Trend Information and Projection.” The trend information and projection must:

(A) Describe how the assumed future growth of medical claims (the medical trends rate) was developed based on generally accepted actuarial principles; and

(B) At a minimum, include historical monthly average claim costs for the two years immediately preceding the period for which the proposed rate is to apply. If the carrier’s structure does not include claims cost, the carrier must submit this information based on allocated costs.

(h) A statement of administrative expenses and premium retention included as an exhibit to the filing and labeled “Exhibit 5: Statement of Administrative Expenses and Premium Retention.” The statement of administrative expenses and premium retention must:

(A) Include a completed chart displaying the five-year trend of administrative costs and enumerating the insurer’s administrative expenses detailed as follows:

(i) Salaries;

(ii) Rent;

(iii) Advertising;

(iv) General office expenses;

(v) Third party administration expenses;

(vi) Legal and other professional fees; and

(vii) Travel and other administrative costs not accounted for under a category in subsections (h)(B)(i)–(vi) of this section;

(B) Explain how the insurer allocates administrative expenses for the filed line of business;

(C) Include a description of the amount retained by the insurer to cover all of the insurer’s non-claim costs including expected profit or contribution to surplus for a nonprofit entity reported on a percentage of premium and per member per month basis; and

(D) Demonstrate the total premium retention for the filing, including total administrative expenses reported under subsection (h)(B) of this section, commissions, taxes, assessments and margin.

(i) Plan relativities included as an exhibit to the filing and labeled “Exhibit 6: Plan Relativities.” Plan relativities must:

(A) Explain the presentation of rates for each benefit plan;

(B) Explain the methodology of how the benefit plan relativities were developed; and

(C) Demonstrate the comparison and reasonableness of benefits and costs between plans.

(j) Information about the insurer’s financial position included as an appendix to the filing and labeled “Appendix I: Insurer’s Financial Position.” The insurer’s financial position may reference documents filed with the department and available to the public, including the insurer’s annual statement. The insurer’s financial position must include:

(A) Information about the insurer’s financial position including but not limited to the insurer’s:

(i) Profitability;

(ii) Surplus;

(iii) Reserves; and

(iv) Investment earnings; and

(B) An analysis, explanation and determination of whether the proposed change in the premium rate is necessary to maintain the insurer’s solvency or to maintain rate stability and prevent excessive rate increases in the future.

(k) Changes in the insurer’s health care cost containment and quality improvement efforts included as an appendix to the filing and labeled “Appendix II: Cost Containment and Quality Improvement Efforts. The cost containment and quality improvement efforts must:

(A) Explain any changes the insurer has made in its health care cost containment efforts and quality improvement efforts since the insurer’s last rate filing for the same category of health benefit plan.

(B) Describe significant new health care cost containment initiatives and quality improvement efforts;

(C) Include an estimate of the potential savings from the initiatives and efforts described in subsection (2(g)(B) of this section together with an estimate of the cost or savings for the projection period; and

(D) Include information about whether the cost containment initiatives reduce costs by eliminating waste, improving efficiency, by improving health outcomes through incentives, by elimination or reduction of covered services or reduction in the fees paid to providers for services.

(l) Certification of compliance labeled “Certification of Compliance.” The certification of compliance must:

(A) Comply with OAR 836-010-0011; and

(B) Certify that the filing complies with all applicable Oregon statutes, rules, product standards and filing requirements.

(m) Third party filer’s letter of authorization labeled “Third Party Authorization.” If the filing is submitted by a person other than the insurer to which the filing applies, the filing must include a letter from the insurer that authorizes the third party to:

(A) Submit the filing to the department;

(B) Correspond with the department on matters pertaining to the rate filing; and

(C) Act on the insurer’s behalf regarding all matters related to the filing.

(3)(a) Within 10 days after receiving a proposed table or schedule of premium rate filing, the director must:

(A) Determine whether the proposed table or schedule of premium rate filing is complete. If the director determines that a filing is complete, the director must review the proposed schedule or table of premium rates in accordance with ORS 742.003, 742.005, 742.007 and 743.018. If the director determines that the filing is not complete, the director must notify the insurer in writing that the filing is deficient and give the insurer an opportunity to provide the missing information.

(B) If the filing is complete, open the 30-day public comment period. For purposes of determining the beginning of the public comment period, the date the carrier files a proposed schedule or table of premium rates shall be the date the director determines that the filing is complete.

(b) Within 10 days after the close of the public comment period, the director must issue a decision approving, disapproving or modifying the proposed table or schedule of premium rate filing.

(4) At the beginning of the public comment period, the director must post on the Insurance Division website all materials submitted under section (2) of this rule.

Stat. Auth.: ORS 743.018, 743.019 & 743.020
Stats. Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730 & 743.767
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0475

Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan

(1) The materials submitted under OAR 836-053-0473 must include information sufficient to allow the director to evaluate the proposed schedule or table of premium rates for approval, disapproval or modification. After conducting an actuarial review of the rate filing, the director may approve a proposed premium rate for a health benefit plan for small employers or for an individual health benefit plan if, in the director’s discretion, the proposed rates meet the requirements of ORS 742.003, 742.005, 742.007 and 743.018.

(2) The director may approve reasonable increases or decreases in administrative expenses supported by the information provided under OAR 836-053-0473. In addition to the materials submitted under OAR 836-053-0473, in order to determine whether the proposed increase or decrease in administrative expenses is reasonable, the director may consider the cost of living for the previous calendar year, based on the Producer Price Index for Direct Health and Medical Insurance Carriers Industry, as published by the Bureau of Labor Statistics of the United States Department of Labor.

Stat. Auth.: ORS 743.018, 743.019 & 743.020
Stats. Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730 & 743.767
Hist.: ID 5-2010, f. & cert. ef. 2-16-10; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0510

Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage

(1) A carrier may not use any health statement except the health statement entitled, “Oregon Standard Health Statement” set forth on the website for the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov to evaluate the health status of an applicant for coverage in a grandfathered individual health benefit plan. In all instances in which a carrier uses the Oregon Standard Health Statement, the carrier must pay for the costs associated with its use or the collection of information described in section (2) of this rule.

(2) In evaluating an Oregon Standard Health Statement, a carrier may request the applicant’s medical records or a statement from the applicant’s attending physician, but such a request may be made only for questions marked "Yes" by the applicant in the numbered questionnaire portion of the statement. Although a carrier's request for additional medical information is limited to the specific questions marked "Yes," a carrier may use all of the information received in response to such a request in evaluating the applicant's health statement.

(3) A carrier may require an applicant for a nongrandfathered individual health benefit plan to provide health-related information for the sole purpose of health care management, including providing or arranging for the provision of services under the plan.

(a) A carrier that chooses to collect health-related information from an applicant before enrollment must:

(A) Prominently state immediately before, and on the same page as, any health-related questions that:

(i) Health-related information provided by the applicant will be used solely for health care management purposes.

(ii) The applicant’s coverage cannot and will not be denied, terminated, delayed, limited or rescinded based on the applicant’s responses or failure to respond to the questions.

(iii) The premium charged for the insurance policy cannot and will not change based on the applicant’s responses or failure to respond to questions.

(B) Limit pre-enrollment health-related questions to whether an applicant:

(i) Has a disability or a chronic health condition

(ii) Has been advised by a licensed medical professional in the twelve months before application that hospitalization, surgery or treatment is necessary or pending.

(iii) Is pregnant.

(b) A carrier that chooses to ask questions described in paragraph (3)(a)(B) of this section, may include the following as examples of a disability or chronic health condition:

(A) Asthma,

(B) Lung disease,

(C) Depression,

(D) Diabetes,

(E) Heart disease,

(F) Chronic back pain,

(G) Chronic joint pain,

(H) Obesity.

(c) A carrier may not delay or refuse to issue nongrandfathered individual coverage to an applicant because the applicant has failed to respond or failed to respond completely to the questions allowed under paragraph (3)(a)(B) of this section.

(d) For purposes of ORS 743.751 and this section, “applicant” includes a prospective enrollee or dependent of a prospective enrollee.

(4) Violation of any provision of this rule is an unfair trade practice under ORS 746.240.

Stat. Auth.: ORS 731.244 & 743.751
Stats. Implemented: ORS 743.751
Hist.: ID 12-1996, f. & cert. ef. 9-23-96; Renumbered from 836-053-0470, ID 5-1998, f. & cert. ef. 3-9-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 9-2004, f. & cert. ef. 11-19-04; ID 9-2011, f. & cert. ef. 2-23-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

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 employer or plan sponsor to do so, binds the employer or plan sponsor to a contract for health benefit plan coverage.

(2) The notice required by ORS 743.737(6), 743.754(8) and 743.894(3) 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 an enrollee’s right to file a grievance 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 notice of rescission required under ORS 743.737(6), 743.754(8) and 743.894(3) 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; online at http://www.insurance.oregon.gov; or by electronic mail to 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 an enrollee’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 ORS 743.777(3), a health carrier may provide the required notice for small employer group health insurance either by first class mail or electronically.

(4)(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the Director of the Department of Consumer and Business Services and in accordance with instructions accessed through the website of the Insurance Division at http://www.insurance.oregon.gov. The notice required by ORS 743.737 (6)(c), 743.754 (8)(c) and 743.894(4) must include information related to group health benefit plan rescissions including but not limited to the total number of:

(A) Fully rescinded group health benefit plans;

(B) Partially rescinded group health benefit plans;

(C) Group health benefit plans in force on December 31 of the report year;

(D) Enrollees affected by a fully rescinded group health benefit plan; and

(E) Enrollees affected by a partially rescinded group health benefit plan.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0830 and 836-053-0835.

Stat. Auth.: ORS 743.018, 743.019, 743.020 & 743.894
Stats. Implemented: ORS 742.003, 742.005, 742.007, 743.018, 743.019, 743.020, 743.730, 743.737, 743.754 & 743.767 & 743.894
Hist.: ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0830

Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy

(1) The notice required by ORS 743.894(2) 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 notice of rescission required by ORS 743.894(2) may be made with the Oregon Insurance Division by writing to PO Box 14480, Salem, OR 97309-0405; by calling (503) 947-7984 or (888) 877-4894; online at http://www.insurance.oregon.gov; or by electronic mail to cp.ins@state.or.us. The statement shall also explain that such complaints do not constitute grievances under the health benefit plan or health insurance policy and may not preserve an enrollee’s rights under the plan or policy.

(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.

(2) Subject to ORS 743.777, a health carrier may provide the notice required under ORS 743.894(2) for individual health insurance either by first class mail or electronically.

(3)(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the Director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov. The notice required by ORS 743.894(4) must include information related to rescission of individual health benefit plans and individual health insurance policies including but not limited to the total number of:

(A) Fully rescinded individual health benefit plans and individual health insurance policies;

(B) Partially rescinded individual health benefit plans and health insurance policies;

(C) Individual health benefit plans and individual health insurance policies in force on December 31 of the report year; and

(D) Enrollees affected by full or partial rescission of an individual health benefit plan or individual health insurance policy.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0825 and 836-053-0835.

Stat. Auth.: ORS 731.244 & 743.894
Stats. Implemented: ORS 743.731 & 743.894
Hist.: ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0835

Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy

(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 an individual’s coverage under a group health insurance policy, including a group health benefit plan under ORS 743.737, 743.754, and 743.894, “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 ORS 743.737(5), 743.754(7) and 743.894(2) to each plan enrollee affected by rescission of coverage under a group health benefit plan or group health insurance policy 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 an enrollee’s right to file a grievance 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 notice of rescission required under ORS 743.737(5), 743.754(7) and 743.894(2) 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; online at http://www.insurance.oregon.gov; or by electronic mail to cp.ins@state.or.us. The statement shall also explain that complaints to the Insurance Division do not constitute grievances under the group health benefit plan or group health insurance policy and may not preserve an enrollee’s rights under the plan or policy.

(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 ORS 743.777, a health carrier may provide the required notice for small employer group health insurance either by first class mail or electronically.

(4)(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the Director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov. The notice required by ORS 743.737(5), 743.754(7) and 743.894(4) must include information related to rescissions of enrollee coverage under a group health benefit plan or group health insurance policy including but not limited to the total number of enrollees affected by full or partial rescission of coverage under a group health benefit plan or group health insurance policy.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0825 and 836-053-0830.

Stat. Auth.: ORS 743.244, 743.737, 743.754 & 743.894
Stats. Implemented: ORS 743.737, 743.754 & 743.894
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

State Continuation of Health Insurance

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.

Stat. Auth.: ORS 731.244 & 743.610
Stats. Implemented: ORS 743.610
Hist.: ID 12-2010, f. & cert. ef. 6-11-10, ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

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

836-053-0863

Notifications

(1) For purposes of the notice required by ORS 743.610(10), an insurer must use the notice set forth on the website for the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov. An insurer:

(a) May incorporate the notice into another document provided that the notice remains prominent.

(b) May modify the font of the document but the font must be at least 12 point.

(c) May add headings, logos and other company identifiers.

(d) Must modify the notice to include the information as indicated in the brackets.

(2) 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.

(3) 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 policyholder.

(4) An insurer that requires a covered person or qualified beneficiary to complete a form to request continuation of coverage must provide the form to the person. The form may be provided by electronic means including via a specific website address. However, if a covered person or qualified beneficiary asks an insurer to provide the forms via mail, the insurer must do so within two business days of the request. Notice pursuant to ORS 743.610(10) is deemed provided upon receipt of any required forms when the forms are mailed by the insurer.

(5) Notice under ORS 743.610(5) provided to a group policyholder pursuant to the instruction of an insurer constitutes notice to the insurer that meets the requirements of ORS 743.610(5).

Stat. Auth.: ORS 731.244 & 743.610
Stats. Implemented: ORS 743.610
Hist.: ID 6-2012(Temp), f. 3-27-12, cert. ef. 4-15-12 thru 10-10-12; ID 16-2012, f. & cert. ef. 8-24-12

Quality Assessment and Improvement

836-053-0900

Purpose; Statutory Authority

OAR 836-053-0900 and 836-053-0910 are adopted under the authority of ORS 731.244 for the purpose of carrying out ORS 743.730 to 743.773 and providing rate filing requirements and procedures for small employer and individual health benefit plans.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.730 - 743.773
Hist.: ID 13-1996(Temp), f. & cert. ef. 9-23-96; ID 2-1997, f. & cert. ef. 3-28-97; ID 5-1998, f. & cert. ef. 3-9-98, Renumbered from 836-053-0180; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-0910

Rate Filing

(1) A carrier must file with the Director of the Department of Consumer and Business Servicesthe appropriate checklists and certification statements as established in OAR 836-010-0011.

(2) A carrier may not:

(a) Offer a small group or individual health benefit plan until the director has determined that the filed geographic average rate meets the applicable statutory requirements.

(b) Modify an approved geographic average rate unless the director has determined that the modification meets the applicable statutory requirements.

(3) Rate filings for small group and individual health benefit plans must be submitted to the director in one of the following electronic formats:

(a) The National Association of Insurance Commissioners’ System for Electronic Rate and Form Filings (SERFF) format; or

(b) PDF format for a filing that is less than three megabytes. For the purpose of this subsection, each filing requirement, such as an exhibit, an actuarial memorandum or a certificate of compliance, must be in a separate PDF format that is less than three megabytes . These filings may be submitted by electronic mail with documents attached in PDF format, or the filings may be submitted on a compact disc with documents attached in PDF format. If submitting by electronic mail, the combined size of the electronic mail plus attached documents being transmitted must be less than four megabytes.

(4) The director must post the contents of rate filings described in section (3) of this rule and rate filing summaries described in 836-053-0473 for public inspection on the website for the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov.

Stat. Auth.: ORS 731.244, 743.019, 743.020
Stats. Implemented: ORS 743.019, 743.020, 743.730 - 743.773
Hist.: ID 13-1996(Temp), f. & cert. ef. 9-23-96; ID 2-1997, f. & cert. ef. 3-28-97; ID 5-1998, f. & cert. ef. 3-9-98, Renumbered from 836-053-0185; ID 13-2007(Temp), f. & cert. ef. 12-21-07 thru 5-10-08; Administrative correction 5-20-08; ID 8-2008, f. & cert. ef. 6-18-08; ID 5-2010, f. & cert. ef. 2-16-10; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

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.

(2) For purposes of OAR 836-053-1000 to 836-053-1200, “insurer” includes a public entity that self insures employee health coverage pursuant to ORS 731.036(6) and a carrier as defined in 743.730 that offers a health benefit plan in Oregon.

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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1010

Insurer Policies

(1) The written policy recognizing the rights of enrollees, which is required of an insurer by ORS 743.804, must be an official corporate policy of the insurer.

(2) An insurer must provide a written summary of the policy required by ORS 743.804 to:

(a) Each participating provider, upon request of the provider; and

(b) Each enrollee, as part of the written general information that is furnished as required by ORS 743.804(5) and OAR 836-053-1030, relating to services, access thereto and related charges and scheduling.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.804
Hist.: ID 1-1998, f. & cert. ef. 1-15-98

836-053-1020

Drug Formularies

(1) For purposes of OAR 836-053-0000 to 836-053-1200:

(a) "Open formulary" means a method used by an insurer to provide prescription drug benefits in which all prescribed FDA approved prescription drug products are covered except for any drug product that is excluded by the insurer pursuant to the insurer's policy regarding medical appropriateness or by the terms of a specific health benefit plan, or except for an entire class of drug product that is excluded by the insurer.

(b) "Closed formulary" means a method used by an insurer to provide prescription drug benefits in which only specified FDA approved prescription drug products are covered, as determined by the insurer, but in which medical exceptions are allowed. Maximum benefits or coverage may be limited to formulary drugs in a health benefit plan with a closed formulary; and

(c) "Mandatory closed formulary" means a method used by an insurer to provide prescription drug benefits in which only specified FDA approved prescription drug products are covered, as determined by the insurer, and in which no exceptions are allowed.

(2) An insurer that uses an open formulary must have a written procedure that includes the written criteria or explains the review process established by the insurer for determining when an item will be limited or excluded pursuant to the insurer's policy regarding medical appropriateness.

(3) An insurer that uses a closed formulary must have a written procedure stating that FDA approved prescription drug products are covered only if they are listed in the formulary. The procedure must also describe how the insurer determines the content of the closed formulary and how the insurer determines the application of a medical exception. The procedure must describe how a provider may request inclusion of a new item in the closed formulary and must ensure that the insurer will issue a timely written response to a provider making such a request.

(4) An insurer that uses a mandatory closed formulary must have a written procedure stating that FDA approved prescription drug products are covered only if they are listed in the formulary and that no exception is allowed. The procedure must describe how the insurer determines the content of the mandatory closed formulary. The procedure must also describe how a provider may request inclusion of a new item in the formulary and must ensure that the insurer will issue a timely written response to a provider making such a request.

(5) An insurer must furnish a copy of the procedures it has adopted under section (2), (3), or (4) of this rule to a provider with authority to prescribe drugs and medications, upon the request of the provider.

(6) Except as provided in section (7) of this rule, a formulary must comply with the requirements of 45 CFR 156.122 and include the greater of:

(a) At least one drug in every United States Pharmacopeia therapeutic category and class; or

(b) The same number of drugs in each United States Pharmacopeia category and class as the prescription drug benefit of the plan described in OAR 836-053-0008(1)(a).

(7) An insurer that issues a small group or individual health benefit plan formulary that does not comply with the requirements of section (6) of this rule must file with the Director of the Department of Consumer and Business Services the form entitled “Formulary-Inadequate Category/Class Count Justification” as set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov. The director may approve a formulary that does not meet the requirements of section (6) of this rule if:

(a) Drugs in a category or class have been discontinued by the manufacturer;

(b) Drugs in a category or class have been deemed unsafe by the Food and Drug Administration or removed from market by the manufacturer due to safety concerns;

(c) Drugs in a category of class have a Drug Efficacy Study Implementation classification;

(d) Drugs in a category or class have become available as generics; or

(e) Drugs in a category or class are provided in a medical setting and are covered under the medical provisions of the plan.

Stat. Auth.: ORS 731.244 & sec. 2, ch.681, OL 2013
Stats. Implemented: ORS 743.804 & sec. 2, ch. 681, OL 2013
Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1030

Written Information to Enrollees

(1) Each insurer must furnish written 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 information described 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) As used inORS 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 information required by ORS 743.804 must include 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 information required by ORS 743.804 must include the information required by ORS 743A.012, 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 743A.012. An insurer may meet the requirement of providing information in 743A.012 by providing adequate disclosure in the information required by 743.804(1) 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 information required by ORS 743.804(1)(b) and (4) 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 and captioned in a manner that clearly indicates that the section addresses grievances and appeals.

(6) The information required by ORS 743.804(1)(b) and (4) must include a notice that states the right of an enrollee 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 electronic mail at: cp.ins@state.or.us;

By writing to the Oregon Division of Insurance, Consumer Advocacy Unit at:

PO Box 14480; Salem, OR 97309-0405; or

Through the Internet at http://www.insurance.oregon.gov/consumer/consumer.html.”

(7) The information required by ORS 743.804(1) 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 information required by ORS 743.804 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 information required by ORS 743.804 must include a list of all participating primary care providers, direct access providers and 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.

(10) If a plan includes risk-sharing arrangements with physicians or other providers, the information required by ORS 743.804 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 or other appropriate wording to describe risk-sharing:

“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 information required by ORS 743.804 for that plan must prominently disclose and explain the formulary provision. The disclosure and explanation must be in boldfaced type or otherwise emphasized.

(12) An insurer that issues a health benefit plan must include a notice with the information required by ORS 743.804 that discloses that additional information is available to enrollees upon request ]. The notice must include the name and telephone number of the insurer's administrative section that handles enrollee requests for information. The notice must also include the contact described in section (6) of this rule and a statement that the following additional information may be available from the Department of Consumer and Business Services: (a) An annual summary of grievances and appeals;

(b) An annual summary of utilization review policies;

(c) An annual summary of quality assessment activities;

(d) The results of all publicly available accreditation surveys;

(e) An annual summary of the insurer's health promotion and disease prevention activities;

(f) An annual summary of scope of network and accessibility of services.

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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

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.
Stat. Auth.: ORS 731.244 & 743.804

Stats. Implemented: ORS 743.804
Hist.: ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1070

Reporting of Grievances; Format and Contents

(1) To comply with the requirements in ORS 743.804, on or before June 30 of each calendar year, an insurer must submit information pertaining to grievances closed in the previous calendar year ending December 31. The data must be reported in the format prescribed by the Director of the Department of Consumer and Business Services as set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov. Filing and reporting requirements in this rule apply to:

(a) A domestic insurer; and

(b) A foreign insurer transacting $2 million or more in health benefit plan premium in Oregon during the calendar year immediately preceding the due date of a required report.

(2) 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.

(3) The data to be included in the annual summary required by section (1) of this rule 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 (4) of this rule;

(c) The number and percentage of grievances in each of the categories listed in section (4) 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.

(4) 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 source-of-injury exclusion, out-of-network or out-of-plan exclusion, annual benefit limits or other limitations of otherwise covered benefits, or imposition of a preexisting condition exclusion in a grandfathered health plan;

(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.

(5) 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 (4) 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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1080

Tracking Grievances

An insurer must 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 or OAR 836-080-0215.
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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1090

Assistance in Filing Grievances

For the purpose of providing assistance to enrollees in filing written grievances, as required by ORS 743.804, an insurer must promptly:

(1) Provide information regarding the use of the insurer’s grievance process to an enrollee who wants to submit a grievance; and

(2) Assist an enrollee in the filing of a grievance when the enrollee states a complaint and requests assistance in putting that complaint into writing.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.804
Hist.: ID 1-1998, f. & cert. ef. 1-15-98

836-053-1100

Internal Appeals Process

(1) An insurer must acknowledge receipt of an appeal from an enrollee not later than the seventh day after receiving the appeal.

(2)An insurer must make a decision on the appeal not later than the 30th day after receiving notice of the appeal.

(3) An otherwise applicable standard for timeliness in sections (1) or (2) 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.

(4) 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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1110

Notice of Complaint Filing with Director

A written decision by an insurer in response to a grievance must prominently disclose the following information:

(1) That the enrollee has a right to file a complaint or seek other assistance from the Insurance Division of the Department of Consumer and Business Services; and

(2) The contact information for the Director of the Department of Consumer and Business Services described in OAR 836-053-1030(6).

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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1130

Annual Summary, Utilization Review

(1) To comply with the requirements of ORS 743.807, an insurer must electronically submit on or before June 30 of each calendar year, an annual utilization review program summary for the preceding calendar year to the Insurance Division in the format required by the Director of the Department of Consumer and Business Services as set forth on the website of the Insurance Division of the Department of Consumer and Business Services at www.insurance.oregon.gov. Filing and reporting requirements in this rule apply to:

(a) A domestic insurer; and

(b) A foreign insurer transacting $2 million or more in health benefit plan premium in Oregon during the calendar year immediately preceding the due date of a required report.

(2) For calendar year 2014 and each subsequent calendar year the annual summary required by section (1) of this rule must:

(a) Describe the insurer’s utilization review policies ;

(b) Provide a summary of established processes and monitoring activities for each of the following program areas:

(A) Program oversight;

(B) Utilization review criteria development, implementation and revision;

(C) List of clinical information, research publications and other information used in the development of pre-service authorization requirements, concurrent review and other utilization review activities;

(D) Provider program participation procedures;

(E) Minimum qualifications of utilization review decision makers;

(F) Time frames for utilization review decisions;

(G) Enrollee and provider communication processes; and

(H) Program monitoring, review, evaluation and update; and

(c) Document:

(A) Delegated utilization review activities, including monitoring and oversight activities of those to whom the activities are delegated; and

(B) Policies for review and audit of delegates and delegated activities.

(3) To minimize duplicative reporting requirements, an insurer may meet the reporting requirements of this rule by submitting to the department either of the following:

(a) A copy of a report prepared for a national accreditation organization. An insurer submitting a copy of a report under this subsection must provide addenda to the report with additional information if the department determines that the report does not provide the information required.

(b) An addendum to an annual filing of the immediately preceding year:

(A) Stating, if applicable, that no information has changed since the previous annual filing; or

(B) Identifying, if applicable, only the information that has changed since the previous annual filing.

(4) An insurer may not submit addenda described in subsection (3)(b) of this rule in two consecutive years.

(5) Nothing in this rule prohibits an insurer from submitting additional information that is significant in relation to its quality assessment and improvement activities.

Stat. Auth.: ORS 731.244 & 743.819
Stats. Implemented: ORS 743.801, 743.804 & 743.807
Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1140

Appeal and Utilization Review Determinations

(1) When a provider first appeals an insurer denial described in ORS 743.807(2)(c):

(a) The insurer must 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 must 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 must 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.

(4) Nothing in this rule prevents 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 a decision by a medical consultant or peer review committee to file such a grievance.

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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1170

Annual Summary, Quality Assessment Activities

(1) To comply with the requirements of ORS 743.814(2) and (3), an insurer offering a managed health benefit plan shall electronically submit on or before June 30 of each calendar year an annual quality assessment program summary for the previous calendar year to the Insurance Division in the format required by the Director of the Department of Consumer and Business Services as set forth on the website of the Insurance Division of the Department of Consumer and Business Services. Filing and reporting requirements in this rule apply to:

(a) A domestic insurer; and

(b) A foreign insurer transacting $2 million or more in health benefit plan premium in Oregon during the calendar year immediately preceding the due date of a required report.

(2) For calendar year 2014 and each subsequent calendar year the annual summary required under section (1) of this rule must:

(a) Identify current quality assessment program accreditations, accrediting organization, accreditation level and date. If the quality assessment program is not accredited, describe plans and timelines, if any, to gain accreditation.

(b) Describe the insurer’s quality assessment program that enables the insurer to evaluate, maintain and improve the quality of health services provided to enrollees.

(c) Identify the frequency of internal quality assessment program review, evaluation, and update.

(d) List quality improvement goals the insurer has identified, measures of success towards meeting those goals and outcomes demonstrated by selected measures.

(e) Provide a summary of policies and monitoring activities established for each of the following program areas:

(A) Internal program monitoring and oversight;

(B) Credentialing of providers;

(C) Provider program participation procedures;

(D) Clinical practice guidelines;

(E) Identification of priorities;

(F) Assessment of enrollee satisfaction; and

(G) Enrollee and provider communication processes

(3) For calendar year 2014 and each subsequent calendar year the annual summary required under section (1) of this rule must provide:

(a) The results of all publicly available federal Health Care Financing Administration reports and accreditation surveys by national accreditation organizations; and

(b) The reporting of the insurer's health promotion and disease prevention activities, if any, as defined in the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance, including:

(A) The following preventive measures:

(i) Childhood immunizations, including the percentage of children in the insurer's managed care health plans who have received appropriate immunizations by their second birthdays; and

(ii) Tobacco use cessation, including the percentage of adult smokers and the percentage of those who have ceased tobacco use after receiving advice to quit smoking from a health professional in health plans of the insurer.

(B) The chronic condition of diabetes as specified in the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance.

(C) The acute condition of pregnancy care. The information must include the percentage of pregnant women in the insurer's health plans that began prenatal care during the first 13 weeks of pregnancy.

(4) To minimize duplicative reporting requirements, the insurer may satisfy the reporting requirements of sections (2) and (3) of this rule by submitting either of the following:

(a) Information prepared by the insurer for another purpose if the information contains the information required by sections (2) and (3) of this rule and the insurer highlights the relevant information to satisfy the reporting requirement; or

(b) An addendum to an annual filing of the immediately preceding year:

(A) Stating, if applicable, that no information has changed since the previous annual filing; or

(B) Identifying, if applicable, only the information that has changed since the previous annual filing.

(5) Summary information described in sections (2) and (3) of this rule may include information prepared by the insurer for the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance and may be submitted on the basis of any sampling method recognized by the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance. A multi-state or regional Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance report may be used for reporting under this subsection if the insurer furnishes with the report the number or an estimate of the number of regional members and Oregon members to whom the report applies.

(6) An insurer may not submit addenda described in sections (2) and (3) of this rule in two consecutive years.

(7) Nothing in this rule prohibits an insurer from submitting additional information that is significant in relation to its quality assessment and improvement activities.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 731.244, 743.814 & 743.819
Stats. Implemented: ORS 743.804 & 743.814
Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 17-1998, f. & cert. ef. 11-16-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1180

Format and Instructions for Report Required by ORS 743.818

(1) As used in this rule:

(a) “Covered lives” means Oregon residents who are employees, dependents of employees, or individuals otherwise eligible for an individual, student health, association, group, or self-insured group health benefit plan or other benefit plan for which reporting is required and who are enrolled for coverage under the terms of the plan as of the close of the calendar quarter.

(b) “Carrier” has the meaning given that term in ORS 743.730(7).

(c) “Zip code” means the 5-digit code:

(A) Of the employee or individual policyholder’s Oregon residence;

(B) Of an Oregon employer group covered by a stop loss policy; or,

(C) In circumstances for which no Oregon zip codes exists, the placeholder code established by the Director of the Department of Consumer and Business Services set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov.

(2) At quarterly intervals covering each year, a carrier authorized to transact health insurance in Oregon must submit information pertaining to covered lives through the reporting system of the Insurance Division in the format established by the Director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Insurance Division of the Department of Consumer and Business Services at http://www.insurance.oregon.gov. The carrier must submit the required information on or before:

(a) May 1 for the first calendar quarter.

(b) August 1 for the second calendar quarter.

(c) November 1 for the third calendar quarter.

(d) February 1 for the fourth calendar quarter.

(3) A carrier claiming exemption from reporting must request an exemption through the reporting system of the Insurance Division on or before the due date for the calendar quarter for which reporting is first due.

(4) A carrier submitting information pertaining to covered lives or requesting an exemption from reporting is subject to the electronic reporting or response requirements of OAR 836-011-0005.

Stat. Auth.: ORS 731.244, 743.745 & 743.818
Stats. Implemented: ORS 743.818
Hist.: ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1190

Annual Summary, Uniform Indicators of Network Adequacy

(1) An insurer offering managed health insurance or preferred provider organization insurance must submit its annual summary required under ORS 743.817 on March 1 of each year. Filing and reporting requirements in this rule apply to:

(a) A domestic insurer; and

(b) A foreign insurer transacting $2 million or more in health benefit plan premium in Oregon during the calendar year immediately preceding the due date of the required report.

(2) The annual summary must include the following matters for the immediately preceding calendar year as of December 31, according to the following uniform indicators:

(a) Whether the insurer has established a requirement or goal for accessibility that providers must meet, in terms of hours, days or weeks, or in the alternative an indication that the insurer does not establish and maintain such a requirement or goal, for the following categories:

(A) Preventive care;

(B) Routine primary care; and

(C) Urgent care.

(b) Whether accessibility to urgent care services outside of regular business hours differs by region or geographical area of the state that the insurer serves, and if so, a description of the differences among the regions or areas.

(c) The number of communications expressing a concern regarding difficulty in obtaining an appointment with a provider, including but not limited to the inability to find a provider with an open practice or to an unreasonable length of time to wait for an appointment. Communications under this section include but are not limited to complaints and grievances from enrollees.

(d) Whether the insurer has a process for ensuring network adequacy that includes oversight, communication and monitoring, and the following information about the process:

(A) The position and department of the individual with the responsibility of ensuring and monitoring the network;

(B) The telephone number, electronic mail address, address or website that enrollees are requested to use in order to express concerns regarding network adequacy;

(C) The website at which enrollees can locate the provider directory, and the frequency with which the website is updated.

(D) The frequency with which an enrollee is specifically notified of changes to the insurer's provider network and the medium or media by which an enrollee is informed.

(E) Information regarding the insurer's monitoring of its network adequacy, including:

(i) The intervals between formal reviews;

(ii) Whether the results of the reviews are reported to senior management or the board of directors, or both, or neither; and

(iii) How the insurer uses its formal reviews to monitor and improve accessibility for clients.

(e) Whether the insurer's provider directory and updates to the directory disclose which providers are fluent in languages other than English and, if so, what languages are available.

(f) Whether the insurer keeps information on which of the physicians in its network have open practices, and if so:

(A) The frequency with which the insurer updates the information; and

(B) Whether enrollees have access to the information and if so, how enrollees may obtain the information.

(g) Any other information that the insurer determines to be significant in documenting the scope of its network or its monitoring of access to services.

(3) To minimize duplicative reporting, an insurer may meet the requirements of section (2) of this rule by submitting to the department either of the following:

(a) A copy of a report prepared by the insurer for a national accreditation organization. An insurer submitting a copy of a report under this subsection must provide addenda to the report with additional information if the department determines that the report does not provide the information required by section (2) of this rule.

(b) An addendum to an annual filing of the immediately preceding year:

(A) Stating, if applicable, that no information has changed since the previous annual filing; or

(B) Identifying, if applicable, only the information that has changed since the previous annual filing.

(4) An insurer may not submit the addendum described in section (3)(b) of this rule in two consecutive years.

Stat. Auth.: ORS 731.244 & 743.819
Stats. Implemented: ORS 743.817
Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 19-2002, f. 9-27-02, cert. ef. 9-28-02; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1200

Prior Authorization Requirements

(1) The provisions of this rule implement the requirements of ORS 743.807 and 743.837, relating to prior authorization determinations. "Prior authorization" means a determination by an insurer prior to provision of services that the insurer will provide reimbursement for the services. "Prior authorization" does not include referral approval for evaluation and management services between providers.

(2) ORS 743.807 and 743.837 apply to prior authorization determinations that:

(a) Are issued orally or in writing by an insurer to a provider regarding the benefit coverage or medical necessity of a medical or mental health service to be provided to an enrollee; and

(b) Are required under and obtained in accordance with the terms of a health benefit plan.

(3) A prior authorization may be limited to the services of a specific provider or to services of a designated group of providers who contract with or are employed by the insurer.

(4) Nothing in this rule shall require a health benefit plan to contain a prior authorization requirement.

(5) Except in the case of misrepresentation relevant to a request for prior authorization, a prior authorization determination shall be binding on the insurer for the period of time specified in section (6) of this rule.

(6) A prior authorization determination shall be binding on the insurer for:

(a) The lesser of the following periods:

(A) Five business days; or

(B) The period during which the enrollee's coverage remains in effect, provided that when the insurer issues the prior authorization, the insurer has specific knowledge that the enrollee's coverage will terminate sooner than five business days following the day the authorization is issued and the insurer specifies the termination date in the authorization; and

(b) The period during which the enrollee's coverage remains in effect beyond the time period established pursuant to subsection (a) of this section, up to a maximum of thirty calendar days.

(7) For purposes of counting days under section (6) of this rule, day 1 occurs on the first business or calendar day, as applicable, following the day on which the insurer issues a prior authorization determination.

(8) An insurer may not impose a restriction or condition on its prior authorization determinations that limits, restricts or effectively eliminates the binding force established for such determinations in ORS 743.837 and this rule.

(9) When an insurer answers requests by providers for prior authorization of nonemergency services as required by ORS 743.807(2)(d), the answer to a request by a provider for prior authorization of nonemergency services must be one of the following:

(a) The requested service is authorized.

(b) The requested service is not authorized.

(c) The entire requested service is not authorized, but a specified portion of the requested service or a specified alternative service is authorized.

(d) The requested service is not authorized because the insurer needs additional specified information in order to make a decision on the request.

Stat. Auth.: ORS 731.244
Stats. Implemented: ORS 743.837 & 743.807
Hist.: ID 1-1998, f. & cert. ef. 1-15-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

External Review

836-053-1300

Purpose and Scope; Application

(1) OAR 836-053-1300 to 836-053-1365 are adopted by the Director of the Department of Consumer and Business Services to implement ORS 743.857 to 743.862, governing the Director’s contracting with independent review organizations for the purpose of resolving disputes relating to adverse decisions by insurers in one or more of the issues specified in 743.857.

(2) OAR 836-053-1300 to 836-053-1365 are operative with respect to disputes for which the initial grievance is filed on or after July 1, 2002 under health benefit plans in existence, issued or renewed on or after July 1, 2002.

Stat. Auth.: ORS 731.244 & 743.858 - 743.862
Stats. Implemented: ORS 743.857 - 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

836-053-1305

Definitions; Authority to Act for Enrollee

(1) As used in OAR 836-053-1300 to 836-053-1365, "medical reviewer" means any of the following persons who is assigned to an independent review case by an independent review organization:

(a) A doctor of medicine or osteopathy licensed under ORS Chapter 677 or under the laws of another state.

(b) A provider as defined in ORS 743.801.

(c) A health care professional licensed, certified or otherwise authorized or permitted by the laws of another state to administer medical or mental health services in the ordinary course of business or practice of a profession.

(2) An action that may be taken by an enrollee under ORS 743.857 to 743.862 or under OAR 836-053-1300 to 836-053-1365 may be taken on behalf of the enrollee by a representative of the enrollee.

Stat. Auth.: ORS 731.244 & 743.858 - 743.862
Stats. Implemented: ORS 743.857 - 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

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

836-053-1315

Performance Criteria

The following are performance criteria that an independent review organization must satisfy when demonstrating its eligibility for contracting with the Director of the Department of Consumer and Business Services to perform independent review responsibilities under ORS 743.862, and in order to continue performing those responsibilities under the contract with the director. For purposes of this rule, an independent review organization must:

(1) Demonstrate its capability of and expertise in reviewing health care, and a history of such review, in terms of the coverage issues that are subject to independent review pursuant to ORS 743.857, in terms of the application of other health plan coverage provisions and in terms of health insurance contract law.

(2) Demonstrate the ability to handle a full range of review cases occurring in this state. An independent review organization may contract with a more specialized review organization, but the independent review organization must ensure that each review conducted meets all the requirements of ORS 743.857, 743.858 and 743.862 and OAR 836-053-1300 to 836-053-1365.

(3) Comply with all conflict of interest provisions in OAR 836-053-1320.

(4) Maintain and assign an adequate number and range of qualified medical reviewers in compliance with OAR 836-053-1310 and 836-053-1315 in order to:

(a) Make determinations regarding the full range of independent review cases occurring in this state under ORS 743.857; and

(b) Meet timelines specified in ORS 743.862 and OAR 836-053-1340, including timelines for expedited review.

(5) Conduct reviews, reach determinations and document determinations consistent with OAR 836-053-1325 and 836-053-1330.

(6) Maintain administrative processes and capabilities in compliance with OAR 836-053-1325 and 836-053-1330.

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 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1317

Professional Qualifications

(1) A doctor of medicine or osteopathy licensed under ORS Chapter 677 or under the laws of another state that govern the licensing of doctors of medicine or osteopathy shall be responsible for each final independent review determination made by an independent review organization, and in making a determination shall consult with other medical reviewers as appropriate.

(2) An independent review organization shall have a medical director who holds a current unrestricted license as a medical doctor or osteopathic physician and has had experience in direct patient care. The medical director shall provide guidance for clinical aspects of the independent review process and oversee the independent review organization's quality assurance and credentialing programs.

(3) An independent review organization shall maintain policies and practices that assure that each medical reviewer:

(a) Holds a current, unrestricted license, certification or registration in this state, or current, unrestricted credentials from another state;

(b) Has at least five years of recent clinical experience;

(c) Is certified by an appropriate member board of the American Board of Medical Specialties if board certification is available for the specialty or profession in which the medical reviewer is engaged; and

(d) Has the ability to apply scientific standards of evidence in judging research literature pertinent to review issues, as demonstrated through relevant training or professional experience.

(4) A medical reviewer who is assigned to a case must have at least five years of recent clinical experience dealing with the same health conditions under review or similar conditions. Exceptions may be made to this requirement in unusual situations when the only experts available for a highly specialized review are in academic or research work and do not meet the clinical experience requirement.

(5) An independent review organization must maintain a training program for staff and medical reviewers, addressing at least:

(a) Confidentiality;

(b) Neutrality and conflict of interest;

(c) Appropriate conduct of reviews; and

(d) Documentation of evidence for determination.

Stat. Auth.: ORS 731.244 & 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

836-053-1320

Conflict of Interest

(1) An independent review organization:

(a) Must not be a subsidiary of, or in any way owned or controlled by, an insurer or an association of insurers or of doctors, providers or other health care professionals;

(b) Must provide information to the Director of the Department of Consumer and Business Services on its own organizational affiliations and potential conflicts of interest at the time of its response to the director's request for proposals and thereafter when material changes occur;

(c) Must immediately turn down a case referred by the director if accepting it would constitute an organizational conflict of interest; and

(d) Must ensure that medical reviewers are free from any actual or potential conflict of interest in assigned cases.

(2) In connection with a case, neither an independent review organization nor any of its medical reviewers may have any material professional, familial or financial affiliation with the health insurer, enrollee, enrollee's provider, that provider's medical or practice group, the facility at which the service would be provided or the developer or manufacturer of a drug or device under review. For the purpose of this section, an affiliation with any director, officer or executive of an independent review organization shall be considered to be an affiliation with the independent review organization.

(3) Except as provided in section (4) of this rule, the following do not constitute violations of this rule:

(a) Staff affiliation with an academic medical center or National Cancer Institute-designated clinical cancer research center;

(b) Staff privileges at a health facility; or

(c) An independent review organization's receipt of an insurer's payment for independent reviews assigned by the director.

(4) A potential medical reviewer shall be considered to have a conflict of interest in connection with a case with regard to a facility or health plan, regardless of revenue from that source, if the potential reviewer is a member of a standing committee of the facility or the health plan, or a provider or other health care professional network that contracts with the health plan.

(5) A conflict of interest may be waived only if both the enrollee and the health plan agree in writing after receiving full disclosure of the conflict, and only if:

(a) The conflict involves a medical reviewer, and no alternate reviewer with necessary special expertise is available; or

(b) The conflict involves an independent review organization and the director determines that seeking a waiver of conflict is preferable to reassigning the dispute to a different independent review organization.

Stat. Auth.: ORS 731.244 & 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 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1325

Procedures for Conducting External Reviews

(1) An independent review organization is subject to the following decision-making standards and procedures:

(a) The independent review process is intended to be neutral and independent of influence by any affected party or by state government. The Director of the Department of Consumer and Business Services may conduct investigations as authorized by law but has no involvement in the disposition of specific cases.

(b) Independent review is a document review process. An enrollee, a health plan or an attending provider may not participate in or attend an independent review in person or obtain reconsideration of a decision by an independent review organization.

(c) An independent review organization shall present cases to medical reviewers in a way that maximizes the likelihood of a clear, unambiguous decision. This may involve stating or restating the questions for review in a clear and precise manner that encourages yes or no answers.

(d) An independent review organization may uphold an adverse determination if the patient or any provider refuses or fails to provide in a timely manner relevant medical records that are available and have been requested pursuant to ORS 743.862. . Pursuant to ORS 743.857, an independent review organization may overturn an adverse determination if the insurer refuses or fails to provide in a timely manner relevant medical records that are available and have been requested.

(e) An independent review organization must maintain written policies and procedures covering all aspects of review.

(2) Once the director refers a dispute, the independent review organization must proceed to a final decision in accordance with the procedural requirements of ORS 743.857 and 743.862 and OAR 836-053-1300 to 836-053-1365 unless requested otherwise by both the insurer and the enrollee.

(3) An independent review organization must decide whether or not the dispute pertains to an adverse benefit determination as described in ORS 743.857(1). If the dispute is covered, it is eligible for external review. An independent review organization must also decide whether the dispute concerns a covered benefit in the health benefit plan. If the dispute concerns a non-covered benefit, the dispute does not qualify for external review.

(4) An independent review organization is subject to the following standards with respect to information to be considered for reviews:

(a) An independent review organization must request as necessary and must accept and consider the following information as relevant to a case referred:

(A) Medical records and other materials that the insurer is required to submit to the independent review organization under ORS 743.857(3), including information identified in that section that is initially missing or incomplete as submitted by the insurer.

(B) For cases in which the insurer's decision addressed whether a course or plan of treatment was medically necessary:

(i) A copy of the definition of medical necessity from the relevant health insurance policy;

(ii) An explanation of how the insurer's decision conformed to the definition of medical necessity; and

(iii) An explanation of how the insurer's decision conformed to the requirement that the definition of medical necessity be uniformly applied.

(C) For cases in which the insurer's decision addressed whether a course or plan of treatment was experimental or investigational:

(i) A copy of the definition of experimental or investigational from the relevant health insurance policy;

(ii) An explanation of how the insurer's decision conformed to that definition of experimental or investigational; and

(iii) An explanation of how the insurer's decision conformed to the requirement that the definition of experimental or investigational be uniformly applied.

(D) Other medical, scientific and cost-effectiveness evidence, as described in section (5) of this rule, that is relevant to the case.

(b) After referral of a case, an independent review organization must accept additional information from the enrollee, the insurer or a provider acting on behalf of the enrollee at the enrollee's request if the information is submitted within five business days of the independent review organization after the enrollee’s receipt of notification of the appointment of the independent review organization or, in the case of an expedited referral, within 24 hours. The additional information must be related to the case and relevant to statutory criteria contained in ORS 743.857.

(c) An independent review organization must ensure the confidentiality of medical records and other personal health information received for use in reviews, in accordance with applicable federal and state laws.

(5) If a course or plan of treatment is determined to be subject to independent review, a determination of whether the adverse decision of an insurer should be upheld or not must be based upon expert clinical judgment, after consideration of relevant medical, scientific and cost-effectiveness evidence and medical standards of practice in the United States. As used in this section:

(a) "Medical, scientific, and cost-effectiveness evidence" means published evidence on results of clinical practice of any health profession that complies with one or more of the following requirements:

(A) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

(B) Peer-reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the National Institute of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medica, Embase, Medline, Medical Literature Analysis and Retrieval System or Health Services Technology Assessment Texts;

(C) Medical journals recognized by the Secretary of Health and Human Services, under Section 1861(t)(2) of the Social Security Act;

(D) The American Hospital Formulary Service-Drug Information, the American Medical Association Drug Evaluation, the American Dental Association Accepted Dental Therapeutics, and the United States Pharmacopoeia-Drug Information;

(E) Findings, studies or research conducted by or under the auspices of a federal government agency or a nationally recognized federal research institute, including the Federal Agency for Healthcare Research and Quality, National Institutes of Health, National Cancer Institute, National Academy of Sciences, Center for Medicaid and Medicare Services, Congressional Office of Technology Assessment, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health services;

(F) Clinical practice guidelines that meet Institute of Medicine criteria; or

(G) In conjunction with other evidence, peer-reviewed abstracts accepted for presentation at major scientific or clinical meetings.

(b) Medical standards of practice include the standards appropriately applied to physicians or other providers or health care professionals, as pertinent to the case.

(6) The following standards govern the assignment by an independent review organization of appropriate medical reviewers to a case:

(a) A medical reviewer assigned to a case must comply with the conflict of interest provisions in OAR 836-053-1320.

(b) An independent review organization shall assign one or more medical reviewers to each case as necessary to meet the requirements of this subsection. The medical reviewer assigned to a case, or the medical reviewers assigned to a case together, must meet each of the following requirements:

(A) Have expertise to address each of the issues that are the source of the dispute.

(B) Be a clinical peer. For purposes of this paragraph, a clinical peer is a physician or other medical reviewer who is in the same or similar specialty that typically manages the medical condition, procedures or treatment under review. Generally, as a peer in a similar specialty, the individual must be in the same profession and the same licensure category as the attending provider. In a profession that has organized, board-certified specialties, a clinical peer generally will be in the same formal specialty.

(C) Have the ability to evaluate alternatives to the proposed treatment.

(c) Each independent review organization must have a policy specifying the methodology for determining the number and qualifications of medical reviewers to be assigned to each case. The number of reviewers shall be governed by the following requirements:

(A) The number of reviewers must reflect the complexity of the case and the goal of avoiding unnecessary cost.

(B) The independent review organization may consider, but shall not be bound by, recommendations regarding complexity from the insurer or attending provider.

(C) The independent review organization shall consider situations such as review of experimental and investigational treatments that may benefit from an expanded panel.

(7) An independent review organization shall notify the enrollee and the insurer of its decision on the enrollee's case and provide documentation and reasons for the , decision including the clinical basis for the decision unless the decision is wholly based on application of coverage provisions.

(a) Documentation of the basis for the decision shall include references to supporting evidence, and if applicable, the reasons for any interpretation regarding the application of health benefit plan coverage provisions, but shall not recommend a course of treatment or otherwise engage in the practice of medicine.

(b) If the decision overrides the health benefit plan's standards governing the coverage issues that are subject to independent review, the reasons shall document why the health benefit plan's standards are unreasonable or inconsistent with sound, evidence-based medical practice.

(c) The written report shall include the qualifications of each medical reviewer but shall not disclose the identity of the reviewer.

(d) Notification of the decision shall be provided initially by phone, e-mail or fax, followed by a written report by mail. In the case of expedited reviews, the initial notification shall be immediate and by phone, followed by a written report.

(8) An independent review organization’s decision shall be final unless, within seven business days of an enrollee’s receipt of the written report of the independent review organization’s decision, the enrollee submits information to the director that the independent review organization failed to materially comply with the procedural requirements of ORS 743.858 or 743.862 or OAR 836-053-1300 to 836-053-1365. If the enrollee is satisfied with the independent review organization’s decision, the enrollee may notify the independent review organization and insurer by electronic mail, fax or telephone, followed by a written notice, stating that the enrollee waives the seven business days before the independent review organization decision is final.

(9) The director shall review the information submitted by the enrollee and, within seven business days, make a written determination whether:

(a) The director is reasonably satisfied that the independent review organization failed to materially comply with the procedural requirements of ORS 743.858 or 743.862 or OAR 836-053-1300 to 836-053-1365; and

(b) The independent review organization’s failure to materially comply with the procedural requirements of ORS 743.858 or743.862 or OAR 836-053-1300 to 836-053-1365 materially affected the independent review organization’s decision.

(10) The director shall send a written notification of the determination to the enrollee and the independent review organization. The independent review organization’s decision will be final if the director is reasonably satisfied that the independent review organization complied with the procedural requirements in ORS 743.858 or743.862 or OAR 836-053-1300 to 836-053-1365.

(11) If an independent review organization failed to materially comply with the procedural requirements in ORS 743.858 or 743.862 or OAR 836-053-1300 to 836-053-1365, the independent review organization shall correct the failure to materially comply by conducting a new external review, at the independent review organization’s cost, and issuing a new decision within ten business days.

(a) Within 24 hours of receipt of the written notification from the director described in section (10) of this rule, the independent review organization shall:

(A) Notify the enrollee and the insurer via electronic mail, fax or telephone that the independent review organization will be conducting a new external review, and

(B) Request from the enrollee or the insurer via electronic mail or fax any information not already provided to the independent review organization that is necessary to correct the material failure to comply with the procedural requirements of ORS 743.858, or743.862 or OAR 836-053-1330 to 836-053-1365.

(12) The enrollee or insurer must provide to the independent review organization any requested information in section (11) of this rule within 48 hours after receipt of the request.

(13) Notification of the independent review organization’s new decision shall be provided to the enrollee and insurer initially via electronic mail, fax or telephone, followed by a written report by mail.

(14) For the purposes of sections (8) to (13) of this rule, “procedural requirements” does not include requirements related to the exercising of medical judgment or decision making by the independent review organization.

(15) The independent review organization’s decision based on the new external review shall be final as of the date of the decision.

(16) Except as provided in this section, an independent review organization shall not disclose the identity of a medical reviewer unless otherwise required by state or federal law. The director shall not require reviewers' identities as part of the contracting process but may examine identified information about reviewers as part of enforcement activities. The identity of the medical director of an independent review organization shall be disclosed upon request of any person.

(17) An independent review organization shall promptly report to the director any attempt by any party, including a state agency, to interfere with the carrying out of the independent review organization’s duties under ORS 743.858 or 743.862 or OAR 836-053-1300 to 836-053-1365.

(18) An independent review organization must maintain business hours, methods of contact (including telephone contact), procedures for after-hours requests and other relevant procedures to ensure timely availability to conduct expedited as well as regular reviews.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 731.244 & 743.858
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 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1330

Criteria and Considerations for External Review Determinations

(1) The following criteria and considerations apply to decisions by an independent review organization:

(a) An independent review organization must use fair procedures in making a decision, and the decision must be consistent with the standards in ORS 743.858 and 743.862 and OAR 836-053-1300 to 836-053-1365.

(b) An independent review organization may override the standards of a health benefit plan governing the coverage issues that are subject to independent review pursuant to ORS 743.857(1) only if the standards are determined upon review to be unreasonable or inconsistent with sound, evidence-based medical practice.

(2) A decision by an independent review organization of a dispute relating to an adverse decision by an insurer is subject to enforcement under ORS 743.857 to 743.864 if:

(a) The dispute relates to an adverse decision on one or more of the following:

(A) Whether a course or plan of treatment is medically necessary;

(B) Whether a course or plan of treatment is experimental or investigational; or

(C) Whether a course or plan of treatment that an enrollee is undergoing is an active course of treatment for purposes of continuity of care under ORS 743.854; and

(b) The decision by the independent review organization is made in accordance with the coverage described in the health benefit plan, including limitations and exclusions expressed in the plan, except that the independent review organization may override the insurer's standards for medically necessary or experimental or investigational treatment, if the independent review organization determines that:

(A) The standards of the insurer are unreasonable or are inconsistent with sound medical practice; or

(B) For cases in which the insurer's decision addressed whether a course or plan of treatment was medically necessary:

(i) The insurer's decision did not conform to the insurer's definition of medically necessary in the relevant health insurance policy, or

(ii) The insurer's decision did not conform to the requirement that the definition of medical necessity be uniformly applied; or

(C) For cases in which the insurer's decision addressed whether a course or plan of treatment was experimental or investigational:

(i) The insurer's decision did not conform to the insurer's definition of experimental or investigational in the relevant health insurance policy, or

(ii) The insurer's decision did not conform to the requirement that the definition of experimental or investigational be uniformly applied.

(3) No provision of OAR 836-053-1300 to 836-053-1365 establishes a standard of medical care or creates or eliminates any cause of action.

Stat. Auth.: ORS 731.244 & 743.858
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 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1335

Procedures for Complaint Investigation

(1) The Director of the Department of Consumer and Business Services may audit, examine and conduct an on-site review of records to investigate complaints alleging that an independent review organization or medical reviewer committed conduct contrary to ORS 743.858 or 743.862, or OAR 836-053-1300 to 836-053-1365 or the contract between the director and the independent review organization.

(2) In addition to the procedures for an enrollee to submit information about an independent review organization’s decision in OAR 836-053-1325, aperson, including, but not limited to, an enrollee, insurer or provider, may submit a written complaint to the director alleging that an independent review organization committed conduct described in this rule. The director may consider the complaint in relation to the terms of the contract with the independent review organization and in relation to ORS 743.858 or 743.862 and OAR 836-053-1300 to 836-053-1365 and take action as appropriate under the contract. The director shall notify the complainant of the results of the director's determinations and of any action taken or to be taken.

Stat. Auth.: ORS 731.244 & 743.858
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 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1337

Preliminary Review by Insurer

When an enrollee applies to an insurer for independent review of a dispute, the insurer shall review the application and advise the enrollee that the application does or does not meet any of the criteria for independent review. The insurer shall send the application to the independent review organization as provided in ORS 743.857 unless the enrollee withdraws the application.

Stat. Auth.: ORS 731.244 & 743.858
Stats. Implemented: ORS 743.861
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

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 the insurer’s reversal. The notice to the enrollee may be given by electronic mail, facsimile or by telephone, followed by a written confirmation within two business days of the insurer.

(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 by electronic mail, facsimile or by telephone, followed by a written confirmation within two business days of the department.

(4) The director shall notify the enrollee of the assignment of the request, not later than the second business day of the department after the director gave notice under section (3) of this rule. 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 in writing regarding a potential conflict of interest of the independent review organization. If sending written documentation will unduly delay the process, the enrollee shall give the notice by electronic mail, facsimileor by telephone, followed by a written confirmation within two business days of the department. 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 fifth 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. Upon request of the enrollee, the independent review organization shall provide to the enrollee 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(4)(b) the independent review organization must consider this additional information if the information is related to the case and relevant to the statutory criteria 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 fifth business day of the independent review organization following the enrollee’s receipt of notice from the director under section (4) of this rule. 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; and

(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 after such a request, the enrollee or the provider of the enrollee shall submit to the independent review organization the additional information or an explanation of why the additional information is not being submitted. 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 external review.

(10) An independent review organization must provide notice to enrollees and the insurer of the result and basis for the decision as provided in OAR 836-053-1325 not later than the fifth day after the independent review organization makes a decision in a nonexpedited case.

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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

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 an 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 decision 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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1345

Quality Assurance Mechanisms

(1) An independent review organization must have a quality assurance program that ensures the timeliness, quality of review and communication of determinations to enrollees and insurers. The program must also ensure the qualifications, impartiality and freedom from conflict of interest of the organization, its staff and medical reviewers. The quality of review of an independent review organization includes the use of appropriate methods to match the case, confidentiality and systematic evaluation of complaints for patterns or trends.

(2) A quality assurance program must include a written plan addressing its scope and objectives; program organization, monitoring and oversight mechanisms; and evaluation and organizational improvement of independent review organization activities. Organizational improvement must include the implementation of action plans to improve or correct identified problems, and communication of the results of action plans to staff and medical reviewers.

(3) An independent review organization shall record complaints in a log. The log shall include for each complaint the nature of the complaint and how it was resolved. Upon request, the independent review organization shall provide the log and complaints to the director for review.

Stat. Auth.: ORS 731.244 & 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 12-2013, f. 12-31-13, cert. ef. 1-1-14

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 non-expedited 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 upon 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; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1355

Synopses

(1) The synopses of decisions required to be filed by independent review organizations under ORS 743.862(5) with the Director of the Department of Consumer and Business Services must meet the requirements of this rule.

(2) Synopses of decisions shall include the following for each decision:

(a) A description of the dispute sought to be reviewed by the independent review organization, including whether the dispute is alleged to concern the determination of medical necessity or experimental or investigational treatment, whether an active course of treatment is occurring for the purpose of determining whether a person is eligible for continuity of care, or whether the dispute concerns some other issue.

(b) A determination by the independent review organization whether the dispute falls within any of the categories of issues that are eligible for independent review.

(c) A determination of the dispute by the independent review organization in favor of the insurer or enrollee.

(3) A synopsis may include a statement describing the illness, condition or other object of medical treatment, subject to section (4) of this rule.

(4) Synopses must exclude all facts and other matters that identify or may identify an enrollee. The facts and other matters include but are not limited to the name or address of an enrollee, the location of the provider office or other place of treatment, and the disease, condition or other treated matter, the disclosure of which may reveal the identity of the enrollee.

Stat. Auth.: ORS 731.244 & 743.862
Stats. Implemented: ORS 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

836-053-1360

External Review Reporting

(1) Each independent review organization shall maintain written records in the aggregate and by insurer on all requests for external review for which it conducted an external review for the Director of the Department of Consumer and Business Services during a calendar year.

(2) Each independent review organization shall submit to the director, by March 31 of each year for the preceding calendar year, a report in the format specified by the director. The report shall include the information required by this section in the aggregate, for each insurer, for Oregon external reviews only. The information to be included in the report as provided in this section is as follows:

(a) The total number of requests for external review received during the reporting period;

(b) The number of requests for external review for which the independent review organization has made a final decision and, of those requests, the number that uphold the insurer's final adverse determination;

(c) The average length of time for final decision by the independent review organization of:

(A) Disputes other than expedited disputes; and

(B) Expedited disputes.

(d) A summary of the types of coverages or cases for which an external review was sought;

(e) The number of requests for which the independent review organization decided that it did not have jurisdiction under ORS 743.857.

(f) The number of external review cases that were terminated as the result of a reconsideration by the insurer of the insurer's final adverse determination after the receipt of additional information from the enrollee or the enrollee's designated representative; and

(g) Any other information the director requests or requires.

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 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1365

Fees for External Reviews

Fees to be imposed by an independent review organization for its external review of disputes shall be as determined in the competitive solicitation process, but shall be as low as is feasible in the request for proposal process. Fees shall be separately established for initial jurisdictional decisions by an independent review organization and for decisions that call for a more extended review.

Stat. Auth.: ORS 731.244 & 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 12-2013, f. 12-31-13, cert. ef. 1-1-14

Annual Reporting Requirements

836-053-1400

Format and Instructions for Report Required by ORS 743.748

(1) A carrier shall submit the information required by ORS 743.748 electronically in the format and according to the directions established by the Director of the Department of Consumer and Business Services and made available on the website of the Insurance Division.

(2) The following terms used in ORS 743.748 have the following meanings for the purpose of the information required by ORS 743.748. References in this section to specific schedules and instructions are to schedules and instructions for the NAIC health annual statement blank. The terms are defined as follows:

(a) "Average amount of premiums per member per month" means total earned premiums as reported on the exhibit of premiums, enrollment and utilization divided by the total member months for the required reporting year.

(b) "Carrier's annual report" is the carrier's annual statement submitted as required by ORS 731.574.

(c) "Medical loss ratio" means the total medical claims cost divided by the total premiums earned, both as reported on the exhibit of premiums, enrollment and utilization.

(d) "Percentage change in the average premium per member per month" means the average amount of premiums per member per month for the reporting year less the average premium per member per month for the preceding reporting year divided by the average premium per member per month for the preceding reporting year.

(e) "Total amount of costs for claims" means incurred claims as reported by the carrier on the exhibit of premiums, enrollment and utilization in its annual statement. If the annual statement blank used by a carrier does not include an exhibit of premiums, enrollment and utilization, “total amount of costs for claims” means total incurred claims costs as calculated by the carrier using the instructions for the exhibit of premiums, enrollment and utilization for reporting the information.

(f) "Total amount of premiums" means earned premium as reported by the carrier on the exhibit of premiums, enrollment and utilization in its annual statement. If the annual statement blank used by a carrier does not include an exhibit of premiums, enrollment and utilization, “total amount of premiums” means total premiums as calculated by the carrier using the instructions for the exhibit of premiums, enrollment, and utilization for reporting the information.

(g) "Total number of members" means total number of members as of December 31 of the reporting year, as reported by the carrier in its annual statement. If the annual statement blank used by a carrier does not include an exhibit of premiums, enrollment and utilization, “total number of members means the total number of members as calculated by” the carrier using the instructions for the exhibit of premiums, enrollment and utilization for reporting the information.

(3) A carrier shall submit the following information by total for all comprehensive hospital and medical products nationwide, for all such products in each Oregon market segment and for the carrier’s association health plans:

(a) Number of members.

(b) Number of member months.

(c) Premiums earned.

(d) Medical claims costs.

(e) Medical loss ratio.

(f) Average premium per member per month for the reporting year.

(g) Average premium per member per month for the preceding reporting year.

(h) Percentage change in premium per member per month from the preceding reporting year.

Stat. Auth.: ORS 731.244, 743.748
Stats. Implemented: ORS 743.748
Hist.: ID 7-2006, f. & cert. ef. 4-14-06; ID 8-2007(Temp), f. 10-24-07, cert. ef. 10-25-07 thru 4-18-08; ID 6-2008, f. & cert. ef. 4-18-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1404

Definitions; Noncontracting Providers; Co-morbidity Disorders

(1) As used in ORS 743A.168, this rule and OAR 836-053-1405:

(a) "Mental or nervous conditions" means any of the following, dependent upon whether the diagnosis is made according to the "Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, Fourth Edition" (DSM-IV) or the "Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition" (DSM-5):

(A) If the condition is diagnosed under the DSM-IV, then all disorders listed in the DSM-IV except for:

(i) Diagnostic codes 317, 318.0, 318.1, 318.2, 319; Mental Retardation;

(ii) Diagnostic codes 315.00, 315.1, 315.2, 315.9; Learning Disorders;

(iii) Diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9; Paraphilias; and

(iv) Diagnostic codes V15.81 through V71.09; "V" codes. This exception does not extend to children 5 years of age or younger for diagnostic codes V61.20; Parent-Child Relational Problem through V61.21; Neglect, Physical Abuse, or Sexual Abuse of Child, and V62.82; Bereavement.

(B) If the condition is diagnosed under the DSM-5, then all disorders listed in the DSM-5 except for:

(i) DSM-5 diagnostic code 319 Intellectual and Unspecified Intellectual Disabilities;

(ii) DSM-5 diagnostic codes 315.00, 315.1, 315.2, Specific Learning Disorders;

(iii) DSM-5 diagnostic code 315.9; Unspecified Neurodevelopmental Disorders;

(iv) DSM-5 diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9; Paraphilia Disorders; and

(v) DSM-5 diagnostic codes V15.81 through V71.09; "V" codes. This exception does not extend to children 5 years of age or younger for DSM-5 diagnostic codes V61.20 through V61.21, and the DSM-5 diagnostic code V62.82; Uncomplicated Bereavement.

(b) "Chemical dependency" means an addictive relationship with any drug or alcohol characterized by a physical or psychological relationship, or both, that interferes on a recurring basis with an individual's social, psychological or physical adjustment to common problems.

(c) "Chemical dependency" does not mean an addiction to, or dependency on:

(A) Tobacco;

(B) Tobacco products; or

(C) Foods.

(2) A non-contracting provider must cooperate with a group health insurer's requirements for review of treatment in ORS 743A.168 (10) and (11) to the same extent as a contracting provider in order to be eligible for reimbursement.

(3) The exception of a disorder in the definition of "mental or nervous conditions" or "chemical dependency" in section (1) of this rule does not include or extend to a co-morbidity disorder accompanying the excepted disorder.

Stat. Auth.: ORS 731.244 & 743A.168
Stats. Implemented: ORS 743A.168
Hist.: ID 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 19-2012(Temp), f. & cert. ef. 12-20-12 thru 6-17-13; ID 3-2013, f. 6-10-13, cert. ef. 6-17-13; ID 19-2014(Temp), f. & cert. ef. 11-14-14 thru 5-12-15

836-053-1405

General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency

(1) A group health insurance policy issued or renewed in this state shall provide coverage or reimbursement for medically necessary treatment of mental or nervous conditions and chemical dependency, including alcoholism, at the same level as, and subject to limitations no more restrictive than those imposed on coverage or reimbursement for medically necessary treatment for other medical conditions.

(2) For the purposes of ORS 743A.168, the following standards apply in determining whether coverage for expenses arising from treatment for chemical dependency, including alcoholism, and for mental or nervous conditions is provided at the same level as, and subject to limitations no more restrictive than, those imposed on coverage or reimbursement of expenses arising from treatment for other medical conditions:

(a) The co-payment, coinsurance, reimbursement, or other cost sharing, including, but not limited to, deductibles for mental or nervous conditions and chemical dependency, including alcoholism, may be no more than the co-payment or coinsurance, or other cost sharing, including, but not limited to, deductibles for medical and surgical services otherwise provided under the health insurance policy.

(b) The co-payment, coinsurance, reimbursement, or other cost sharing, including, but not limited to, deductibles for wellness and preventive services for mental or nervous conditions and chemical dependency, including alcoholism, may be no more than the co-payment or coinsurance, or other cost sharing, including, but not limited to, deductibles for wellness and preventive services otherwise provided under the health insurance policy.

(c) Annual or lifetime limits for treatment of mental or nervous conditions and chemical dependency, including alcoholism, may be no less than the annual or lifetime limits for medical and surgical services otherwise provided under the health insurance policy.

(d) The co-payment, coinsurance, reimbursement, or other cost sharing, including, but not limited to, deductibles expenses for prescription drugs intended to treat mental or nervous conditions and chemical dependency, including alcoholism, may be no more than the co-payment or coinsurance, or other cost sharing expenses for prescription drugs prescribed for other medical services provided under the health insurance policy.

(e) Classification of prescription drugs into open, closed, or tiered drug benefit formularies, for drugs intended to treat mental or nervous conditions and chemical dependency, including alcoholism, must be by the same process as drug selection for formulary status applied for drugs intended to treat other medical conditions, regardless of whether such drugs are intended to treat mental or nervous conditions, chemical dependency, including alcoholism, or other medical conditions.

(3) A group health insurance policy issued or renewed in this state must contain a single definition of medical necessity that applies uniformly to all medical, mental or nervous conditions, and chemical dependency, including alcoholism..

(4) A group health insurer that issues or renews a group health insurance policy in this state shall have policies and procedures in place to ensure uniform application of the policy's definition of medical necessity to all medical, mental or nervous conditions, and chemical dependency, including alcoholism.

(5) Coverage for expenses arising from treatment for mental or nervous conditions and chemical dependency, including alcoholism, may be managed through common methods designed to limit eligible expenses to treatment that is medically necessary only if similar limitations or requirements are imposed on coverage for expenses arising from other medical condition. Common methods include, but are not limited to, selectively contracted panels, health policy benefit differential designs, preadmission screening, prior authorization of services, case management, utilization review, or other mechanisms designed to limit eligible expenses to treatment that is medically necessary.

(6) Coverage of mental or nervous conditions and chemical dependency, including alcoholism, may be limited for in-home services.

(7) Nothing in this rule prevents a group health insurance policy from providing coverage for conditions or disorder excepted under the definition of "mental or nervous condition" in OAR 836-053-1400.

(8) The Director shall review OAR 836-053-1400 and this rule and any other materials within two years of the rules' effective date to determine whether the requirements set forth in the rules are uniformly applied to all medical, mental or nervous conditions, and chemical dependency, including alcoholism.

Stat. Auth.: ORS 731.244 & 743A.168
Stats. Implemented: ORS 743A.168
Hist.: ID 13-2006, f. 7-14-06 cert. ef. 1-1-07; ID 19-2012(Temp), f. & cert. ef. 12-20-12 thru 6-17-13; ID 3-2013, f. 6-10-13, cert. ef. 6-17-13

836-053-1406

Definitions

(1) As used in ORS 743.874 and 743.876, “provider” means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services in the practice of a profession.

(2) As used in ORS 743.876, for the purpose of an insurer’s procedure for providing an estimate of an enrollee’s costs for a covered out-of-network procedure or service:

(a) The “allowable charge” for a covered procedure or service is the estimated amount established under the insurance policy, whether expressed as an “allowable charge,” “allowable expense,” “eligible fee” or other term denoting the amount on which the benefit is calculated.

(b) The “billed charge” is the estimated amount charged by a provider for performance of a procedure or service.

Stat. Auth.: ORS 731.244 & 743.893
Stats. Implemented: ORS 743.874 & 743.876
Hist.: ID 16-2008, f. & cert. ef. 9-24-08

Cost Estimates

836-053-1410

Procedures

(1) An insurer must allocate covered procedures or services to the categories established in ORS 743.874(3) and 743.876(3) in a manner that will enable the insurer to provide a reasonable estimate of an enrollee’s share of costs for a procedure or service. An insurer must determine its allocation according to its Oregon block of business at least once every 12 months to ensure that the procedures and services are currently the most common procedures in the categories.

(2) When an insurer provides a combined estimate for two or more procedures or services, the insurer must apply its standard method of payment to arrive at the combined estimate or other payment method that will achieve an accurate estimate. With the estimate provided under this section, he insurer must disclose to the enrollee that the estimate includes the costs of two or more procedures or services.

(3) With any estimate, an insurer must disclose whether the estimate applies only to those costs specifically relating to the procedure or service, such as is given in commonly used procedure codes, or applies to an episode of care that includes the procedure or service and its related costs.

(4) As required by the director, an insurer must file the following information for the purpose of assessing the effect of the disclosure requirements in ORS 743.874 and 743.876:

(a) The number of requests for estimates under ORS 743.874 and 743.876 received by the insurer in a calendar year; and

(b) Of the requests in paragraph (a) of this subsection, the number of requests for in-network procedures and services and the number of requests for out-of-network procedures and services.

Stat. Auth.: ORS 731.244 & 743.893
Stats. Implemented: ORS 743.874, 743.876 & 743.878
Hist.: ID 16-2008, f. & cert. ef. 9-24-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

836-053-1415

Instructions

(1) An insurer must make available to enrollees detailed instructions by telephone and Internet for obtaining estimates and benefit information under ORS 743.874 and 743.876. At a minimum, the instructions must:

(a) Specify the information needed by the insurer to provide the estimate, including but not limited to information for identifying the procedure or service and the provider;

(b) Describe how an enrollee may obtain an estimate and find benefit information for an in-network procedure, and inform the enrollee that an estimate is not required by law to be provided for a procedure or service that is not included in the insurer’s categories; and

(c) Provide a general explanation for obtaining an estimate for an out-of-network procedure or service and specify the information needed for the most accurate estimates.

(2) The instructions described in section (1) of this rule may include a statement that the accuracy of an estimate may depend on the specificity and accuracy of the information provided by the enrollee.

Stat. Auth.: ORS 731.244 & 743.893
Stats. Implemented: ORS 743.874 & 743.876
Hist.: ID 16-2008, f. & cert. ef. 9-24-08; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

The official copy of an Oregon Administrative Rule is contained in the Administrative Order filed at the Archives Division, 800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the published version are satisfied in favor of the Administrative Order. The Oregon Administrative Rules and the Oregon Bulletin are copyrighted by the Oregon Secretary of State. Terms and Conditions of Use

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

© 2013 State of Oregon All Rights Reserved​