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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
INSURANCE DIVISION
DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
INSURANCE DIVISION
DIVISION 100
HEALTH INSURANCE REFORM
Children’s Health Insurance Childrens Reinsurance Program
836-100-0010 [Renumbered to 836-100-0020]
836-100-0011
Purpose and Statutory Authority
(1) The purpose of OAR 836-100-0011 to 836-100-0045 is to assure that children have affordable health care coverage options in Oregon’s individual health insurance market and the Healthy KidsConnect program with guaranteed issue and no pre-existing condition period through the establishment of a Children’s Reinsurance Program.
(2) OAR 836-100-0011 to 836-100-0045 are adopted pursuant to the authority of the Department of Consumer and Business Services under ORS 731.244 to carry out the purposes of ORS 743.731 and chapter 131, Oregon Laws 2011 (Enrolled Senate Bill 514) to encourage the availability of individual health benefit plans and Healthy KidsConnect coverage for individuals under the age of 19 who are not enrolled in employer-sponsored group health plans.
Stat. Auth.:
ORS 731.244 & 743.731
Stats
Implemented: ORS 743.731 & 2011 OL Ch. 131 (Enrolled SB 514)
Hist.:
ID 10-2011, f. & cert. ef. 7-5-11
836-100-0016
Definitions
As used in OAR 836-100-0011 to 836-100-0045:
(1) “Applicant” means a child under the age of 19 or the parent or adult representative of a child who is applying for coverage under an individual health benefit plan or under a Healthy KidsConnect health benefit plan, either as a child-only or as a member of a family policy.
(2) “Carrier” means an insurance company or health care service contractor holding a valid certificate of authority from the Director of the Department of Consumer and Business Services that authorizes the transaction of health insurance.
(3) “Claim” includes a request for payment under the terms of an individual health benefit plan or under a Healthy KidsConnect health benefit plan, or the costs of utilization or for an encounter between a provider and a child covered by the Children’s Reinsurance Program.
(4) “DCBS” or “department” means the Department of Consumer and Business Services or any entity or agency administering the Children’s Reinsurance Program on behalf of the Department of Consumer and Business Services.
(5) “Healthy KidsConnect” means a health benefit plan established pursuant to ORS 414.231.
(6) “Standard Health Statement” means the Oregon Standard Health Statement described in OAR 836-053-0510.
Stat. Auth.:
ORS 731.244 & 743.731
Stats
Implemented: ORS 743.731 & 2011 OL Ch. 131 (Enrolled SB 514)
Hist.:
ID 10-2011, f. & cert. ef. 7-5-11
836-100-0020
Non-grandfathered Individual and Healthy KidsConnect Health Insurance Enrollment for Persons Under 19 Years of Age
(1) A carrier that issues a non-grandfathered individual or Healthy KidsConnect health benefit plan may not limit, exclude, or deny health insurance coverage under a non-grandfathered individual or Healthy KidsConnect health insurance policy based on health status or preexisting condition of a person under the age of 19 years. However, a carrier may cede to the Children’s Reinsurance Program the risk of a person under the age of 19 years in accordance with OAR 836-100-0011 to 836-100-0045.
(2) Coverage under a health benefit plan:
(a) Ceded under OAR 836-100-0011 to 836-100-0045 shall be effective on the date the insurer normally makes coverage effective under the benefit plan selected.
(b) Must be effective from the moment of birth for a newly born child of the insured in accordance with ORS 743A.090.
(c) Must be effective upon placement for adoption for an adopted child of the insured in accordance with ORS 743A.090.
(3) A carrier that issues a non-grandfathered individual health benefit plan need not provide coverage to an applicant if the applicant previously had coverage with the carrier during the 12 months prior to the application for coverage and that coverage was terminated:
(a) For conduct that constituted the basis for a legally valid rescission;
(b) For failing to abide by the terms and conditions of the insurance contract, including but not limited to the failure to pay premiums in a timely manner; or
(c) By the policyholder.
Stat. Auth.: ORS 731.244
& 743.733
Stats
Implemented: ORS 743.731, 743A.090, 743.769 & 2011 OL Ch. 131 (Enrolled SB 514)
Hist.:
ID 19-2010(Temp), f. & cert. ef. 9-23-10 thru 3-21-11; ID 3-2011, f. & cert.
ef. 2-10-11; Renumbered from 836-100-0010, ID 10-2011, f. & cert. ef. 7-5-11
836-100-0025
Eligible Carriers and Plans
(1) A carrier that issues an individual or Healthy KidsConnect health benefit plan in Oregon to children under 19 years of age must issue the plan on a guaranteed issue basis with no pre-existing conditions.
(2) A carrier may consider information provided on the standard health statement or other internally available health records or data of the carrier for the purpose of determining whether to cede a risk.
(3) A carrier:
(a) May cede to the Children’s Reinsurance Program under OAR 836-100-0011 to 836-100-0045 the risk of an applicant accepted for coverage under any individual health benefit plan offered by the carrier in Oregon on or after August 1, 2011.
(b) May not cede a risk for a person under the age of 19 who enrolls in a portability health benefit plan as defined in ORS 743.760, unless the applicant is currently ceded with the carrier.
(c) Shall notify DCBS if the carrier decides to cede the risk. At the time the carrier notifies the department, the carrier must provide the following to the department:
(A) Information about the plan that the applicant selected;
(B) An explanation of the basis for the premium for the applicant;
(C) Demographic information in accordance with application materials provided by the program.
(4) If a child insured under a health benefit plan provided by a carrier and not ceded by the carrier under the Children’s Reinsurance Program subsequently applies with the same carrier for coverage under a health benefit plan that provides more comprehensive coverage, the carrier may exercise the option to cede the risk at the time the child changes health benefit plans. The carrier shall comply with the same time limits for exercising the option to cede as set forth in OAR 836-100-0040.
(5) A carrier participating in the Healthy Kids program may cede risks acquired under that program only if the carrier first receives the enrollment notification from the Healthy KidsConnect office on or after August 1, 2011;
Stat. Auth.:
ORS 731.244 & 743.731
Stats
Implemented: ORS 743.731 & 2011 OL Ch. 131 (Enrolled SB 514)
Hist.:
ID 10-2011, f. & cert. ef. 7-5-11
836-100-0030
Role of Carrier that Cedes Risk
(1) When a carrier cedes risk to the Children’s Reinsurance Program:
(a) The carrier shall continue to administer and manage the policy for the insured in accordance with the policy terms including but not limited to managing the risk to reduce costs.
(b) The carrier may not retain any portion of the premium.
(2) A designation as a ceded risk will last until January 1, 2014. If a child attains an age of 19 or older before January 1, 2014, the child shall remain in the program as a ceded risk as long as the child remains with the same carrier. If a child changes carriers, the new carrier may make a new determination about whether to cede the risk in accordance with OAR 836-100-0025.
(3) Each carrier shall submit to DCBS a report for risks ceded to the Children’s Reinsurance Program for which the carrier continues to manage and provide administrative support. The report shall be submitted in accordance with a schedule agreed upon by the department and the carrier and shall include for each insured:
(a) Identification;
(b) Reported claims;
(c) Reported paid claims; and
(d) Premium received or earned.
Stat. Auth.:
ORS 731.244 & 743.731
Stats
Implemented: ORS 743.731
Hist.:
ID 10-2011, f. & cert. ef. 7-5-11
836-100-0035
Administrative Costs and Variable Expenses under Children’s Reinsurance Program
For health benefit plan coverage provided by a carrier participating in the Children’s Reinsurance Program, a carrier may not retain a premium for:
(1) Child only policies for which the risk is ceded to the Children’s Reinsurance Program.
(2)Any portion of a family or subscriber and children policy ceded to the program. For a family policy or a subscriber and children policy, the total premium allocated to a child for whom coverage is ceded shall be calculated by determining the total premium due for all children on the policy, divided by the number of children on the policy.
Stat. Auth.:
ORS 731.244 & 743.731
Stats
Implemented: ORS 743.731 & 2011 OL Ch. 131 (Enrolled SB 514)
Hist.:
ID 10-2011, f. & cert. ef. 7-5-11
836-100-0040
Health Assessment Period
(1) Except as provided in section (2) of this rule, the carrier shall determine whether to cede a risk to the Children’s Reinsurance Program within 105 days after the effective date of coverage. The Healthy KidsConnect carrier shall determine whether to cede a risk to the Children’s Reinsurance Program within 105 days after the effective date of coverage.
(2) If a carrier opts not to cede a risk within the first 105 days from the effective date of coverage, the carrier may retroactively cede the risk within six months after for the effective date of coverage if:
(a) The carrier identifies an error in the standard health statement; and
(b) The error is such that, had the carrier known about the condition to which the error pertains within the 105 days allowed to determine whether to cede the risk, the carrier would have ceded the risk.
(3) The ceding of a risk under this rule shall be retroactive to the insured’s effective date of coverage.
Stat. Auth.:
ORS 731.244 & 743.731
Stats
Implemented: ORS 743.731 & 2011 OL Ch. 131 (Enrolled SB 514)
Hist.:
ID 10-2011, f. & cert. ef. 7-5-11
836-100-0045
Claims and Premium Reconciliation
(1) A carrier shall submit the report required by the Children’s Reinsurance Program to obtain reimbursement of claims paid on a ceded life.
(2) Any adjustments for third party liabilities recovered by a health carrier shall be adjusted and reconciled according to the reporting and reconciliation schedule of the Children’s Reinsurance Program.
(3) A carrier may retain pharmacy rebates.
(4) Commercial reinsurance recoveries shall be adjusted and reconciled according to the reporting and reconciliation schedule of the Children’s Reinsurance Program.
(5) Premiums received in excess of claims submitted will be retained by the Children’s Reinsurance Program to apply toward payment of future claims incurred by ceded lives.
(6) Claims incurred during an active period of coverage for a ceded life must be filed within 12 months of the date of service and no later than December 31, 2014 to be eligible for reimbursement through the Children’s Reinsurance Program.
Stat. Auth.:
ORS 731.244 & 743.731
Stats
Implemented: ORS 743.731 & 2011 OL Ch. 131 (Enrolled SB 514)
Hist.:
ID 10-2011, f. & cert. ef. 7-5-11
Administrative Streamlining and Simplification
836-100-0100
Authority; Purpose; Scope
(1) OAR 836-100-0100 to 836-100-0120 are adopted by the Director of the Department of Consumer and Business Services pursuant to section 2, chapter 130, Oregon Laws 2011 (Enrolled Senate Bill 94). The purpose of OAR 836-100-0100 to 836-100-0120 is to establish the uniform administrative standards that health insurers and health care entities are required to comply with under section 2, chapter 130, Oregon Laws 2011 (Enrolled Senate Bill 94). The uniform standards have been developed by the Office for Oregon Health Policy and Research in consultation with stakeholders pursuant to section 3, chapter 130, Oregon Laws 2011 (Enrolled Senate Bill 94).
(2) The uniform standards adopted under OAR 836-100-0100 to 836-100-0120 apply to all health insurers and health care entities in Oregon as specified in each companion guide.
Stat. Auth.:
ORS 731.244 & 2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Stats.
Implemented: 2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Hist.:
ID 12-2011, f. & cert. ef. 7-15-11
836-100-0105
Definitions
(1) “Electronic transaction” means to conduct a transaction:
(a) Through the use of a computer program or an electronic or other automated means independently to initiate an action or respond to electronic records or performances in whole or in part, without review or action by an individual; or
(b) Through the use of a web portal or the internet.
(2)(a) “Health care entity” includes:
(A) A health care service contractor as required under ORS 750.055;
(B) A multiple employer welfare arrangement as required under ORS 750.333;
(C) A prepaid managed care health services organization as defined in ORS 414.736;
(D) Any entity licensed as a third party administrator under ORS 744.702;
(E) Any person or public body that either individually or jointly established a self-insurance plan, program or contract, including but not limited to persons and public bodies that are otherwise exempt from the Insurance Code under ORS 731.036;
(F) A health care clearinghouse or other entity that processes or facilitates the processing of health care financial and administrative transactions from a nonstandard format to a standard format; and
(G) Any other person identified by the department that processes health care financial and administrative transactions between a health care provider and an entity described in this subsection.
(b) “Health care entity” does not include a pharmacy or a pharmacy benefits manager.
(3) “Health insurer” means any insurer authorized to transact health insurance in Oregon.
(4) “Oregon Companion Guide” means one of the compilations of uniform standards adopted by the Department of Consumer and Business Services and posted on the Oregon Insurance Division’s website that provide standards for health care financial and administrative transactions. The following Oregon Companion Guides are applicable to respective transactions with health insurers and health care entities in Oregon:
(a) Oregon Companion Guide for the Implementation of the ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271).
(b) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X222 Health Care Claim: Professional (837).
(c) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X223 Health Care Claim: Institutional (837).
(d) The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X224 Health Care Claim: Dental (837).
(5) “Oregon Companion Guide Oversight Committee” means the committee appointed jointly by the Department of Consumer and Business Services and the Oregon Health Authority to carry out the responsibilities under OAR 836-100-0120.
(6) “Provider” means a health care provider that provides health care or medical services within Oregon for a fee and is eligible for reimbursement for these services.
Stat. Auth.: ORS 731.244 &
2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Stats. Implemented: 2011 OL
Ch. 130 Sec. 2 (Enrolled SB 94)
Hist.: ID 12-2011, f. &
cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11
836-100-0110
Adoption of Standards
(1) All health insurers and health care entities must conduct eligibility benefit inquiry and response transactions with health care providers as electronic transactions that conform to the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to section 3, chapter 130, Oregon Laws 2011 (Enrolled Senate Bill 94) as set forth in the Oregon Companion Guide for Health Care Eligibility Benefit Inquiry and Response in accordance with the following schedule:
(a) On and after January 1, 2012 for those health care providers that submit the inquiry electronically on the effective date of these rules.
(b) On and after October 1, 2012, for all inquiries from all health care providers.
(2) All health insurers and health care entities must conduct claims or encounter transactions with health care providers in conformance with the uniform standards developed by the Office for Oregon Health Policy and Research pursuant to section 3, chapter 130, Oregon Laws 2011 (Enrolled Senate Bill 94) as set forth in the Oregon Companion Guide for Health Care Claim: Professional, Oregon Companion Guide for Health Care Claim: Institutional and Oregon Companion Guide for Health Care Claim: Dental in accordance with the following schedule:
(a) On and after October 1, 2012 for those health care providers that conduct claims or encounter transactions electronically on the effective date of these rules.
(b) On and after January 1, 2013, all claims or encounter transactions with all health care providers must be conducted electronically.
Stat. Auth.: ORS 731.244 &
2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Stats. Implemented: 2011 OL
Ch. 130 Sec. 2 (Enrolled SB 94)
Hist.: ID 12-2011, f. &
cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11
836-100-0115
Waiver
(1) If a health insurer or health care entity demonstrates that the insurer or entity is certified by the Council for Affordable Quality Healthcare’s (CAQH) Committee on Operating Rules for Information Exchange (CORE), the Director of the Department of Consumer and Business Services shall grant a waiver from the requirement to comply with the Oregon Companion Guide. A health insurer or health care entity granted a waiver under this subsection shall be deemed in compliance with the standards of the applicable Oregon Companion Guide.
(2) Until January 1, 2014, the Director of the Department of Consumer and Business Services may grant a waiver to a health insurer or health care entity subject to OAR 836-100-0110 that demonstrates that the health insurer or health care entity is unable to comply with its provisions, or for whom compliance would be an undue hardship. A health insurer or health care entity requesting a waiver must submit a letter of need to the director. If the health insurer or health care entity requires an extension of the waiver, the health insurer or health care entity may apply to the Director of the Department of Consumer and Business Services for a temporary waiver of some or all of the provisions of the applicable Oregon Companion Guide. The waiver request must:
(a) Specify the name of the Oregon Companion Guide for which the waiver is requested;
(b) Indicate whether the waiver is for the entire Oregon Companion Guide or for specific provisions in the Oregon Companion Guide for which a waiver is requested.
(c) Explain the reasons the health insurer or health care entity is unable to comply or for which compliance would cause undue hardship, including systemic or structural impediments, financial hardship, and any other factors the health insurer or health care entity believes pertinent to the request.
(d) Specify the period of time for which the waiver is requested. After January 1, 2014, an insurer or health care entity may not request a waiver for a period longer than twelve months. An insurer or entity may request a waiver for an additional twelve months as previous waivers lapse.
(e) Include the insurer’s or entity’s plan for coming into compliance with the provisions of OAR 836-100-0110 during the time granted by the waiver.
(3)(a) After considering a request for a waiver submitted under section (1) of this rule, and at the director’s discretion, the director may grant or deny the request.
(b) In considering whether to allow a waiver requested pursuant to section (1) of this rule, the director shall consider the efforts of the health insurer or health care entity to comply with federal requirements contained in Section 1104 of the Patient Protection and Affordable Care Act.
(4) Information and standards related to CORE certification are located at the CAQH website: http://www.caqh.org/benefits.php
Stat. Auth.: ORS 731.244 &
2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Stats. Implemented: 2011 OL
Ch. 130 Sec. 2 (Enrolled SB 94)
Hist.: ID 12-2011, f. &
cert. ef. 7-15-11; ID 16-2011, f. & cert. ef. 10-31-11
836-100-0120
Review and Update of Standards
(1) The Department of Consumer and Business Services and the Oregon Health Authority shall jointly appoint an Oregon Companion Guide Oversight Committee. The members appointed to the committee must demonstrate knowledge of the transactions subject to the Oregon Companion Guides, financial knowledge, operational industry or business expertise, or knowledge of the technology necessary to implement the requirements of the companion guides.
(2) The Oregon Companion Guide Oversight Committee shall meet as needed to review the implementation of the administrative standards encompassed by the Oregon Companion Guides. The committee shall address issues identified by the Department of Consumer and Business Services and the Oregon Health Authority, including but not limited to:
(a) Consider and make recommendations to Oregon Health Authority and Department of Consumer and Business Services about needed changes to the guides in order to keep the guide up to date with industry and federal government driven changes.
(b) Provide reports to Department of Consumer and Business Services and Oregon Health Authority regarding health insurer and provider participation, successes and areas for improvement.
(c) Review any proposed changes developed by Oregon Health Authority to the standards or companion guides.
(d) Review any proposed changes developed by Department of Consumer and Business Services to the rules requiring compliance with the companion guides.
Stat. Auth.:
ORS 731.244 & 2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Stats.
Implemented: 2011 OL Ch. 130 Sec. 2 (Enrolled SB 94)
Hist.:
ID 12-2011, f. & cert. ef. 7-15-11
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