The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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 836-053-0760;
(e) OAR 836-053-0780;
(f) OAR 836-053-0785;
(g) OAR 836-053-0790;
(h) OAR 836-053-0800;
(i) OAR 836-053-0825;
(j) OAR 836-053-0830;
(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
836-053-0015
Definition of Small Employer
(1) This rule is adopted for the purpose
of modifying the definition of small employer as authorized in ORS 743.730.
(2) This rule establishes
the definition of small employer to be used in any instance in which the definition
set forth in ORS 743.730(27) would apply and in rules of the Insurance Division
of the Department of Consumer and Business Services for the period beginning on
January 1, 2016 and ending on December 31, 2017.
(3) As used in ORS 743.730
and rules of the Insurance Division, Department of Consumer and Business Services,
“small employer” means, in connection with a group health benefit plan
with respect to a calendar year and a plan year, an employer who employed an average
of at least one but not more than 50 employees on business days during the preceding
calendar year and who employs at least one employee on the first day of the plan
year.
(4) For purposes of determining
the number of employees in a group health benefit plan, insurers and producers should
follow the guidance entitled, “Revised Counting Methodology for Determining
Small or Large Group,” as set forth in Exhibit A of this rule.
[ED. NOTE:
Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 731.244 & 743.730(27)
Stats. Implemented: ORS 743.730
Hist.: ID 12-2015(Temp),
f. & cert. ef. 10-16-15 thru 4-11-16
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. A carrier must follow the
methodology and address the issues included in the “Revised Counting Methodology
for Determining Small or Large Group,” as set forth in Exhibit A of OAR 836-053-0015
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 the criteria set forth in Exhibit A and completion
of a group eligibility waiting period, if applicable.
(2) Impermissible employee
eligibility criteria include:
(a) Health status;
(b) Disability; and
(c) A requirement that an
employee be actively at work when coverage would otherwise begin.
(3) 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,
743.730 & 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; ID 12-2015(Temp), f. & cert. ef. 10-16-15 thru
4-11-16
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
Oregon Confidential Communications
Request Form
836-053-0600
Purpose; Statutory Authority; Applicability
(1) OAR 836-053-0600 to 836-053-0615
are adopted for the purpose of implementing sections 2, 3 and 12, chapter 470, Oregon
Laws 2015.
(2) The requirements set
forth in OAR 836-053-0600 to 836-053-0615 apply to carriers and third party administrators
for health benefit plans issued or renewed on or after January 1, 2016.
Stat. Auth: ORS 731.244 & OL 2015,
Sections 2 & 3

Stats. Implemented: Ch 470,
OL 2015 Sections 2, 3 & 12

Hist.: ID 8-2015(Temp), f.
& cert. ef. 9-15-15 thru 3-4-16
836-053-0605
Definitions for OAR 836-053-0600
to 836-053-0615
As used in OAR 836-053-0600 to 836-053-0615:
(1) The definitions set forth
in Section 2, chapter 470; Oregon Laws 2015 apply to the use of those terms in these
rules.
(2) “Enrollee”
includes a person covered under a health benefit plan and a dependent of a person
covered under a health benefit plan.
Stat. Auth: ORS 731.244 & OL 2015,
Sections 2 & 3

Stats. Implemented: Ch 470,
OL 2015 Sections 2, 3 & 12

Hist.: ID 8-2015(Temp), f.
& cert. ef. 9-15-15 thru 3-4-16
836-053-0610
Carrier Response to Request for
Confidentiality
(1) A carrier or third party administrator
must do all of the following:
(a) Allow enrollees to submit
the standardized form entitled “Oregon Confidential Communication Request”
set forth on the Insurance Division website of the Department of Consumer and Business
Services at www.insurance.oregon.gov.
(b) Acknowledge receipt of
the enrollee’s form and respond to an enrollee’s confidential communications
request.
(c) Include with the acknowledgement
any information the enrollee needs about the effect of the request and the process
for changing the status of the request.
(2) A carrier or third party
administrator must communicate with providers about the protections afforded to
enrollees under chapter 470, Oregon Laws 2015 and at a minimum provide information
about how to access the “Oregon Confidential Communication Request Form.”
A carrier or third party administrator is not limited to providing information about
the form.
Stat. Auth: ORS 731.244 & OL 2015,
Sections 2 & 3

Stats. Implemented: Ch 470,
OL 2015 Sections 2, 3 & 12

Hist.: ID 8-2015(Temp), f.
& cert. ef. 9-15-15 thru 3-4-16
836-053-0615
Carrier Reporting Requirements
(1) In order to comply with the requirements
of section 3, chapter 470, Oregon Laws 2015, not later than December 1, 2015, carriers
and third party administrators shall submit the following to the Department of Consumer
and Business Services:
(a) Information about internal
and external education and outreach activities that the carrier or third party administrator
will conduct to inform Oregonians about their right to have protected health information
redirected. The information reported shall include mechanisms the carrier or third
party administrator proposes to use to assess the effectiveness of the education
and outreach activities.
(b) Baseline data for the
period of October 1, 2014 through September 30, 2015 that explains:
(A) The total number of requests
to redirect confidential information received by the carrier or third party administrator
and of these, the number of requests to redirect confidential information that are
received via:
(i) Telephone;
(ii) Email; and
(iii) Hard copy.
(B) The timeliness of processing
the redirection requests segregated by method of request.
(C) The number of complaints
and grievances received related to confidential communications. This number must
also include the applicable grievances tracked in accordance with OAR 836-053-1080.
(D) Total number of enrolled
members.
(E) Total number of policyholders
or certificate holders.
(F) Total number of dependent
members.
(2) Not later than September
1, 2016, carriers and third party administrators shall submit to the department
the following data for the period of January 1, 2016 through June 30, 2016:
(a)(A) The total number of
requests to redirect confidential information received by the carrier or third party
administrator and of these, the number of requests to redirect confidential information
that are received via:
(i) Telephone;
(ii) Email;
(iii) Hard copy.
(B) The timeliness of processing
the redirection requests segregated by method of request.
(C) The number of complaints
and grievances received related to confidential communications.
(D) Total number of enrolled
members.
(E) Total number of policyholders
or certificate holders.
(F) Total number of dependent
members.
(b) The following information
to assist the department in determining the extent and effectiveness of the education
and outreach activities conducted by the carrier or third party administrator:
(A) Explanation of how and
when the process was presented to members; and
(B) Copies of outreach and
education materials used over the period of January 1, 2016 through June 30, 2016.
Stat. Auth: ORS 731.244 & OL 2015,
Sections 2 & 3

Stats. Implemented: Ch 470,
OL 2015 Sections 2, 3 & 12

Hist.: ID 8-2015(Temp), f.
& cert. ef. 9-15-15 thru 3-4-16
Rescission of Health Benefit Plan
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
836-053-1205
Uniform Prescription Drug Prior
Authorization Request Form
(1) As used in this rule:
(a) “Material information”
means information that is:
(A) Related to the patient’s
clinical condition sufficient to enable an individual with the appropriate training
and experience to determine whether the prescription authorization request should
be approved or disapproved; or
(B) Required by state or
federal law for dispensing restricted prescription drugs.
(b) “Payer” means
a person described in ORS 743.061(2) that requires prior authorization for prescription
drug benefits.
(c) “Request form”
means the Uniform Prescription Drug Prior Authorization Request Form set forth in
Exhibit A of this rule.
(2) Any payer that requires
prior authorization for a prescription drug benefit must accept a request for prior
authorization for a prescription drug on the request form. A payer also may accept
a prescription drug prior authorization request submitted on a form other than the
request form.
(3)(a) On or before July
1, 2015, a payer shall make the request form electronically available on their websites.
(b) On and after July 1,
2015, a payer shall:
(A) Accept the request form
through any reasonable means of transmission, including but not limited to paper,
electronic, or another mutually agreeable accessible method of transmission or using
an internet or web-based system.
(B) Request from the prescribing
provider only the minimum amount of material information necessary to approve or
disapprove the prescription drug prior authorization request.
(C) Notify the prescribing
provider within two business days after receipt of a completed request form that:
(i) The prescribing provider’s
request is approved;
(ii) The prescribing provider’s
request is disapproved as not medically necessary or not a covered benefit;
(iii) The prescribing provider’s
request is missing material information necessary to approve or disapprove the request;
or
(iv) The patient is no longer
eligible for coverage.
(4) A payer shall deliver
any notice to a prescribing provider required under section (3) of this rule in
the same manner the provider submitted the request form, or another mutually agreeable
accessible method of notification.
(5) If a provider requests
prescription drug prior authorization telephonically, through a web portal, or by
any other manner of transmission, the payer may not require the prescribing provider
to provide more information than is required by the request form.
(6) If a payer disapproves
a prescribing provider’s prior authorization request:
(a) Pursuant to paragraph
(3)(b)(C))(ii) or (iii), the payer shall include in the notice of disapproval an
accurate and clear written explanation of the specific reasons for disapproving
the prior authorization request.
(b) Pursuant to paragraph
(3)(b)(C)(iii), the payer also shall include in the notice of disapproval an accurate
and clear written explanation that specifically identifies the missing material
information that is necessary to approve or disapprove the prior authorization request.
(7) Every payer that conducts
prescription drug prior authorizations shall have written policies and procedures
in place to ensure that the payer complies with the requirements of ORS 743.065
and this rule.
(8) Requiring information
in excess of the minimum material information specified by the request form shall
constitute a failure to accept the request form, in violation of section (2) of
this rule. A payer may not disapprove a request form on grounds of missing information
under paragraph (3)(b)(C)(iii) of this rule if the form provides the minimum amount
of material information in accordance with subsection (3)(b)(B) of this rule.
Stat. Auth.: ORS 731.244, 743.065

Stats. Implemented: ORS 743.065

Hist.: ID 4-2015, f. &
cert. ef. 5-27-15
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
Cost Estimates
836-053-1404
Definitions; Noncontracting Providers;
Co-Morbidity Disorders
(1) As used in ORS 743A.168, this rule
and OAR 836-053-1405 to 836-053-1408:
(a) "Mental or nervous conditions"
means any mental disorder covered by diagnostic categories listed in 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).
(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; ID 3-2015, f. & cert. ef. 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
836-053-1407
Prohibited Exclusions
(1) An insurer may not deny benefits
for a medically necessary treatment or service for a mental or nervous condition
based solely upon:
(a) The enrollee’s
interruption of or failure to complete a prior course of treatment;
(b) The insurer’s categorical
exclusion of such treatment or service when applied to a class of mental or nervous
conditions; or
(c) The fact that a court
ordered the enrollee to receive or obtain the treatment or service for a mental
or nervous condition, unless otherwise allowed by law.
(2) Nothing in this section:
(a) Requires coverage of
a treatment or service that is or may be specifically excluded from coverage under
state law.
(b) Prohibits an insurer
from including a provision in a contract related to the insurer’s general
responsibility to pay for any service under the plan such as an exclusion for third
party liability.
(c) Requires an insurer to
pay for services provided to an enrollee by a school or halfway house or received
as part of an educational or training program. However, an insurer may be required
to provide coverage of treatment or services related to the enrollee’s education
that are provided by a provider and that are included in a medically necessary treatment
plan.
Stat. Auth.: ORS 731.244 & 743A.168

Stats. Implemented: ORS 743A.168

Hist.: ID 3-2015, f. &
cert. ef. 5-12-15
836-053-1408
Required Disclosures
(1) Insurers must provide an enrollee
or an enrollee’s authorized representative reasonable access to and copies
of all documents, records, and other information relevant to an enrollee’s
claim or request for coverage.
(2) Insurers must provide
the criteria, processes, standards and other factors used to make medical necessity
determinations of benefits for mental or nervous conditions. This information must
be made available free of charge by the insurer to any current or potential enrollee,
beneficiary, or contracting provider upon request, within a reasonable time and
in a manner that provides reasonable access to the requestor.
(3) Compliance with these
disclosure requirements is not determinative of compliance with any other provisions
of applicable federal or state law.
Stat. Auth.: ORS 731.244 & 743A.168

Stats. Implemented: ORS 743A.168

Hist.: ID 3-2015, f. &
cert. ef. 5-12-15
 
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
Primary Care Services Reporting
836-053-1500
Purpose; Statutory Authority; Applicability
(1) OAR 836-053-1500 to 836-053-1510
are adopted for the purpose of implementing section 1, chapter 575, Oregon Laws
2015.
(2) The requirements set
forth in OAR 836-053-1500 to 836-053-1510 apply to prominent carriers.
Stat. Auth: ORS 731.244 & 2015 OL
Ch. 575 Sec. 1

Stats. Implemented: &
2015 OL Ch. 575 Sec. 1 & 3
Hist.: ID 13-2015(Temp),
f. & cert. ef. 10-20-15 thru 4-8-16
836-053-1505
Definitions for OAR 836-053-1500
to 836-053-1510
As used in OAR 836-053-1500 to 836-053-1510:
(1) The definitions set forth
in Section 2, chapter 575; Oregon Laws 2015 apply to the use of those terms in these
rules.
(2) “Prominent carrier”
means:
(a) A carrier with annual
premium income of $200 million or more in direct health premiums written and is
not also licensed as a Coordinated Care Organization;
(b) The Public Employees’
Benefit Board; and
(c) The Oregon Educators
Benefit Board.
(3) “Non-claims based
primary care expenditures” means resources given to a primary care provider
or practice for the following services or arrangements:
(a) Capitation or salaried
arrangements with primary care providers or practices not billed or captured through
claims;
(b) Risk-based reconciliation
for arrangements with primary care providers or practices not billed or captured
through claims;
(c) Payments to Patient-Centered
Primary Care Homes or Patient-Centered Medical Homes based upon that recognition
or payments for participation in proprietary or other multi-payer medical home initiatives;
(d) Retrospective incentive
payments to primary care providers or practices based on performance aimed at decreasing
cost or improving value for a defined population of patients;
(e) Prospective incentive
payments to primary care providers or practices aimed at developing capacity for
improving care for a defined population of patients;
(f) Payments for Health Information
Technology structural changes at a primary care practice such as electronic records
and data reporting capacity from those records; or
(g) Workforce expenses including
payments or expenses for supplemental staff or supplemental activities integrated
into the primary care practice (i.e. practice coaches, patient educators, patient
navigators, nurse care managers, etc.).
(4) “Non-claims based
total health care expenditures” means resources given to a provider or practice
for the following services or arrangements:
(a) Capitation or salaried
arrangements with providers or practices not billed or captured through claims;
(b) Risk-based reconciliation
for arrangements with providers or practices not billed or captured through claims;
(c) Payments to Patient-Centered
Primary Care Homes, Patient-Centered Medical Homes, or Patient-Centered Specialty
Practices based upon that recognition or payments for participation in proprietary
or other multi-payer medical home or specialty care initiatives;
(d) Retrospective incentive
payments to providers or practices based on performance aimed at decreasing cost
or improving value for a defined population of patients;
(e) Prospective incentive
payments to providers or practices aimed at developing capacity for improving care
for a defined population of patients;
(f) Payments for Health Information
Technology structural changes at a practice such as electronic records and data
reporting capacity from those records; or
(g) Workforce expenses including
payments or expenses for supplemental staff or supplemental activities integrated
into the practice (i.e. practice coaches, patient educators, patient navigators,
nurse care managers, etc.).
(5) ”Patient-Centered
Medical Home” means a practice or provider who has been recognized as such
by the National Committee for Quality Assurance.
(6) “Patient-Centered
Primary Care Home” means a health care team or clinic as defined in ORS 414.655,
meets the standards pursuant to OAR 409-055-0040, and has been recognized through
the process pursuant to OAR 409-055-0040.
(7) “Patient-Centered
Specialty Practice” means a practice or provider who has been recognized as
such by the National Committee for Quality Assurance.
(8) “Practice”
means an individual, facility, institution, corporate entity, or other organization
which provides direct health care services or items, also termed a performing provider,
or bills, obligates and receives reimbursement on behalf of a performing provider
of services, also termed a billing provider. The term provider refers to both performing
providers and billing providers unless otherwise specified.
(9) “Primary care”
means family medicine, general internal medicine, naturopathic medicine, obstetrics
and gynecology, pediatrics or general psychiatry.
(10) “Primary care
provider” means:
(a) A physician, naturopath,
nurse practitioner, physician assistant or other health professional licensed or
certified in this state, whose clinical practice is in the area of primary care.
(b) A health care team or
clinic that has been certified by the Oregon Health Authority as a Patient-Centered
Primary Care Home.
Stat. Auth: ORS 731.244 & 2015 OL
Ch. 575 Sec. 1
Stats. Implemented: &
2015 OL Ch. 575 Sec. 1 & 3
Hist.: ID 13-2015(Temp),
f. & cert. ef. 10-20-15 thru 4-8-16
836-053-1510
Prominent Carrier Reporting Requirements
(1) Each prominent carrier shall submit
to the Department of Consumer and Business Services all non-claims based primary
care expenditures for calendar year 2014 using the approved file layout and format
set forth on the Insurance Division website of the Department of Consumer and Business
Services at www.insurance.oregon.gov.
(2) Each prominent carrier
shall submit to Department all non-claims based total health care expenditures for
calendar year 2014 using the approved file layout and format set forth on the Insurance
Division website of the Department of Consumer and Business Services at www.insurance.oregon.gov.
(3) Each category included
in the approved file format is mutually exclusive; therefore, expenditures shall
only be accounted for in one category.
(4) All data shall be submitted
to the Department no later than December 31, 2015.
(5) Claims-based primary
care and total health care expenditures will be calculated for each prominent carrier
by the Oregon Health Authority using data from the All-Payer All-Claims Database.
(6) Expenditures for services
or activities outside the primary care setting, regardless of a primary care capacity
building intent, are not considered primary care expenditures for purposes of this
report.
Stat. Auth: ORS 731.244 & 2015 OL
Ch. 575 Sec. 1
Stats. Implemented: &
2015 OL Ch. 575 Sec. 1 & 3
Hist.: ID 13-2015(Temp),
f. & cert. ef. 10-20-15 thru 4-8-16

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