Bill Text: OR HB2376 | 2011 | Regular Session | Introduced
Bill Title: Relating to health insurance; declaring an emergency.
Spectrum: Unknown
Status: (Failed) 2011-06-30 - In committee upon adjournment. [HB2376 Detail]
Download: Oregon-2011-HB2376-Introduced.html
76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 418
House Bill 2376
Ordered printed by the Speaker pursuant to House Rule 12.00A (5).
Presession filed (at the request of House Interim Committee on
Health Care)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Authorizes Department of Consumer and Business Services to
enforce health insurance requirements of federal law. Modifies
definition of 'health benefit plan' and includes student health
insurance within definition. Prohibits health insurer from
canceling, rescinding or refusing to renew policy on or after
September 23, 2010, except for fraud or intentional
misrepresentation of material fact. Requires health insurers to
notify covered persons and department regarding rescinded
policies on or after September 23, 2010. Prohibits preexisting
condition exclusion for insureds under 19 years of age who are
enrolled in certain types of health insurance. Requires coverage
of federally specified preventive health services and limited
cost-sharing for preventive services in health benefit plans
issued on or after September 23, 2010. Prohibits health insurers
from offering rate differentials for highly compensated
employees. Removes exception for association health plans from
specified provisions of Insurance Code. Prohibits lifetime dollar
limits on essential health benefits covered by health insurance.
Imposes new requirements for internal and external review of
adverse benefit determinations in health benefit plans offered or
renewed on or after September 23, 2010. Allows enrollee to seek
external review through Director of Department of Consumer and
Business Services. Requires insurers to allow female enrollee
access to obstetrical or gynecological care without referral or
prior authorization.
Abolishes Health Insurance Reform Advisory Committee.
Declares emergency, effective on passage.
A BILL FOR AN ACT
Relating to health insurance; creating new provisions; amending
ORS 243.252, 413.032, 731.146, 731.232, 731.236, 731.244,
731.248, 731.252, 731.256, 731.264, 731.300, 731.302, 731.358,
731.362, 731.402, 731.418, 731.426, 731.988, 732.543, 733.170,
734.043, 737.245, 742.021, 743.101, 743.405, 743.683, 743.730,
743.731, 743.733, 743.734, 743.736, 743.737, 743.745, 743.748,
743.751, 743.752, 743.754, 743.758, 743.760, 743.761, 743.766,
743.767, 743.801, 743.804, 743.806, 743.807, 743.845, 743.857,
743.859, 743.861, 743.862, 743.863, 743.864, 743.878, 743.913,
743A.080, 743A.090, 743A.110, 744.718, 746.650, 750.055,
750.313 and 750.333 and section 13, chapter 752, Oregon Laws
2007, and section 4, chapter 75, Oregon Laws 2010; repealing
section 12, chapter 752, Oregon Laws 2007; and declaring an
emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + As used in ORS 743.730 to 743.773,
'grandfathered health plan' has the meaning given that term in 29
C.F.R. 2590.715-1251. + }
SECTION 2. { + Section 3 of this 2011 Act is added to and made
a part of ORS 743.730 to 743.773. + }
SECTION 3. { + (1) Notwithstanding any other provision of law,
a health benefit plan must provide coverage of preventive health
services as prescribed by the United States Department of Health
and Human Services pursuant to 42 U.S.C. 300gg-13.
(2) A health benefit plan may not impose cost-sharing
requirements on an enrollee for preventive health services unless
the preventive health services are provided by out-of-network
providers according to criteria prescribed by the Department of
Consumer and Business Services in rules adopted consistent with
45 C.F.R. 147.130. + }
SECTION 4. { + Section 5 of this 2011 Act is added to and made
a part of the Insurance Code. + }
SECTION 5. { + (1) An insurer may not rescind a health benefit
plan or the coverage of any individual under a group or
individual health insurance policy unless:
(a)(A) The individual or a person seeking coverage on behalf of
the individual performs an act, practice or omission that
constitutes fraud; or
(B) The individual makes an intentional misrepresentation of a
material fact as prohibited by the terms of the plan or policy;
and
(b) The insurer provides at least 30 days' advance written
notice, in the form and manner prescribed by the Department of
Consumer and Business Services, to each plan enrollee or primary
subscriber who would be affected by the rescission of coverage.
(2) An insurer that rescinds a plan or policy must provide
notice of the rescission to the department in the form and manner
prescribed by the department no later than 30 days after the date
that the rescission takes effect.
(3) As used in this section, 'a person seeking coverage on
behalf of the individual' does not include an insurance producer
or an employee or authorized representative of an insurance
producer or carrier. + }
SECTION 6. ORS 243.252 is amended to read:
243.252. (1) The state may pay none of the cost of making
health benefit plan coverage available to a retired state
employee who is an eligible employee and to family members or may
agree, by collective bargaining agreement or otherwise, to pay
part or all of that cost.
(2) Nothing in subsection (1) of this section or other law,
except ORS 243.886, prohibits a collective bargaining unit from
agreeing with an employer that is a public body, as defined in
ORS 174.109, to establish a retiree medical trust, voluntary
employees' beneficiary association, health reimbursement
arrangement or other agreement for health care expenses of
employees or retirees if the provisions of the trust,
association, arrangement or other agreement comply with the
requirements of the Insurance Code { + and federal health
insurance law + }.
SECTION 7. ORS 413.032 is amended to read:
413.032. (1) The Oregon Health Authority is established. The
authority shall:
(a) Carry out policies adopted by the Oregon Health Policy
Board;
(b) Develop a plan for the Oregon Health Insurance Exchange in
accordance with section 17, chapter 595, Oregon Laws 2009;
(c) Administer the Oregon Prescription Drug Program;
(d) Administer the Family Health Insurance Assistance Program;
(e) Provide regular reports to the board with respect to the
performance of health services contractors serving recipients of
medical assistance, including reports of trends in health
services and enrollee satisfaction;
(f) Guide and support, with the authorization of the board,
community-centered health initiatives designed to address
critical risk factors, especially those that contribute to
chronic disease;
(g) Be the state Medicaid agency for the administration of
funds from Titles XIX and XXI of the Social Security Act and
administer medical assistance under ORS chapter 414;
(h) In consultation with the Director of the Department of
Consumer and Business Services, periodically review and recommend
standards and methodologies to the Legislative Assembly for:
(A) Review of administrative expenses of health insurers;
(B) Approval of rates; and
(C) Enforcement of rating rules adopted by the Department of
Consumer and Business Services;
(i) Structure reimbursement rates for providers that serve
recipients of medical assistance to reward comprehensive
management of diseases, quality outcomes and the efficient use of
resources and to promote cost-effective procedures, services and
programs including, without limitation, preventive health, dental
and primary care services, web-based office visits, telephone
consultations and telemedicine consultations;
(j) Guide and support community three-share agreements in which
an employer, state or local government and an individual all
contribute a portion of a premium for a community-centered health
initiative or for insurance coverage; and
(k) Develop, in consultation with the Department of Consumer
and Business Services { - and the Health Insurance Reform
Advisory Committee - } , one or more products designed to provide
more affordable options for the small group market.
(2) The Oregon Health Authority is authorized to:
(a) Create an all-claims, all-payer database to collect health
care data and monitor and evaluate health care reform in Oregon
and to provide comparative cost and quality information to
consumers, providers and purchasers of health care about Oregon's
health care systems and health plan networks in order to provide
comparative information to consumers.
(b) Develop uniform contracting standards for the purchase of
health care, including the following:
(A) Uniform quality standards and performance measures;
(B) Evidence-based guidelines for major chronic disease
management and health care services with unexplained variations
in frequency or cost;
(C) Evidence-based effectiveness guidelines for select new
technologies and medical equipment; and
(D) A statewide drug formulary that may be used by publicly
funded health benefit plans.
(c) Submit directly to the Legislative Counsel, no later than
October 1 of each even-numbered year, requests for measures
necessary to provide statutory authorization to carry out any of
the authority's duties or to implement any of the board's
recommendations. The measures may be filed prior to the beginning
of the legislative session in accordance with the rules of the
House of Representatives and the Senate.
(3) The enumeration of duties, functions and powers in this
section is not intended to be exclusive nor to limit the duties,
functions and powers imposed on or vested in the Oregon Health
Authority by ORS 413.006 to 413.064 or by other statutes.
SECTION 8. ORS 731.146 is amended to read:
731.146. (1) 'Transact insurance' means one or more of the
following acts effected by mail or otherwise:
(a) Making or proposing to make an insurance contract.
(b) Taking or receiving any application for insurance.
(c) Receiving or collecting any premium, commission, membership
fee, assessment, due or other consideration for any insurance or
any part thereof.
(d) Issuing or delivering policies of insurance.
(e) Directly or indirectly acting as an insurance producer for,
or otherwise representing or aiding on behalf of another, any
person in the solicitation, negotiation, procurement or
effectuation of insurance or renewals thereof, the dissemination
of information as to coverage or rates, the forwarding of
applications, the delivering of policies, the inspection of
risks, the fixing of rates, the investigation or adjustment of
claims or losses, the transaction of matters subsequent to
effectuation of the policy and arising out of it, or in any other
manner representing or assisting a person with respect to
insurance.
(f) Advertising locally or circularizing therein without regard
for the source of such circularization, whenever such advertising
or circularization is for the purpose of solicitation of
insurance business.
(g) Doing any other kind of business specifically recognized
{ + under the Insurance Code or federal health insurance
laws + } as constituting the doing of an insurance business
{ - within the meaning of the Insurance Code - } .
(h) Doing or proposing to do any insurance business in
substance equivalent to any of paragraphs (a) to (g) of this
subsection in a manner designed to evade { - the provisions
of - } { + any requirements for insurers under + } the
Insurance Code { + or federal health insurance laws + }.
(2) Subsection (1) of this section does not include, apply to
or affect the following:
(a) Making investments within a state by an insurer not
admitted or authorized to do business within such state.
(b) Except as provided in ORS 743.015, doing or proposing to do
any insurance business arising out of a policy of group life
insurance or a policy of blanket health insurance, if the master
policy was validly issued to cover a group organized primarily
for purposes other than the procurement of insurance and was
delivered in and pursuant to the laws of another state in which:
(A) The insurer was authorized to do an insurance business;
(B) The policyholder is domiciled or otherwise has a bona fide
situs; and
(C) With respect to a policy of blanket health insurance, the
policy was approved by the director of such state.
(c) Except as provided in ORS 743.015, doing or proposing to do
any insurance business arising out of a policy of group health
insurance, if the master policy was validly issued to cover an
employer group other than an association, trust or multiple
employer welfare arrangement and was delivered in and pursuant to
the laws of another state in which:
(A) The insurer was authorized to do an insurance business; and
(B) The policyholder is domiciled or otherwise has a bona fide
situs.
(d) Investigating, settling, or litigating claims under
policies lawfully written within a state, or liquidating assets
and liabilities, all resulting from the insurer's former
authorized operations within such state.
(e) Transactions within a state under a policy subsequent to
its issuance if the policy was lawfully solicited, written and
delivered outside the state and did not cover a subject of
insurance resident, located or to be performed in the state when
issued.
(f) The continuation and servicing of life or health insurance
policies remaining in force on residents of a state if the
insurer has withdrawn from such state and is not transacting new
insurance therein.
(3) If mail is used, an act shall be deemed to take place at
the point where the matter transmitted by mail is delivered and
takes effect.
SECTION 9. ORS 731.146, as amended by section 6, chapter 752,
Oregon Laws 2007, is amended to read:
731.146. (1) 'Transact insurance' means one or more of the
following acts effected by mail or otherwise:
(a) Making or proposing to make an insurance contract.
(b) Taking or receiving any application for insurance.
(c) Receiving or collecting any premium, commission, membership
fee, assessment, due or other consideration for any insurance or
any part thereof.
(d) Issuing or delivering policies of insurance.
(e) Directly or indirectly acting as an insurance producer for,
or otherwise representing or aiding on behalf of another, any
person in the solicitation, negotiation, procurement or
effectuation of insurance or renewals thereof, the dissemination
of information as to coverage or rates, the forwarding of
applications, the delivering of policies, the inspection of
risks, the fixing of rates, the investigation or adjustment of
claims or losses, the transaction of matters subsequent to
effectuation of the policy and arising out of it, or in any other
manner representing or assisting a person with respect to
insurance.
(f) Advertising locally or circularizing therein without regard
for the source of such circularization, whenever such advertising
or circularization is for the purpose of solicitation of
insurance business.
(g) Doing any other kind of business specifically recognized
{ + under the Insurance Code or federal health insurance
laws + } as constituting the doing of an insurance business
{ - within the meaning of the Insurance Code - } .
(h) Doing or proposing to do any insurance business in
substance equivalent to any of paragraphs (a) to (g) of this
subsection in a manner designed to evade { - the provisions
of - } { + any requirements for insurers under + } the
Insurance Code { + or federal health insurance laws + }.
(2) Subsection (1) of this section does not include, apply to
or affect the following:
(a) Making investments within a state by an insurer not
admitted or authorized to do business within such state.
(b) Except as provided in ORS 743.015, doing or proposing to do
any insurance business arising out of a policy of group life
insurance or group health insurance, or both, or a policy of
blanket health insurance, if the master policy was validly issued
to cover a group organized primarily for purposes other than the
procurement of insurance and was delivered in and pursuant to the
laws of another state in which:
(A) The insurer was authorized to do an insurance business;
(B) The policyholder is domiciled or otherwise has a bona fide
situs; and
(C) With respect to a policy of blanket health insurance, the
policy was approved by the director of such state.
(c) Investigating, settling, or litigating claims under
policies lawfully written within a state, or liquidating assets
and liabilities, all resulting from the insurer's former
authorized operations within such state.
(d) Transactions within a state under a policy subsequent to
its issuance if the policy was lawfully solicited, written and
delivered outside the state and did not cover a subject of
insurance resident, located or to be performed in the state when
issued.
(e) The continuation and servicing of life or health insurance
policies remaining in force on residents of a state if the
insurer has withdrawn from such state and is not transacting new
insurance therein.
(3) If mail is used, an act shall be deemed to take place at
the point where the matter transmitted by mail is delivered and
takes effect.
SECTION 10. ORS 731.232 is amended to read:
731.232. (1) For the purpose of an investigation or proceeding
under the Insurance Code { + or pursuant to federal health
insurance laws + }, the Director of the Department of Consumer
and Business Services may administer oaths and affirmations,
subpoena witnesses, compel their attendance, take evidence and
require the production of books, papers, correspondence,
memoranda, agreements or other documents or records which the
director considers relevant or material to the inquiry. Each
witness who appears before the director under a subpoena shall
receive the fees and mileage provided for witnesses in ORS 44.415
(2).
(2) If a person fails to comply with a subpoena so issued or a
party or witness refuses to testify on any matters, the judge of
the circuit court for any county, on the application of the
director, shall compel obedience by proceedings for contempt as
in the case of disobedience of the requirements of a subpoena
issued from such court or a refusal to testify therein.
SECTION 11. ORS 731.236 is amended to read:
731.236. (1) The Director of the Department of Consumer and
Business Services shall enforce the provisions of the Insurance
Code { + and federal health insurance laws + } for the public
good, and shall execute the duties imposed by the code.
(2) The director has the powers and authority expressly
conferred by or reasonably implied from the provisions of the
Insurance Code { + and federal health insurance laws + }.
(3) The director may conduct such examinations and
investigations of insurance matters, in addition to examinations
and investigations expressly authorized, as the director
considers proper to determine whether any person has violated any
provision of the Insurance Code { + or federal health insurance
laws, + } or to secure information useful in the lawful
administration of any such provision. The cost of such additional
examinations and investigations shall be borne by the state.
(4) The director has such additional powers and duties as may
be provided by other laws of this state.
SECTION 12. ORS 731.244 is amended to read:
731.244. In accordance with the applicable provisions of ORS
chapter 183, the Director of the Department of Consumer and
Business Services may make reasonable rules necessary for or as
an aid to the effectuation of the Insurance Code { + and federal
health insurance laws + }. No such rule shall extend, modify or
conflict with the Insurance Code { + , federal health insurance
laws + } or the reasonable implications thereof.
SECTION 13. ORS 731.248 is amended to read:
731.248. (1) Orders of the Director of the Department of
Consumer and Business Services shall be effective only when in
writing and signed by the director or by the authority of the
director. Orders shall be filed in the Department of Consumer and
Business Services.
(2) Every such order shall state:
(a) Its effective date;
(b) Its intent or purpose;
(c) The grounds on which based; and
(d) The provisions of the Insurance Code { + or federal health
insurance laws + } pursuant to which action is taken or proposed
to be taken.
(3) Except as may be provided in the Insurance Code respecting
particular procedures, an order or notice may be given by
delivery to the person to be ordered or notified or by mailing it
by certified or registered mail, return receipt requested,
postage prepaid, addressed to the person at the residence or
principal place of business of the person as last of record in
the department. Notice so mailed shall be deemed to have been
given when deposited in a letter depository of a United States
post office.
SECTION 14. ORS 731.252 is amended to read:
731.252. (1) Whenever the Director of the Department of
Consumer and Business Services has reason to believe that any
person has been engaged or is engaging or is about to engage in
any violation of the Insurance Code { + or federal health
insurance laws + }, the director may issue an order, directed to
such person, to discontinue or desist from such violation or
threatened violation. The copy of the order forwarded to the
person involved shall set forth a statement of the specific
charges and the fact that the person may request a hearing within
20 days of the date of mailing. Where a hearing is requested, the
director shall set a date for the hearing to be held within 30
days after receipt of the request, and shall give the person
involved written notice of the hearing date at least seven days
prior thereto. The person requesting the hearing must establish
to the satisfaction of the director that such order should not be
complied with. The order shall become final 20 days after the
date of mailing unless within such 20-day period the person to
whom it is directed files with the director a written request for
a hearing. To the extent applicable and not inconsistent with the
foregoing, the provisions of ORS chapter 183 shall govern the
hearing procedure and any judicial review thereof. Where the
hearing has been requested, the director's order shall become
final at such time as the right to further hearing or review has
expired or been exhausted.
(2) No order of the director under this section or order of a
court to enforce the same shall in any way relieve or absolve any
person affected by such order from any liability under any other
laws of this state.
(3) The powers vested in the director pursuant to this section
are supplementary and not in lieu of any other powers to suspend
or revoke certificates of authority or licenses or to enforce any
penalties, fines or forfeitures, authorized by law with respect
to any violation for which an order of discontinuance has been
issued.
SECTION 15. ORS 731.256 is amended to read:
731.256. (1) The Director of the Department of Consumer and
Business Services may institute such actions or other lawful
proceedings as the director may deem necessary for the
enforcement of any provision of the Insurance Code { + or other
law applicable to insurance operations + } or { + of + } any
order or action made or taken by the director in pursuance of
law.
(2) If the director has reason to believe that any person has
violated any provision of the Insurance Code or other law
applicable to insurance operations, for which criminal
prosecution is provided and in the opinion of the director would
be in order, the director shall give the information relative
thereto to the Attorney General or district attorney having
jurisdiction of any such violation. The Attorney General or
district attorney promptly shall institute such action or
proceedings against such person as the information requires or
justifies.
SECTION 16. ORS 731.264 is amended to read:
731.264. (1) A complaint made to the Director of the Department
of Consumer and Business Services against any person regulated by
the Insurance Code { + or federal health insurance laws + }, and
the record thereof, shall be confidential and may not be
disclosed except as provided in ORS 705.137. No such complaint,
or the record thereof, shall be used in any action, suit or
proceeding except to the extent considered necessary by the
director in the prosecution of apparent violations of the
Insurance Code or other law.
(2) Data gathered pursuant to an investigation by the director
of a complaint shall be confidential, may not be disclosed except
as provided in ORS 705.137 and may not be used in any action,
suit or proceeding except to the extent considered necessary by
the director in the investigation or prosecution of apparent
violations of the Insurance Code or other law.
(3) Notwithstanding subsections (1) and (2) of this section,
the director shall establish by rule a method for publishing an
annual statistical report containing the insurer's name and the
number, percentage, type and disposition of complaints received
by the Department of Consumer and Business Services against each
insurer transacting insurance within this state.
SECTION 17. ORS 731.300 is amended to read:
731.300. (1) The Director of the Department of Consumer and
Business Services shall examine every authorized insurer,
including an audit of the financial affairs of such insurer, as
often as the director determines an examination to be necessary
but at least once each five years. An examination shall be
conducted for the purpose of determining the financial condition
of the insurer, its ability to fulfill its obligations and its
manner of fulfillment, the nature of its operations and its
compliance with the Insurance Code { + and federal health
insurance laws + }. The director may also make such an
examination of any surplus lines insurance producer or any person
holding the capital stock of an authorized insurer or surplus
lines insurance producer for the purpose of controlling the
management thereof as a voting trustee or otherwise, or both.
(2) Instead of conducting an examination of an authorized
foreign or alien insurer, the director may accept an examination
report on the insurer that is prepared by the insurance
department for the state of domicile or state of entry of the
insurer if:
(a) At the time of the examination the insurance department of
the state was accredited under the Financial Regulation Standards
and Accreditation Program or successor program of the National
Association of Insurance Commissioners; or
(b) The examination was performed under the supervision of an
accredited insurance department or with the participation of one
or more examiners who are employed by such an accredited
insurance department and who, after a review of the examination
work papers and report, state under oath that the examination was
performed in a manner consistent with the standards and
procedures required by their insurance department.
(3) Examination of an alien insurer shall be limited to its
insurance transactions, assets, trust deposits and affairs in the
United States except as otherwise required by the director.
SECTION 18. ORS 731.302 is amended to read:
731.302. (1) When the Director of the Department of Consumer
and Business Services determines that an examination should be
conducted, the director shall appoint one or more examiners to
perform the examination and instruct them as to the scope of the
examination. In conducting the examination, each examiner shall
consider the guidelines and procedures in the examiner handbook,
or its successor publication, adopted by the National Association
of Insurance Commissioners. The director may prescribe the
examiner handbook or its successor publication and employ other
guidelines and procedures that the director determines to be
appropriate.
(2) When making an examination, the director may retain
appraisers, independent actuaries, independent certified public
accountants or other professionals and specialists as needed. The
cost of retaining such professionals and specialists shall be
borne by the person that is the subject of the examination.
(3) At any time during the course of an examination, the
director may take other action pursuant to the Insurance
Code { + or federal health insurance laws + }.
(4) Facts determined { - and conclusions made - } pursuant
to an examination shall be presumptive evidence of the relevant
facts
{ - and conclusions - } in any judicial or administrative
action.
SECTION 19. ORS 731.358 is amended to read:
731.358. Upon application { + , + } a domestic insurer shall be
granted a certificate of authority to transact any class of
insurance permitted by the Insurance Code and provided for in its
articles of incorporation upon its compliance with all the laws
of this state { - and - } { + , + } the rules of the
Department of Consumer and Business Services relating to such
insurers { + and federal health insurance laws + }.
SECTION 20. ORS 731.362 is amended to read:
731.362. (1) A foreign or alien insurer may be authorized to
transact insurance in this state when it has complied with the
following requirements:
(a) It shall file with the Director of the Department of
Consumer and Business Services a certified copy of its charter,
articles of incorporation or deed of settlement and a statement
of its financial condition and business in all states in such
form and detail as the director may require, signed and sworn to
by at least two of its executive officers or the United States
manager.
(b) It shall satisfy the director that it is fully and legally
organized under the laws of its state or government to do the
business it proposes to transact.
(c) It shall satisfy the director that it is possessed of and
will maintain at all times its required capitalization.
(d) It shall make such deposits with the Department of Consumer
and Business Services as are required by the provisions of the
Insurance Code.
(2) Upon compliance with the requirements of this section and
all other requirements imposed on such insurer by the Insurance
Code { + and federal health insurance laws + }, the director
shall issue to it a certificate of authority.
SECTION 21. ORS 731.402 is amended to read:
731.402. (1) The Director of the Department of Consumer and
Business Services shall issue to an insurer a certificate of
authority if upon completion of the application for a certificate
of authority by the insurer the director finds, from the
application and such other investigation and information the
director may acquire, that the insurer is fully qualified and
entitled thereto under the Insurance Code { + and federal health
insurance laws + }.
(2) The director shall take all necessary action and shall
either issue or refuse to issue a certificate of authority within
a reasonable time after the completion of the application for
such authority.
(3) The certificate of authority, if issued, shall specify the
class or classes of insurance the insurer is authorized to
transact in this state. The director may issue authority limited
to particular subclasses of insurance or types of insurance
coverages within the scope of a class of insurance.
SECTION 22. ORS 731.418 is amended to read:
731.418. (1) The Director of the Department of Consumer and
Business Services may refuse to continue or may suspend or revoke
an insurer's certificate of authority if the director finds after
{ + notice and an opportunity for + } a hearing that:
(a) The insurer has violated or failed to comply with any
lawful order of the director, { - or any provision of - } the
Insurance Code { + or federal health insurance laws + } other
than those for which suspension or revocation is mandatory.
(b) The insurer is in unsound condition, or in such condition
or using such methods and practices in the conduct of its
business, as to render its further transaction of insurance in
this state hazardous or injurious to its policyholders or to the
public.
(c) The insurer has failed, after written request by the
director, to remove or discharge an officer or director who has
been convicted in any jurisdiction of an offense which, if
committed in this state, constitutes a misdemeanor involving
moral turpitude or a felony, or is punishable by death or
imprisonment under the laws of the United States, in any of which
cases the record of the conviction shall be conclusive evidence.
(d) The insurer is affiliated with and under the same general
management, interlocking directorate or ownership as another
insurer that transacts direct insurance in this state without
having a certificate of authority { - therefor - } , except as
permitted under the Insurance Code { + or federal law + }.
(e) The insurer or an affiliate or holding company of the
insurer refuses to be examined or any director, officer, employee
or representative of the insurer, affiliate or holding company
refuses to submit to examination relative to the affairs of the
insurer, or to produce its accounts, records, and files for
examination when required by the director or an examiner of the
Department of Consumer and Business Services, or refuse to
perform any legal obligation relative to the examination.
(f) The insurer has failed to pay any final judgment rendered
against it in this state upon any policy, bond, recognizance or
undertaking issued or guaranteed by it, within 30 days after the
judgment became final, or within 30 days after time for taking an
appeal has expired, or within 30 days after dismissal of an
appeal before final determination, whichever date is the later.
(g) The insurer { - fails - } { + has failed + } to comply
with ORS 742.534 (1).
(h) The insurer has failed to comply with ORS 476.270 (1), (2)
or (3) or 654.097 (1).
{ - (2) Without advance notice or a hearing thereon, the
director may suspend immediately the certificate of authority of
any insurer as to which proceedings for receivership,
conservatorship, rehabilitation, or other delinquency
proceedings, have been commenced in any state by the public
insurance supervisory official of such state. - }
{ + (2) If an insurance official of any state commences
receivership, conservatorship, rehabilitation or other
delinquency proceedings against any insurer, the director may
immediately suspend the insurer's certificate of authority
without advance notice or an opportunity for a hearing. + }
SECTION 23. ORS 731.426 is amended to read:
731.426. (1) In an order suspending the certificate of
authority of an insurer, the Director of the Department of
Consumer and Business Services may provide that the suspension
expires at the end of a specified period or when the director
determines that the cause or causes of the suspension have
terminated. During the suspension the director may rescind or
shorten the suspension by further order.
(2) During the suspension period the insurer shall not solicit
or write any new business in this state, but shall file its
annual statement and pay fees, licenses and taxes as required
under the Insurance Code, and may service its business already in
force in this state, as if the certificate of authority had
continued in full force.
(3) Upon expiration of a specific suspension period, if within
such period the certificate of authority has not terminated, the
insurer's certificate of authority automatically shall reinstate
unless the director finds that the cause or causes of the
suspension have not terminated, or that the insurer is otherwise
not in compliance with the requirements of the Insurance
Code { + or federal health insurance laws + }, and of which the
director shall give the insurer notice not less than 30 days in
advance of the expiration of the suspension period.
(4) When the director determines that a suspension should
expire because the cause or causes have terminated, the director
shall reinstate the certificate of authority of the insurer
unless the certificate of authority has expired within the
suspension period.
(5) Upon reinstatement of the insurer's certificate of
authority, the authority of its insurance producers in this state
to represent the insurer shall likewise reinstate. The director
promptly shall notify the insurer and its insurance producers in
this state of record in the Department of Consumer and Business
Services, of such reinstatement. If pursuant to ORS 731.422 the
director has published notice of suspension, in like manner the
director shall publish notice of the reinstatement.
SECTION 24. ORS 731.988 is amended to read:
731.988. (1) Any person who violates any provision of the
Insurance Code, any lawful rule or final order of the Director of
the Department of Consumer and Business Services or any judgment
made by any court upon application of the director, shall forfeit
and pay to the General Fund of the State Treasury a civil penalty
in an amount determined by the director of not more than $10,000
for each offense. In the case of individual insurance producers,
adjusters or insurance consultants, the civil penalty shall be
not more than $1,000 for each offense. Each violation shall be
deemed a separate offense.
(2) In addition to the civil penalty set forth in subsection
(1) of this section, any person who violates any provision of the
Insurance Code, any lawful rule or final order of the director or
any judgment made by any court upon application of the director,
may be required to forfeit and pay to the General Fund of the
State Treasury a civil penalty in an amount determined by the
director but not to exceed the amount by which such person
profited in any transaction which violates any such provision,
rule, order or judgment.
(3) In addition to the civil penalties set forth in subsections
(1) and (2) of this section, any insurer that is required to make
a report under ORS 742.400 and that fails to do so within the
specified time may be required to pay to the General Fund of the
State Treasury a civil penalty in an amount determined by the
director but not to exceed $10,000.
(4) A civil penalty imposed under this section may be recovered
either as provided in subsection (5) of this section or in an
action brought in the name of the State of Oregon in any court of
appropriate jurisdiction.
(5) Civil penalties under this section shall be imposed and
enforced in the manner provided by ORS 183.745.
(6) The provisions of this section are in addition to and not
in lieu of any other enforcement provisions contained in the
Insurance Code { + or federal health insurance laws + }.
SECTION 25. ORS 732.543 is amended to read:
732.543. (1) Whenever it appears to the Director of the
Department of Consumer and Business Services that any person has
committed or is about to commit a violation of any provision of
ORS 732.517 to 732.546 or of any rule or order issued by the
director under ORS 732.517 to 732.546, the director may apply to
the Circuit Court for Marion County for an order enjoining the
person, and any director, officer, employee or agent of the
person, from the violation, and for such other equitable relief
as the nature of the case and the interests of the policyholders,
creditors and shareholders of any insurer or the public may
require.
(2) No security that is the subject of any agreement or
arrangement regarding acquisition, or that is acquired or to be
acquired, in contravention of ORS 732.517 to 732.546 or of any
rule or order issued by the director under ORS 732.517 to
732.546, may be voted at any shareholder's meeting, or may be
counted for quorum purposes, and any action of shareholders
requiring the affirmative vote of a percentage of shares may be
taken as though such securities were not issued and outstanding.
However, no action taken at any such meeting shall be invalidated
by the voting of such securities unless the action would
materially affect control of the insurer or unless the courts of
this state have so ordered. If an insurer or the director has
reason to believe that any security of the insurer has been or is
about to be acquired in contravention of ORS 732.517 to 732.546
or any rule or order issued by the director under ORS 732.517 to
732.546, the insurer or the director may apply to the Circuit
Court for Marion County, or to the circuit court for the county
in which the insurer has its principal place of business in this
state, if any, to enjoin the violation, to enjoin the voting of
any security so acquired, to void any vote of such security
already cast at any meeting of shareholders, and for such other
equitable relief as the nature of the case and the interests of
the insurer's policyholders, creditors and shareholders or the
public may require.
(3) In any case in which a person has acquired or is proposing
to acquire any voting securities of an insurer in violation of
ORS 732.517 to 732.546 or any rule or order issued by the
director under ORS 732.517 to 732.546, the Circuit Court for
Marion County, or the circuit court for the county in which the
insurer has its principal place of business in this state, if
any, upon the application of the insurer or the director and on
such notice as the court deems appropriate, may seize or
sequester any voting securities of the insurer owned directly or
indirectly by the person, and issue any order with respect to the
voting securities as may be appropriate to effect the provisions
of ORS 732.517 to 732.546. Notwithstanding any other provision of
law, for the purposes of this section, the situs of the ownership
of the securities of domestic insurers is located in this state.
(4) The director may exercise remedies available under this
section in addition to or in lieu of any other remedy or
administrative action available to the director under the
Insurance Code { + or federal health insurance laws + }.
SECTION 26. ORS 733.170 is amended to read:
733.170. An insurer shall keep its books, records, accounts and
transaction source data in such manner that the Director of the
Department of Consumer and Business Services may readily verify
its statements of financial condition and ascertain whether the
insurer is unimpaired, has given proper treatment to
policyholders and has complied with the Insurance Code { + and
federal health insurance laws + }.
SECTION 27. ORS 734.043 is amended to read:
734.043. (1) For any reason stated in subsection (2) of this
section, the Director of the Department of Consumer and Business
Services by order may place under supervision:
(a) A domestic insurer; or
(b) A foreign or alien insurer, if the insurance regulatory
official of its state of domicile or entry has asked the director
to apply this section and ORS 734.047, 734.051 and 734.055 to the
insurer.
(2) The director may place an insurer under supervision if upon
examination or at any other time the director determines that:
(a) The condition of the insurer renders the continuance of its
business hazardous to the public or to its insureds.
(b) The insurer has refused to permit examination of its books,
papers, accounts, records or affairs by the director or any
deputy, examiner or employee representing the director.
(c) A domestic insurer has unlawfully removed from this state
books, papers, accounts or records necessary for an examination
of the insurer.
(d) The insurer has failed to comply promptly with the
applicable financial reporting statutes or rules and any request
of the Department of Consumer and Business Services relating
thereto.
(e) The insurer has failed to observe an order of the director
to make good, within the time prescribed by law, any prohibited
deficiency in its capital, capital stock or surplus.
(f) The insurer is continuing to transact insurance or write
business after its certificate of authority has been revoked or
suspended by the director.
(g) The insurer, by contract or otherwise, has done any of the
following unlawfully, in violation of an order of the director or
without first having obtained written approval of the director:
(A) Totally reinsured its entire outstanding business; or
(B) Merged or consolidated substantially its entire property or
business with another insurer.
(h) The insurer has engaged in any transaction in which it is
not authorized to engage under the laws of this state.
(i) The insurer has failed to comply with any other order of
the director.
(j) The insurer has failed to comply with any other applicable
provisions of the Insurance Code { + or federal health insurance
laws + }.
(k) The business of the insurer is being conducted
fraudulently.
(L) The insurer agrees to supervision.
(3) If the director determines that one or more conditions set
forth in subsection (2) of this section exist, the director may
do all of the following:
(a) Notify the insurer of the determination of the director.
(b) Furnish to the insurer a written list of the requirements
to abate the condition or conditions determined to exist.
(c) Notify the insurer that it is under the supervision of the
director and that the director is applying this section and ORS
734.047, 734.051 and 734.055.
(4) The director may act as the supervisor to conduct the
supervision and otherwise carry out an order under subsection (1)
of this section or may appoint another person as supervisor.
(5) The director or the appointed supervisor may prohibit any
person from taking any of the following actions during the period
of supervision without the prior approval of the director or
supervisor:
(a) Disposing of, conveying or encumbering any of the insurer's
assets or its business in force.
(b) Withdrawing from any of the insurer's bank accounts.
(c) Lending any of the insurer's funds.
(d) Investing any of the insurer's funds.
(e) Transferring any of the insurer's property.
(f) Incurring any debt, obligation or liability on behalf of
the insurer.
(g) Merging or consolidating the insurer with another insurer
or other person.
(h) Entering into any new reinsurance contract or treaty.
(i) Approving new premiums or renewing any policies.
(j) Terminating, surrendering, forfeiting, converting or
lapsing any insurance policy, certificate or contract, except for
nonpayment of premiums due.
(k) Releasing, paying or refunding premium deposits, accrued
cash or loan values, unearned premiums, or other reserves on any
insurance policy, certificate or contract.
(L) Making any material change in management.
(m) Increasing salaries and benefits of officers or directors.
(n) Making or increasing preferential payment of bonuses,
dividends or other payments determined by the director to be
preferential.
(o) Any other action affecting the business or condition of the
insurer.
(6) The director may apply to any circuit court for any
restraining order, preliminary and permanent injunctions and
other orders necessary to enforce a supervision order.
(7) During the period of supervision, the insurer may file a
written request for a hearing to review the supervision or any
action taken or proposed to be taken. A request under this
subsection shall not suspend the supervision. The insurer must
specify in the request the manner in which the action being
complained of would not result in improving the condition of the
insurer. The hearing shall be held within 30 days after the
filing of the request. The director shall complete the review of
the supervision or other action and shall take action under
subsection (8) of this section if appropriate within 30 days
after the record for the hearing is closed.
(8) The director shall release an insurer from supervision if
the director determines upon hearing that none of the conditions
giving rise to the supervision exist.
SECTION 28. ORS 737.245 is amended to read:
737.245. In the event any insurer shall in collusion with any
other insurer conspire to fix, set or adhere to insurance rates
except as expressly sanctioned by the Insurance Code { + or
federal health insurance laws + }, such insurer shall be liable
to any person damaged thereby for an amount equal to three times
the amount of such damage together with the damaged party's
attorney fees.
SECTION 29. ORS 742.021 is amended to read:
742.021. (1) Insurance policies shall contain such standard or
uniform provisions as are required by the applicable provisions
of the Insurance Code { + and federal health insurance laws + }.
However, the insurer may at its option substitute for one or more
of such provisions corresponding provisions of different wording
approved by the Director of the Department of Consumer and
Business Services { - which - } { + that + } are in each
instance not less favorable in any respect to the insured or the
beneficiary.
(2) If any standard or uniform provision is in whole or in part
inapplicable to or inconsistent with the coverage provided by a
particular form of policy { + , + } the insurer, with the
approval of the director, shall omit from such policy any
inapplicable provision or part of a provision { - , - } and
shall modify any inconsistent provision or part of a provision in
such manner as to make the provision as contained in the policy
consistent with the coverage provided by the policy.
(3) Except as provided in subsection (2) of this section,
{ - no - } { + a + } policy { - shall - } { + may not + }
contain any provision inconsistent with or contradictory to any
standard or uniform provision used or required to be used.
SECTION 30. ORS 743.101 is amended to read:
743.101. (1) The purpose of the Life and Health Insurance
Policy Language Simplification Act is to establish minimum
standards for language used in policies and certificates of life
insurance and health insurance delivered or issued for delivery
in this state in order to facilitate ease of reading.
(2) ORS 743.100 to 743.109 is not intended to increase the risk
assumed by insurers or to supersede their obligation to comply
with the substance of other { - Insurance Code - }
provisions { + of the Insurance Code or federal law + }
applicable to insurance policies. ORS 743.100 to 743.109 is not
intended to impede flexibility and innovation in the development
of policy forms or content or to lead to the standardization of
policy forms or content.
SECTION 31. ORS 743.405 is amended to read:
743.405. An individual health insurance policy must meet the
following requirements:
(1) The entire money and other considerations therefor shall be
expressed therein.
(2) The time at which the insurance takes effect and terminates
shall be expressed therein.
(3) It shall purport to insure only one person, except that a
policy may insure, originally or by subsequent amendment, upon
the application of an adult member of a family who shall be
deemed the policyholder, any two or more eligible members of that
family, including husband, wife, dependent children or any
children under a specified age { - , which shall not exceed 19
years, - } and any other person dependent upon the policyholder.
(4) The policy may not be issued individually to an individual
in a group of persons as described in ORS 743.522 for the purpose
of separating the individual from health insurance benefits
offered or provided in connection with a group health benefit
plan.
(5) Except as provided in ORS 743.498, the style, arrangement
and overall appearance of the policy may not give undue
prominence to any portion of the text, and every printed portion
of the text of the policy and of any indorsements or attached
papers shall be plainly printed in lightfaced type of a style in
general use, the size of which shall be uniform and not less than
10 point with a lower case unspaced alphabet length not less than
120 point. Captions shall be printed in not less than 12-point
type. As used in this subsection, 'text' includes all printed
matter except the name and address of the insurer, name or title
of the policy, the brief description if any, and captions and
subcaptions.
(6) The exceptions and reductions of indemnity must be set
forth in the policy. Except those required by ORS 743.411 to
743.477 { - and 743A.160 - } , exceptions and reductions shall
be printed at the insurer's option either included with the
applicable benefit provision or under an appropriate caption such
as EXCEPTIONS, or EXCEPTIONS AND REDUCTIONS. However, if an
exception or reduction specifically applies only to a particular
benefit of the policy, a statement of the exception or reduction
must be included with the applicable benefit provision.
(7) Each form constituting the policy, including riders and
indorsements, must be identified by a form number in the lower
left-hand corner of the first page of the policy.
(8) The policy may not contain provisions purporting to make
any portion of the charter, rules, constitution or bylaws of the
insurer a part of the policy unless such portion is set forth in
full in the policy, except in the case of the incorporation of or
reference to a statement of rates or classification of risks, or
short rate table filed with the Director of the Department of
Consumer and Business Services.
SECTION 32. ORS 743.683 is amended to read:
743.683. (1) No Medicare supplement insurance policy, contract
or certificate in force in { - the - } { + this + } state
shall contain benefits { - which - } { + that + } duplicate
benefits provided by Medicare.
(2) The Director of the Department of Consumer and Business
Services shall adopt by rule specific standards for policy
provisions of Medicare supplement policies and certificates. The
standards shall be in addition to and in accordance with
applicable { + state and federal + } laws { - of this
state - } . No requirement of the Insurance Code relating to
minimum required policy benefits, other than the minimum
standards contained in ORS 743.680 to 743.689, shall apply to
Medicare supplement policies. The standards may cover, but not
be limited to:
(a) Terms of renewability;
(b) Initial and subsequent conditions of eligibility;
(c) Nonduplication of coverage;
(d) Probationary periods;
(e) Benefit limitations, exceptions and reductions;
(f) Elimination periods;
(g) Requirements for replacement;
(h) Recurrent conditions; and
(i) Definitions of terms.
(3) Provisions established by the director governing
eligibility for Medicare supplement insurance shall not be
limited to persons qualifying for Medicare by reason of age.
(4) The director may adopt by rule standards that specify
prohibited policy provisions not otherwise specifically
authorized by statute which, in the opinion of the director, are
unjust, unfair or unfairly discriminatory to any person insured
or proposed for coverage under a Medicare supplement policy.
(5) Notwithstanding any other provision of law of this state, a
Medicare supplement policy may not deny a claim for losses
incurred more than six months from the effective date of coverage
for a preexisting condition. The policy may not define a
preexisting condition more restrictively than a condition for
which medical advice was given or treatment was recommended by or
received from a physician within six months before the effective
date of coverage.
(6) The director shall adopt by rule standards for benefits and
claims payment under Medicare supplement policies.
SECTION 33. ORS 743.730 is amended to read:
743.730. For purposes of ORS 743.730 to 743.773:
(1) 'Actuarial certification' means a written statement by a
member of the American Academy of Actuaries or other individual
acceptable to the Director of the Department of Consumer and
Business Services that a carrier is in compliance with the
provisions of ORS 743.736, 743.760 or 743.761, based upon the
person's examination, including a review of the appropriate
records and of the actuarial assumptions and methods used by the
carrier in establishing premium rates for small employer and
portability health benefit plans.
(2) 'Affiliate' of, or person 'affiliated' with, a specified
person means any carrier who, directly or indirectly through one
or more intermediaries, controls or is controlled by or is under
common control with a specified person. For purposes of this
definition, 'control' has the meaning given that term in ORS
732.548.
(3) 'Affiliation period' means, under the terms of a group
health benefit plan issued by a health care service contractor, a
period:
(a) That is applied uniformly and without regard to any health
status related factors to an enrollee or late enrollee in lieu of
a preexisting { - conditions provision - } { + condition
exclusion + };
(b) That must expire before any coverage becomes effective
under the plan for the enrollee or late enrollee;
(c) During which no premium shall be charged to the enrollee or
late enrollee; and
(d) That begins on the enrollee's or late enrollee's first date
of eligibility for coverage and runs concurrently with any
eligibility waiting period under the plan.
(4) 'Basic health benefit plan' means a health benefit plan
{ - for small employers that is required to be offered by all
small employer carriers and approved by the Director of the
Department of Consumer and Business Services in accordance with
ORS 743.736 - } { + approved by the director under ORS
743.736 + }.
(5) 'Bona fide association' means an association that meets the
requirements of 42 U.S.C. { - 300gg-11 - } { + 300gg-91 + }
as amended and in effect on { - July 1, 1997 - } { + March
23, 2010 + }.
(6) 'Carrier { + , + } ' { + except as provided in ORS
743.760, + } means any person who provides health benefit plans
in this state, including a licensed insurance company, a health
care service contractor, a health maintenance organization, an
association or group of employers that provides benefits by means
of a multiple employer welfare arrangement or any other person or
corporation responsible for the payment of benefits or provision
of services.
{ - (7) 'Committee' means the Health Insurance Reform
Advisory Committee created under ORS 743.745. - }
{ - (8) - } { + (7) + } 'Creditable coverage' means prior
health care coverage as defined in 42 U.S.C. 300gg as amended and
in effect on
{ - July 1, 1997 - } { + February 17, 2009 + }, and includes
coverage remaining in force at the time the enrollee obtains new
coverage.
{ - (9) 'Department' means the Department of Consumer and
Business Services. - }
{ - (10) - } { + (8) + } 'Dependent' means the spouse or
child of an eligible employee, subject to applicable terms of the
health benefit plan covering the employee.
{ - (11) 'Director' means the Director of the Department of
Consumer and Business Services. - }
{ - (12) - } { + (9) + } 'Eligible employee' means an
employee { - of a small employer - } who works on a regularly
scheduled basis, with a normal work week of 17.5 or more hours.
The employer may determine hours worked for eligibility between
17.5 and 40 hours per week subject to rules of the carrier.
'Eligible employee' does not include employees who work on a
temporary, seasonal or substitute basis. Employees who have been
employed by the { - small - } employer for fewer than 90 days
are not eligible employees unless the
{ - small - } employer so allows.
{ - (13) - } { + (10) + } 'Employee' means any individual
employed by an employer.
{ - (14) - } { + (11) + } 'Enrollee' means an employee,
dependent of the employee or an individual otherwise eligible for
a group, individual or portability health benefit plan who has
enrolled for coverage under the terms of the plan.
{ - (15) - } { + (12) + } 'Exclusion period' means a period
during which specified treatments or services are excluded from
coverage.
{ - (16) - } { + (13) + } 'Financially impaired' means a
{ - member - } { + carrier + } that is not insolvent and is:
(a) Considered by the director { - of the Department of
Consumer and Business Services - } to be potentially unable to
fulfill its contractual obligations; or
(b) Placed under an order of rehabilitation or conservation by
a court of competent jurisdiction.
{ - (17)(a) - } { + (14)(a) + } 'Geographic average rate'
means the arithmetical average of the lowest premium and the
corresponding highest premium to be charged by a carrier in a
geographic area established by the director for the carrier's:
(A) { - Small employer - } Group health benefit plans;
(B) Individual health benefit plans; or
(C) Portability health benefit plans.
(b) 'Geographic average rate' does not include premium
differences that are due to differences in benefit design or
family composition.
{ - (18) - } { + (15) + } 'Group eligibility waiting
period' means, with respect to a group health benefit plan, the
period of employment or membership with the group that a
prospective enrollee must complete before plan coverage begins.
{ - (19)(a) - } { + (16)(a) + } 'Health benefit plan' means
any { + :
(A) + } Hospital expense, medical expense or hospital or
medical expense policy or certificate { - , - } { + ;
(B) + } Health care service contractor or health maintenance
organization subscriber contract { - , any - } { + ;
(C) Student health insurance policy; or
(D) + }Plan provided by a multiple employer welfare
arrangement or by another benefit arrangement defined in the
federal Employee Retirement Income Security Act of 1974, as
amended.
(b) 'Health benefit plan' does not include { + :
(A) + } Coverage for accident only, specific disease or
condition only, credit { - , - } { + or + } disability income
{ - , - } { + ;
(B) + } Coverage of Medicare services pursuant to contracts
with the federal government { - , - } { + ;
(C) + } Medicare supplement insurance policies { - , - }
{ + ;
(D) + } Coverage of CHAMPUS services pursuant to contracts with
the federal government { - , - } { + ;
(E) + } Benefits delivered through a flexible spending
arrangement established pursuant to section 125 of the Internal
Revenue Code of 1986, as amended, when the benefits are provided
in addition to a group health benefit plan { - , - } { + ;
(F) Separately offered + } long term care insurance, { +
including, but not limited to, coverage of nursing home care,
home health care and community-based care;
(G) + } { - hospital indemnity only, - } { + Independent,
noncoordinated, hospital-only indemnity insurance or other fixed
indemnity insurance;
(H) + } Short term health insurance policies { - (the
duration of which does not exceed six months including renewals),
student accident and health insurance policies, - } { + that
are in effect for periods of 12 months or less, including the
term of a renewal of the policy;
(I) + } Dental only { - , - } { + coverage;
(J) + } Vision only { - , - } { + coverage;
(K) + } { - a policy of - } Stop-loss coverage that meets
the requirements of ORS 742.065 { - , - } { + ;
(L) + } Coverage issued as a supplement to liability insurance
{ - , - } { + ;
(M) + } Insurance arising out of a workers' compensation or
similar law { - , - } { + ;
(N) + } Automobile medical payment insurance or insurance under
which benefits are payable with or without regard to fault and
that is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance { - . - } { + ;
or
(O) Any employee welfare benefit plan that is exempt from state
regulation because of the federal Employee Retirement Income
Security Act of 1974, as amended. + }
{ - (c) Nothing in this subsection shall be construed to
regulate any employee welfare benefit plan that is exempt from
state regulation because of the federal Employee Retirement
Income Security Act of 1974, as amended. - }
{ + (c) For purposes of this subsection, a short term health
insurance policy is renewed if an insurer issues a new short term
health insurance policy to a policyholder within 60 days after
the expiration of a policy previously issued by the insurer to
the policyholder. + }
{ - (20) - } { + (17) + } 'Health statement' means any
information that is intended to inform the carrier or insurance
producer of the health status of an enrollee or prospective
enrollee in a health benefit plan. 'Health statement' includes
the standard health statement { - developed by the Health
Insurance Reform Advisory Committee - } { + approved by the
director under ORS 743.745 + }.
{ + (18) 'Highly compensated individual' means a highly
compensated individual as defined in 26 U.S.C. 105 or as
otherwise defined, in a manner consistent with federal law, by
the director by rule. + }
{ - (21) 'Implementation of chapter 836, Oregon Laws 1989 '
means that the Health Services Commission has prepared a priority
list, the Legislative Assembly has enacted funding of the list
and all necessary federal approval, including waivers, has been
obtained. - }
{ - (22) - } { + (19) + } 'Individual coverage waiting
period' means a period in an individual health benefit plan
during which no premiums may be collected and health benefit plan
coverage issued is not effective.
{ - (23) - } { + (20) + } 'Initial enrollment period' means
a period of at least 30 days following commencement of the first
eligibility period for an individual.
{ - (24) - } { + (21) + } 'Late enrollee' means an
individual who enrolls in a group health benefit plan subsequent
to the initial enrollment period during which the individual was
eligible for coverage but declined to enroll. However, an
eligible individual shall not be considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg as amended and in effect on
{ - July 1, 1997 - } { + February 17, 2009 + };
(b) The individual applies for coverage during an open
enrollment period;
(c) A court has ordered that coverage be provided for a spouse
or minor child under { - a covered - } { + an + } employee's
{ + employer sponsored + } health benefit plan and request for
enrollment is made within 30 days after issuance of the court
order;
(d) The individual is employed by an employer { - who - }
{ + that + } offers multiple health benefit plans and the
individual elects a different health benefit plan during an open
enrollment period; or
(e) The individual's coverage under Medicaid, Medicare,
CHAMPUS, Indian Health Service or a publicly sponsored or
subsidized health plan, including { + , + } but not limited
to { + , + } the medical assistance program under ORS chapter
414, has been involuntarily terminated within 63 days
{ - of - } { + after + } applying for coverage in a group
health benefit plan.
{ - (25) - } { + (22) + } 'Multiple employer welfare
arrangement' means a multiple employer welfare arrangement as
defined in section 3 of the federal Employee Retirement Income
Security Act of 1974, as amended, 29 U.S.C. 1002, that is subject
to ORS 750.301 to 750.341.
{ - (26) - } { + (23) + } 'Oregon Medical Insurance Pool'
means the pool created under ORS 735.610.
{ - (27) - } { + (24) + } 'Preexisting { - conditions
provision - } { + condition exclusion + } ' means a health
benefit plan provision applicable to an enrollee or late enrollee
that excludes coverage for services, charges or expenses incurred
during a specified period immediately following enrollment for a
condition for which medical advice, diagnosis, care or treatment
was recommended or received during a specified period immediately
preceding enrollment. For purposes of ORS 743.730 to 743.773:
(a) Pregnancy does not constitute a preexisting condition
except as provided in ORS 743.766;
(b) Genetic information does not constitute a preexisting
condition in the absence of a diagnosis of the condition related
to such information; and
(c) { + Notwithstanding any other provision of law, except for
grandfathered health plan coverage of individuals, + } a
preexisting
{ - conditions provision shall - } { + condition exclusion
may + } not be applied to { - a newborn child or adopted child
who obtains coverage in accordance with ORS 743A.090 - } { + an
individual who is under 19 years of age + }.
{ - (28) - } { + (25) + } 'Premium' includes insurance
premiums or other fees charged for a health benefit plan,
including the costs of benefits paid or reimbursements made to or
on behalf of enrollees covered by the plan.
{ - (29) - } { + (26) + } 'Rating period' means the
12-month calendar period for which premium rates established by a
carrier are in effect, as determined by the carrier.
{ - (30)(a) - } { + (27)(a) + } 'Small employer' means an
employer that employed an average of at least two but not more
than 50 employees on business days during the preceding calendar
year, the majority of whom are employed within this state, and
that employs at least two eligible employees on the date on which
coverage takes effect under a health benefit plan { - issued by
a small employer carrier - } { + offered by the employer + }.
{ - (b) Any person that is treated as a single employer under
subsection (b), (c), (m) or (o) of section 414 of the Internal
Revenue Code of 1986 shall be treated as one employer for
purposes of this subsection. - }
{ - (c) - } { + (b) + } The determination of whether an
employer that was not in existence throughout the preceding
calendar year is a small employer shall be based on the average
number of employees that it is reasonably expected the employer
will employ on business days in the current calendar year.
{ - (31) 'Small employer carrier' means any carrier that
offers health benefit plans covering eligible employees of one or
more small employers. A fully insured multiple employer welfare
arrangement otherwise exempt under ORS 750.303 (4) may elect to
be a small employer carrier governed by the provisions of ORS
743.733 to 743.737. - }
SECTION 34. ORS 743.731 is amended to read:
743.731. The purposes of ORS 743.730 to 743.773 are:
(1) To promote the availability of health insurance coverage to
groups regardless of their enrollees' health status or claims
experience;
(2) To prevent abusive rating practices;
(3) To require disclosure of rating practices to purchasers of
small employer, portability and individual health benefit plans;
(4) To establish limitations on the use of preexisting
{ - conditions provisions - } { + condition exclusions + };
(5) To make basic health benefit plans available to all small
employers;
(6) To encourage the availability of portability and individual
health benefit plans for individuals who are not enrolled in
group health benefit plans;
(7) To improve renewability and continuity of coverage for
employers and covered individuals;
(8) To improve the efficiency and fairness of the health
insurance marketplace; and
(9) To ensure that health insurance coverage in Oregon
satisfies the requirements of the Health Insurance Portability
and Accountability Act of 1996 (P.L. 104-191) { + and the
Patient Protection and Affordable Care Act (P.L. 111-148) as
amended by the Health Care and Education Reconciliation Act (P.L.
111-152), + } and that enforcement authority for those
requirements is retained by the Director of the Department of
Consumer and Business Services.
SECTION 35. ORS 743.733 is amended to read:
743.733. (1) If an affiliated group of employers is treated as
a single employer under subsection (b), (c), (m) or (o) of
section 414 of the Internal Revenue Code of 1986, a carrier may
issue a single group health benefit plan to the affiliated group
on the basis of the number of employees in the affiliated group
if the group requests such coverage.
(2) If a { - small employer - } carrier determines that an
employer has more than 50 employees, the carrier may provide a
quote for a group health benefit plan that is not subject to ORS
743.733 to 743.737. If the employer's workforce consists of at
least two but not more than 50 eligible employees, the
{ - small group - } carrier shall inform the employer that if
coverage is limited to the eligible employees, the carrier must
treat the employer as a small employer and shall provide a
separate quote on that basis.
(3) Subsequent to the issuance of a health benefit plan to a
small employer, a { - small employer - } carrier shall
determine annually the number of employees of the employer for
purposes of determining the employer's ongoing eligibility as a
small employer. The provisions of ORS 743.733 to 743.737 shall
continue to apply to a health benefit plan issued to a small
employer until the plan anniversary date following the date the
employer no longer meets the definition of a small employer.
SECTION 36. Section 13, chapter 752, Oregon Laws 2007, as
amended by section 4, chapter 81, Oregon Laws 2010, is amended to
read:
{ + Sec. 13. + } The amendments to ORS 731.146, 731.484,
731.486, 743.734 and 743.748 by sections 6 to 8 and 10, chapter
752, Oregon Laws 2007, { - and - } section 3 { + , chapter 81,
Oregon Laws 2010, and sections 9, 39 and 44 of this 2011 Act + }
{ - of this 2010 Act - } become operative on January 2, 2014.
SECTION 37. { + Section 12, chapter 752, Oregon Laws 2007, is
repealed. + }
SECTION 38. ORS 743.734, as amended by section 9, chapter 752,
Oregon Laws 2007, and section 2, chapter 81, Oregon Laws 2010, is
amended to read:
743.734. (1) Every { - group - } health benefit plan shall
be subject to the provisions of ORS 743.733 to 743.737, if the
plan provides health benefits covering one or more employees of a
small employer and if any one of the following conditions is met:
(a) Any portion of the premium or benefits is paid by a small
employer or any eligible employee is reimbursed, whether through
wage adjustments or otherwise, by a small employer for any
portion of the health benefit plan premium; or
(b) The health benefit plan is treated by the employer or any
of the eligible employees as part of a plan or program for the
purposes of section 106, section 125 or section 162 of the
Internal Revenue Code of 1986, as amended.
(2) Except as provided in ORS 743.733 to 743.737 { + and
section 3 of this 2011 Act + }, no { + state + } law requiring
the coverage or the offer of coverage of a health care service or
benefit applies to the basic health benefit plans offered or
delivered to a small employer.
(3) Except as otherwise provided by law or ORS 743.733 to
743.737, no health benefit plan offered to a small employer
shall:
(a) Inhibit a { - small employer - } carrier from
contracting with providers or groups of providers with respect to
health care services or benefits; or
(b) Impose any restriction on the ability of a { - small
employer - } carrier to negotiate with providers regarding the
level or method of reimbursing care or services provided under
health benefit plans.
(4) Except to determine the application of a preexisting
{ - conditions provision - } { + condition exclusion + } for
a late enrollee { + who is 19 years of age or older + }, a
{ - small employer - } carrier shall not use health statements
when offering small employer health benefit plans and shall not
use any other method to determine the actual or expected health
status of eligible enrollees. Nothing in this subsection shall
prevent a carrier from using health statements or other
information after enrollment for the purpose of providing
services or arranging for the provision of services under a
health benefit plan.
(5) Except { - in the case of a late enrollee and as
otherwise provided in this section - } { + as provided in this
section and ORS 743.737 + }, a { - small employer - } carrier
shall not impose different terms or conditions on the coverage,
premiums or contributions of any eligible employee { - in - }
{ + of + } a small employer { - group - } that are based on
the actual or expected health status of any eligible employee.
(6) { + (a) + } A { - small employer - } carrier may provide
different health benefit plans to different categories of
employees of a small employer { + that has at least 26 but no
more than 50 eligible employees + } when the employer has chosen
to establish different categories of employees in a manner that
does not relate to the actual or expected health status of such
employees or their dependents. The categories must be based on
bona fide employment-based classifications that are consistent
with the employer's usual business practice { + and may not
discriminate in favor of highly compensated individuals + }.
{ - Except as provided in ORS 743.736 (10): - }
{ - (a) - } { + (b) + } { - When - } { + Except as
provided in ORS 743.736 (8), + } a
{ - small employer - } carrier { + that + } offers coverage
to a small employer with no more than 25 eligible employees
{ - , the small employer carrier - } shall offer coverage to
all eligible employees of the small employer, without regard to
the actual or expected health status of any eligible employee.
{ - (b) When a small employer carrier offers coverage to a
small employer with at least 26 but not more than 50 eligible
employees, the small employer carrier may limit coverage to the
categories of employees that the small employer has established
as eligible for coverage, provided that the categories are based
on bona fide employment-based classifications that are consistent
with the employer's usual business practice. - }
(c) If { - the - } { + a + } small employer elects to offer
coverage to dependents of eligible employees, the { - small
employer - } carrier shall offer coverage to all dependents of
eligible employees, without regard to the actual or expected
health status of any eligible dependent.
(7) A health benefit plan issued to a small employer group
through an association health plan is exempt from subsection (1)
of this section. For purposes of this subsection, an association
health plan is group health insurance described in ORS 743.522
(2) or a health benefit plan that:
(a) Is delivered or issued for delivery to:
(A) An association or trust established in this state, that
meets applicable requirements of ORS 743.524 or 743.526, or to a
multiple employer welfare arrangement located inside this state,
subject to ORS 750.301 to 750.341; or
(B) An association or trust established in another state, that
is approved by the Director of the Department of Consumer and
Business Services under ORS 731.486 (7), or a multiple employer
welfare arrangement located in another state that complies with
ORS 750.311; and
(b) Satisfies all of the following:
(A) The initial premium rate for the association health plan
does not vary by more than 50 percent across the groups of small
employers under the plan.
(B) The association policyholder does not discriminate in
membership requirements based on actual or expected health status
of individual enrollees or prospective enrollees, in accordance
with ORS 743.752 (5).
(C) Small employer groups that have two or more eligible
employees and that meet the membership requirements for the
association are not excluded from the association health plan.
(D) Except as provided in subsection (8) of this section, the
association health plan maintains a 95 percent retention rate.
(8)(a) The 95 percent retention rate in subsection (7) of this
section does not include employer groups that:
(A) Go out of business, whether through merger, acquisition or
any other reason;
(B) No longer meet eligibility requirements for membership in
the association, including failure to pay association dues;
(C) No longer meet participation requirements for employers
that are set forth in the plan documents; or
(D) Fail to pay premiums.
(b) An association health plan that fails to maintain the 95
percent retention rate during any year may have 12 months to
correct the retention level before losing the exemption under
subsection (7) of this section.
(c) The director may exempt an association health plan from the
95 percent retention rate requirement in subsection (7) of this
section according to criteria prescribed by the director by rule.
{ + (9) Notwithstanding any other provision of law, an
insurer may not deny, delay or terminate participation of an
individual in a health benefit plan or exclude coverage otherwise
provided to an individual under a plan, other than a
grandfathered health plan, based on a preexisting condition of
the individual if the individual is under 19 years of age. + }
SECTION 39. ORS 743.734, as amended by section 9, chapter 752,
Oregon Laws 2007, sections 2 and 3, chapter 81, Oregon Laws 2010,
and section 38 of this 2011 Act, is amended to read:
743.734. (1) Every { - group - } health benefit plan shall
be subject to the provisions of ORS 743.733 to 743.737, if the
plan provides health benefits covering one or more employees of a
small employer and if any one of the following conditions is met:
(a) Any portion of the premium or benefits is paid by a small
employer or any eligible employee is reimbursed, whether through
wage adjustments or otherwise, by a small employer for any
portion of the health benefit plan premium; or
(b) The health benefit plan is treated by the employer or any
of the eligible employees as part of a plan or program for the
purposes of section 106, section 125 or section 162 of the
Internal Revenue Code of 1986, as amended.
(2) Except as provided in ORS 743.733 to 743.737 { + and
section 3 of this 2011 Act + }, no { + state + } law requiring
the coverage or the offer of coverage of a health care service or
benefit applies to the basic health benefit plans offered or
delivered to a small employer.
(3) Except as otherwise provided by law or ORS 743.733 to
743.737, no health benefit plan offered to a small employer
shall:
(a) Inhibit a { - small employer - } carrier from
contracting with providers or groups of providers with respect to
health care services or benefits; or
(b) Impose any restriction on the ability of a { - small
employer - } carrier to negotiate with providers regarding the
level or method of reimbursing care or services provided under
health benefit plans.
(4) Except to determine the application of a preexisting
{ - conditions provision - } { + condition exclusion + } for
a late enrollee { + who is 19 years of age or older + }, a
{ - small employer - } carrier shall not use health statements
when offering small employer health benefit plans and shall not
use any other method to determine the actual or expected health
status of eligible enrollees. Nothing in this subsection shall
prevent a carrier from using health statements or other
information after enrollment for the purpose of providing
services or arranging for the provision of services under a
health benefit plan.
(5) Except { - in the case of a late enrollee and as
otherwise provided in this section - } { + as provided in this
section and ORS 743.737 + }, a { - small employer - } carrier
shall not impose different terms or conditions on the coverage,
premiums or contributions of any eligible employee { - in - }
{ + of + } a small employer { - group - } that are based on
the actual or expected health status of any eligible employee.
(6) { + (a) + } A { - small employer - } carrier may provide
different health benefit plans to different categories of
employees of a small employer { + that has at least 26 but no
more than 50 eligible employees + } when the employer has chosen
to establish different categories of employees in a manner that
does not relate to the actual or expected health status of such
employees or their dependents. The categories must be based on
bona fide employment-based classifications that are consistent
with the employer's usual business practice { + and may not
discriminate in favor of highly compensated individuals + }.
{ - Except as provided in ORS 743.736 (10): - }
{ - (a) - } { + (b) + } { - When - } { + Except as
provided in ORS 743.736 (8), + } a
{ - small employer - } carrier { + that + } offers coverage
to a small employer with no more than 25 eligible employees
{ - , the small employer carrier - } shall offer coverage to
all eligible employees of the small employer, without regard to
the actual or expected health status of any eligible employee.
{ - (b) When a small employer carrier offers coverage to a
small employer with at least 26 but not more than 50 eligible
employees, the small employer carrier may limit coverage to the
categories of employees that the small employer has established
as eligible for coverage, provided that the categories are based
on bona fide employment-based classifications that are consistent
with the employer's usual business practice. - }
(c) If { - the - } { + a + } small employer elects to offer
coverage to dependents of eligible employees, the { - small
employer - } carrier shall offer coverage to all dependents of
eligible employees, without regard to the actual or expected
health status of any eligible dependent.
{ + (7) Notwithstanding any other provision of law, an
insurer may not deny, delay or terminate participation of an
individual in a health benefit plan or exclude coverage otherwise
provided to an individual under a plan, other than a
grandfathered health plan, based on a preexisting condition of
the individual if the individual is under 19 years of age. + }
SECTION 40. ORS 743.736 is amended to read:
743.736. { - (1) In order to improve the availability and
affordability of health benefit coverage for small employers, the
Health Insurance Reform Advisory Committee created under ORS
743.745 shall submit to the Director of the Department of
Consumer and Business Services two basic health benefit plans
pursuant to ORS 743.745. One plan shall be in the form of
insurance and the second plan shall be consistent with the
requirements of the federal Health Maintenance Organization Act,
42 U.S.C. 300e et seq. - }
{ - (2)(a) The director shall approve the basic health
benefit plans following a determination that the plans provide
for maximum accessibility and affordability of needed health care
services and following a determination that the basic health
benefit plans substantially meet the social values that underlie
the ranking of benefits by the Health Services Commission and
that the basic health benefit plans are substantially similar to
the Medicaid reform program under chapter 836, Oregon Laws 1989,
funded by the Legislative Assembly. - }
{ - (b) The basic health benefit plans shall include benefits
mandated under ORS 743A.168 until mental health, alcohol and
chemical dependency services are fully integrated into the Health
Services Commission's priority list, and as funded by the
Legislative Assembly, and chapter 836, Oregon Laws 1989, is
implemented. - }
{ - (c) The commission shall aid the director by reviewing
the basic health benefit plans and commenting on the extent to
which the plans meet these criteria. - }
{ - (3) - } { + (1) + } { - After the director's approval
of the basic health benefit plans submitted by the committee
pursuant to subsection (1) of this section, each small
employer - } { + A + } carrier shall submit to the Director
{ + of the Department of Consumer and Business Services, for
approval in accordance with ORS 742.003, + } the policy form or
forms containing its basic health benefit plan. { - Each policy
form must be submitted as prescribed by the director and is
subject to review and approval pursuant to ORS 742.003. - }
{ - (4)(a) As a condition of transacting business in the
small employer health insurance market in this state, every small
employer carrier shall offer small employers an approved basic
health benefit plan and any other plans that have been submitted
by the small employer carrier for use in the small employer
market and approved by the director. - }
{ - (b) Nothing in this subsection shall require a small
employer carrier to resubmit small employer health benefit plans
that were approved by the director prior to October 1, 1996, nor
shall small employer carriers be required to reinitiate new plan
selection procedures for currently enrolled small employers prior
to the small employer's next health benefit plan coverage
anniversary date. - }
{ - (c) - } { + (2) + } A carrier that offers a health
benefit plan in the small employer market only through one or
more bona fide associations is not required to offer that health
benefit plan to small employers that are not members of the bona
fide association.
{ - (5) - } { + (3) + } { - A small employer - } { +
A + } carrier shall issue to a small employer any { - small
employer - } health benefit plan { + , including a basic health
benefit plan, that is + } offered by the carrier if the small
employer applies for the plan and agrees to make the required
premium payments and to satisfy the other provisions of the
health benefit plan.
{ - (6) - } { + (4) + } A multiple employer welfare
arrangement, professional or trade association or other similar
arrangement established or maintained to provide benefits to a
particular trade, business, profession or industry or their
subsidiaries shall not issue coverage to a group or individual
that is not in the same trade, business, profession or industry
as that covered by the arrangement. The arrangement shall accept
all groups and individuals in the same trade, business,
profession or industry or their subsidiaries that apply for
coverage under the arrangement and that meet the requirements for
membership in the arrangement. For purposes of this subsection,
the requirements for membership in an arrangement shall not
include any requirements that relate to the actual or expected
health status of the prospective enrollee.
{ - (7) - } { + (5) + } { - A small employer - } { +
A + } carrier shall, pursuant to
{ - subsections (4) and (5) - } { + subsection (3) + }of
this section, { - offer coverage to or accept applications from
a - } { + accept applications from and offer coverage to a
small employer + } group covered under an existing { - small
employer - } health benefit plan { + regardless of + } whether
{ - or not - } a prospective enrollee is excluded from coverage
under the existing plan because of late enrollment. When a
{ - small employer - } carrier accepts an application for
{ - such - } a { + small employer + } group, the carrier may
continue to exclude the prospective enrollee excluded from
coverage by the replaced plan until the prospective enrollee
would have become eligible for coverage under that replaced plan.
{ - (8) - } { + (6) + } { - No small employer carrier
shall be required to offer coverage or accept applications
pursuant to subsections (4) and (5) - } { + A carrier is not
required to accept applications from and offer coverage pursuant
to subsection (3) + } of this section if the director finds that
acceptance of an application or applications would endanger the
carrier's ability to fulfill its contractual obligations or
result in financial impairment of the carrier.
{ - (9) - } { + (7) + } { - Every small employer - }
{ + A + } carrier shall market fairly all { - small
employer - } health benefit plans { + in which a small employer
is legally eligible to enroll and that are not grandfathered
health plans, including basic health benefit plans, that are + }
offered by the carrier to small employers in the geographical
areas in which the carrier makes coverage available or provides
benefits.
{ - (10)(a) - } { + (8)(a) + } { - No small employer
carrier shall be - } { + A carrier is not + }required to { +
accept applications from or + } offer coverage { - or accept
applications - } pursuant to { - subsections (4) and (5) - }
{ + subsection (3) + } of this section { - in the case of any
of the following - } :
(A) To a small employer if the small employer is not physically
located in the carrier's approved service area;
(B) To an employee { + of a small employer + } if the employee
does not work or reside within the carrier's approved service
areas; or
(C) Within an area where the carrier reasonably anticipates,
and demonstrates to the satisfaction of the director, that it
will not have the capacity in its network of providers to deliver
services adequately to the enrollees of those groups because of
its obligations to existing group contract holders and enrollees.
(b) A carrier that does not offer coverage pursuant to
paragraph (a)(C) of this subsection shall not offer coverage in
the applicable service area to new employer groups other than
small employers until the carrier resumes enrolling groups of new
small employers in the applicable area.
{ - (11) - } { + (9) + } For purposes of ORS 743.733 to
743.737, except as provided in this subsection, carriers that are
affiliated carriers or that are eligible to file a consolidated
tax return pursuant to ORS 317.715 shall be treated as one
carrier and any restrictions or limitations imposed by ORS
743.733 to 743.737 apply as if all health benefit plans delivered
or issued for delivery to small employers in this state by the
affiliated carriers were issued by one carrier. However, any
insurance company or health maintenance organization that is an
affiliate of a health care service contractor located in this
state, or any health maintenance organization located in this
state that is an affiliate of an insurance company or health care
service contractor, may treat the health maintenance organization
as a separate carrier and each health maintenance organization
that operates only one health maintenance organization in a
service area in this state may be considered a separate carrier.
{ - (12) - } { + (10) + } { - A small employer - } { +
A + } carrier that { - , after September 29, 1991, - } elects
to discontinue offering all of its
{ - small employer - } health benefit plans { + to small
employers + } under ORS 743.737 { - (5)(e) - } { +
(6)(e) + }, elects to discontinue renewing all such plans or
elects to discontinue offering and renewing all such plans is
prohibited from offering health benefit plans { - in the small
employer market - } { + to small employers + } in this state
for a period of five years from one of the following dates:
(a) The date of notice to the director pursuant to ORS 743.737
{ - (5)(e) - } { + (6)(e) + }; or
(b) If notice is not provided under paragraph (a) of this
subsection, from the date on which the director provides notice
to the carrier that the director has determined that the carrier
has effectively discontinued offering { - small employer - }
health benefit plans { + to small employers + } in this state.
SECTION 41. ORS 743.737 is amended to read:
743.737. { - Health benefit plans covering small employers
shall be subject to the following provisions: - }
(1) A preexisting { - conditions provision - } { +
condition exclusion + } in a small employer health benefit plan
shall apply only to a condition for which medical advice,
diagnosis, care or treatment was recommended or received during
the six-month period immediately preceding the enrollment date of
an enrollee or late enrollee. As used in this section, the
enrollment date of an enrollee shall be the earlier of the
effective date of coverage or the first day of any required group
eligibility waiting period and the enrollment date of a late
enrollee shall be the effective date of coverage.
(2) A preexisting { - conditions provision - } { +
condition exclusion + } in a small employer health benefit plan
shall { - terminate its effect - } { + expire + } as follows:
(a) For an enrollee, { - not later than the first of - }
{ + on the earlier of + } the following dates:
(A) Six months { - following - } { + after + } the
enrollee's effective date of coverage; or
(B) Ten months { - following - } { + after + } the start of
any required group eligibility waiting period.
(b) For a late enrollee, not later than 12 months
{ - following - } { + after + } the late enrollee's effective
date of coverage.
(3) In applying a preexisting { - conditions provision - }
{ + condition exclusion + } to an enrollee or late enrollee,
except as provided in this subsection, all small employer health
benefit plans shall reduce the duration of the provision by an
amount equal to the enrollee's or late enrollee's aggregate
periods of creditable coverage if the most recent period of
creditable coverage is ongoing or ended within 63 days
{ - of - } { + after + } the enrollment date in the new small
employer health benefit plan. The crediting of prior coverage in
accordance with this subsection shall be applied without regard
to the specific benefits covered during the prior period. This
subsection does not preclude, within a small employer health
benefit plan, application of:
(a) An affiliation period that does not exceed two months for
an enrollee or three months for a late enrollee; or
(b) An exclusion period for specified covered services, as
established { - by the Health Insurance Reform Advisory
Committee - } { + under ORS 743.745 + }, applicable to all
individuals enrolling for the first time in the small employer
health benefit plan.
{ + (4) A health benefit plan issued to a small employer may
not apply a preexisting condition exclusion to a person under 19
years of age. + }
{ - (4) - } { + (5) + } Late enrollees { + in a small
employer health benefit plan who are 19 years of age or older
+ }may be { - excluded from coverage - } { + denied
enrollment + } for up to 12 months or may be subjected to a
preexisting { - conditions provision - } { + condition
exclusion + } for up to 12 months. If both { - an exclusion
from coverage period - } { + a denial of enrollment + } and a
preexisting { - conditions provision - } { + condition
exclusion + } are applicable to a late enrollee, the combined
period shall not exceed 12 months.
{ - (5) - } { + (6) + } Each small employer health benefit
plan shall be renewable with respect to all eligible enrollees at
the option of the policyholder, small employer or contract holder
{ - except - } { + unless + }:
(a) { - For nonpayment of the required premiums by - } The
policyholder, small employer or contract holder { + fails to pay
the required premiums + }.
(b) { - For fraud or misrepresentation of - } The
policyholder, small employer or contract holder or, with respect
to coverage of individual enrollees, { - the enrollees or their
representatives - } { + an enrollee or a representative of an
enrollee engages in fraud or makes an intentional
misrepresentation of a material fact as prohibited by the terms
of the plan + }.
(c) { - When - } The number of enrollees covered under the
plan is less than the number or percentage of enrollees required
by participation requirements under the plan.
(d) { - For noncompliance with - } The small employer
{ - carrier's employer - } { + fails to comply with the + }
contribution requirements under the health benefit plan.
(e) { - When - } The carrier discontinues offering or
renewing, or offering and renewing, all of its small employer
health benefit plans in this state or in a specified service area
within this state. In order to discontinue plans under this
paragraph, the carrier:
(A) Must give notice of the decision to the { - Director of
the - } Department of Consumer and Business Services and to all
policyholders covered by the plans;
(B) May not cancel coverage under the plans for 180 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in the entire state or,
except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel coverage under the plans for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in a specified service area
because of an inability to reach an agreement with the health
care providers or organization of health care providers to
provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and
renewing, all health benefit plans issued by the carrier in the
small employer market in this state or in the specified service
area.
(f) { - When - } The carrier discontinues offering and
renewing a small employer health benefit plan in a specified
service area within this state because of an inability to reach
an agreement with the health care providers or organization of
health care providers to provide services under the plan within
the service area. In order to discontinue a plan under this
paragraph, the carrier:
(A) Must give notice to the { - director - } { +
department + } and to all policyholders covered by the plan;
(B) May not cancel coverage under the plan for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph; and
(C) Must offer in writing to each small employer covered by the
plan, all other small employer health benefit plans { + that a
small employer is legally eligible to purchase and + } that the
carrier offers { + to small employers + } in the specified
service area. The carrier shall issue any such plans pursuant to
the provisions of ORS 743.733 to 743.737. The carrier shall offer
the plans at least 90 days prior to discontinuation.
(g) { - When - } The carrier discontinues offering or
renewing, or offering and renewing, a health benefit plan for all
small employers in this state or in a specified service area
within this state, other than a plan discontinued under paragraph
(f) of this subsection { + or a grandfathered health plan + }.
With respect to plans that are being discontinued, the carrier
must:
(A) Offer in writing to each small employer covered by the
plan, all health benefit plans { + that a small employer is
legally eligible to purchase and + } that the carrier offers
{ + to small employers + } in the specified service area.
(B) Issue any such plans pursuant to the provisions of ORS
743.733 to 743.737.
(C) Offer the plans at least 90 days prior to discontinuation.
(D) Act uniformly without regard to the claims experience of
the affected policyholders or the health status of any current or
prospective enrollee.
(h) { - When - } The Director { + of the Department of
Consumer and Business Services + } orders the carrier to
discontinue coverage in accordance with procedures specified or
approved by the director upon finding that the continuation of
the coverage would:
(A) Not be in the best interests of the enrollees; or
(B) Impair the carrier's ability to meet contractual
obligations.
(i) { - When, - } In the case of a small employer health
benefit plan that delivers covered services through a specified
network of health care providers, there is no longer any enrollee
who lives, resides or works in the service area of the provider
network.
(j) { - When, - } In the case of a health benefit plan that
is offered in the small employer market only through one or more
bona fide associations, the membership of an employer in the
association ceases and the termination of coverage is not related
to the health status of any enrollee.
{ - (k) For misuse of a provider network provision. As used
in this paragraph, 'misuse of a provider network provision' means
a disruptive, unruly or abusive action taken by an enrollee that
threatens the physical health or well-being of health care staff
and seriously impairs the ability of the carrier or its
participating providers to provide services to an enrollee. An
enrollee under this paragraph retains the rights of an enrollee
under ORS 743.804. - }
{ - (L) - } { + (6) + } A { - small employer - } carrier
may modify a small employer health benefit plan at the time of
coverage renewal. The modification is not a discontinuation of
the plan under
{ - paragraphs (e) and (g) of this - } subsection { + (5)(e)
and (g) of this section + }.
{ - (6) - } { + (7) + } Notwithstanding any provision of
subsection { - (5) - } { + (6) + } of this section to the
contrary, { + a carrier may rescind + } any small employer
{ - carrier - } health benefit plan { + , or the coverage of an
enrollee under a plan, + } subject to the provisions of ORS
743.733 to 743.737 { - may be rescinded by a small employer
carrier for fraud, material misrepresentation or concealment by a
small employer and the coverage of an enrollee may be rescinded
for fraud, material misrepresentation or concealment by the
enrollee. - } { + if the small employer or the enrollee:
(a) Performs an act, practice or omission that constitutes
fraud; or
(b) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the plan. + }
{ - (7) - } { + (8) + } A { - small employer - } carrier
may continue to enforce reasonable employer participation and
contribution requirements on small employers applying for
coverage. However, participation and contribution requirements
shall be applied uniformly among all small employer groups with
the same number of eligible employees applying for coverage or
receiving coverage from the { - small employer - } carrier. In
determining minimum participation requirements, a carrier shall
count only those employees who are not covered by an existing
group health benefit plan, Medicaid, Medicare, CHAMPUS, Indian
Health Service or a publicly sponsored or subsidized health plan,
including but not limited to the medical assistance program under
ORS chapter 414.
{ - (8) - } { + (9) + } Premium rates for small employer
health benefit plans shall be subject to the following
provisions:
(a) Each { - small employer - } carrier issuing health
benefit plans to small employers must file its geographic average
rate for a rating period with the { - director - }
{ + department + } at least once every 12 months.
(b)(A) The premium rates charged during a rating period for
health benefit plans issued to small employers may not vary from
the geographic average rate by more than 50 percent on or after
January 1, 2008, except as provided in subparagraph (D) of this
paragraph.
(B) The variations in premium rates described in subparagraph
(A) of this paragraph shall be based solely on the factors
specified in subparagraph (C) of this paragraph. A { - small
employer - } carrier may elect which of the factors specified in
subparagraph (C) of this paragraph apply to premium rates for
{ + health benefit plans for + } small employers. The factors
that are based on contributions or participation may vary with
the size of the employer. All other factors must be applied in
the same actuarially sound way to all small { - employers - }
{ + employer health benefit plans + }.
(C) The variations in premium rates described in subparagraph
(A) of this paragraph may be based on one or more of the
following factors:
(i) The ages of enrolled employees and their dependents;
(ii) The level at which the small employer contributes to the
premiums payable for enrolled employees and their dependents;
(iii) The level at which eligible employees participate in the
health benefit plan;
(iv) The level at which enrolled employees and their dependents
engage in tobacco use;
(v) The level at which enrolled employees and their dependents
engage in health promotion, disease prevention or wellness
programs;
(vi) The period of time during which a small employer retains
uninterrupted coverage in force with the same { - small
employer - } carrier; and
(vii) Adjustments to reflect the provision of benefits not
required to be covered by the basic health benefit plan and
differences in family composition.
(D)(i) The premium rates determined in accordance with this
paragraph may be further adjusted by a { - small employer - }
carrier to reflect the expected claims experience of { - a - }
{ + the covered + } small employer, but the extent of this
adjustment may not exceed five percent of the annual premium rate
otherwise payable by the small employer. The adjustment under
this subparagraph may not be cumulative from year to year.
(ii) { - Except for small employers with 25 or fewer
employees, - } The premium rates adjusted under this
subparagraph { + , except rates for small employers with 25 or
fewer employees, + } are not subject to the provisions of
subparagraph (A) of this paragraph.
(E) A { - small employer - } carrier shall apply the
carrier's schedule of premium rate variations as approved by
{ - the Director of - } the department { - of Consumer and
Business Services - } and in accordance with this paragraph.
Except as otherwise provided in this section, the premium rate
established { + by a carrier + } for a { + small employer + }
health benefit plan { - by a small employer carrier - } shall
apply uniformly to all employees of the small employer enrolled
in that plan.
(c) Except as provided in paragraph (b) of this subsection, the
variation in premium rates between different { - small
employer - } health benefit plans offered by a { - small
employer - } carrier { + to small employers + } must be based
solely on objective differences in plan design or coverage and
must not include differences based on the risk characteristics of
groups assumed to select a particular health benefit plan.
(d) A { - small employer - } carrier may not increase the
rates of a health benefit plan issued to a small employer more
than once in a 12-month period. Annual rate increases shall be
effective on the plan anniversary date of the health benefit plan
issued to a small employer. The percentage increase in the
premium rate charged to a small employer for a new rating period
may not exceed the sum of the following:
(A) The percentage change in the geographic average rate
measured from the first day of the prior rating period to the
first day of the new period; and
(B) Any adjustment attributable to changes in age, except an
additional adjustment may be made to reflect the provision of
benefits not required to be covered by the basic health benefit
plan and differences in family composition.
(e) Premium rates for { + small employer + } health benefit
plans shall comply with the requirements of this section.
{ - (9) - } { + (10) + } In connection with the offering
for sale of any health benefit plan to a small employer, each
{ - small employer - } carrier shall make a reasonable
disclosure as part of its solicitation and sales materials of:
(a) The full array of health benefit plans that are offered to
small employers by the carrier;
(b) The authority of the carrier to adjust rates, and the
extent to which the carrier will consider age, family composition
and geographic factors in establishing and adjusting rates;
(c) Provisions relating to renewability of policies and
contracts; and
(d) Provisions affecting any preexisting { - conditions
provision - } { + condition exclusion + }.
{ - (10)(a) - } { + (11)(a) + } Each { - small
employer - } carrier shall maintain at its principal place of
business a complete and detailed description of its rating
practices and renewal underwriting practices { + relating to its
small employer health benefit plans + }, including information
and documentation that demonstrate that its rating methods and
practices are based upon commonly accepted actuarial practices
and are in accordance with sound actuarial principles.
(b) { - Each small employer - } { + A + } carrier
{ + offering a small employer health benefit plan + } shall file
with the { - director - } { + department + } at least once
every 12 months an actuarial certification that the carrier is in
compliance with ORS 743.733 to 743.737 and that the rating
methods of the { - small employer - } carrier are actuarially
sound. Each { - such - } certification shall be in a uniform
form and manner and shall contain such information as specified
by the
{ - director - } { + department + }. A copy of { - such - }
{ + each + } certification shall be retained by the { - small
employer - } carrier at its principal place of business.
(c) A { - small employer - } carrier shall make the
information and documentation described in paragraph (a) of this
subsection available to the { - director - } { +
department + } upon request. Except as provided in ORS 743.018
and except in cases of violations of ORS 743.733 to 743.737, the
information shall be considered proprietary and trade secret
information and shall not be subject to disclosure { - by the
director - } to persons outside the department
{ - of Consumer and Business Services - } except as agreed to
by the
{ - small employer - } carrier or as ordered by a court of
competent jurisdiction.
{ - (11) - } { + (12) + } A { - small employer - }
carrier shall not provide any financial or other incentive to any
insurance producer that would encourage the insurance producer to
market and sell health benefit plans of the carrier to small
employer groups based on a small employer group's anticipated
claims experience.
{ - (12) - } { + (13) + } For purposes of this section, the
date a small employer health benefit plan is continued shall be
the anniversary date of the first issuance of the health benefit
plan.
{ - (13) - } { + (14) + } A { - small employer - }
carrier must include a provision that offers coverage to all
eligible employees { + of a small employer + } and to all
dependents { + of the eligible employees + } to the extent the
employer chooses to offer coverage to dependents.
{ - (14) - } { + (15) + } All small employer health benefit
plans shall contain special enrollment periods during which
eligible employees and dependents may enroll for coverage, as
provided in 42 U.S.C. 300gg as amended and in effect on
{ - July 1, 1997 - } { + February 17, 2009 + }.
{ + (16) A group health benefit plan may not impose lifetime
dollar limits on the essential health benefits prescribed by the
United States Secretary of Health and Human Services pursuant to
42 U.S.C. 300gg-11. + }
SECTION 42. ORS 743.745 is amended to read:
743.745. { + (1) + } The Director of the Department of
Consumer and Business Services shall { - appoint a Health
Insurance Reform Advisory Committee. This committee shall consist
of at least one insurance producer, one representative of a
health maintenance organization, one representative of a health
care service contractor, one representative of a domestic
insurer, one representative of a labor organization and one
representative of consumer interests and shall have
representation from the broad range of interests involved in the
small employer and individual market and shall include members
with the technical expertise necessary to carry out the following
duties: - }
{ - (1)(a) Subject to approval by the director, the committee
shall recommend - } { + determine + } the form and level of
coverages under the basic health benefit plans pursuant to ORS
743.736 to be made available by { - small employer - }
carriers and the portability health benefit plans to be made
available pursuant to ORS 743.760 or 743.761. The { - committee
shall - } { + director may + } take into consideration the
levels of health benefit plans provided in Oregon and the
appropriate medical and economic factors and shall establish
benefit levels, cost sharing, exclusions and limitations. The
health benefit plans described in this section may include cost
containment features including, but not limited to:
{ - (A) - } { + (a) + } Preferred provider provisions;
{ - (B) - } { + (b) + } Utilization review of health care
services including review of medical necessity of hospital and
physician services;
{ - (C) - } { + (c) + } Case management benefit
alternatives;
{ - (D) - } { + (d) + } Other managed care provisions;
{ - (E) - } { + (e) + } Selective contracting with
hospitals, physicians and other health care providers; and
{ - (F) - } { + (f) + } Reasonable benefit differentials
applicable to participating and nonparticipating providers.
{ - (b) The committee shall submit the basic and portability
health benefit plans and other recommendations to the director
within the time period established by the director. The health
benefit plans and other recommendations shall be deemed approved
unless expressly disapproved by the director within 30 days after
the date the director receives the plans. - }
(2) In order to ensure the broadest availability of small
employer { + , portability + } and individual health benefit
plans, { - the committee shall recommend for approval by - }
the director { + may approve + } market conduct and other
requirements for carriers and insurance producers, including
{ - requirements developed as a result of a request by the
director, relating to the following - } :
(a) Registration by each carrier with the Department of
Consumer and Business Services of { - its - } { + the
carrier's + } intention to
{ - be a small employer carrier - } { + offer group health
benefit plans + } under ORS 743.733 to 743.737 or { - a carrier
offering - } individual health benefit plans, or both.
{ - (b) Publication by the department of Consumer and
Business Services or the committee of a list of all small
employer carriers and carriers offering individual health benefit
plans, including a potential requirement applicable to insurance
producers and carriers that no health benefit plan be sold to a
small employer or individual by a carrier not so identified as a
small employer carrier or carrier offering individual health
benefit plans. - }
{ - (c) - } { + (b) + } To the extent deemed necessary by
the { - committee - } { + director + } to ensure the fair
distribution of high-risk individuals and groups among carriers,
periodic reports by carriers and insurance producers concerning
small employer, portability and individual health benefit plans
issued, provided that reporting requirements shall be limited to
information concerning case characteristics and numbers of health
benefit plans in various categories marketed or issued { - , or
both, - } to small employers and individuals.
{ - (d) - } { + (c) + } Methods concerning periodic
demonstration by { - small employer carriers, - } carriers
offering { - individual - } health benefit plans { + to
individuals or small employers + } and insurance producers that
the { - small employer and individual - } carriers { + and
insurance producers + } are marketing or issuing { - , or
both, - } health benefit plans { - to small employers or
individuals - } in fulfillment of the purposes of ORS 743.730 to
743.773.
(3) { - Subject to the approval of the director of the
Department of Consumer and Business Services, the committee - }
{ + The director + } shall develop a standard health statement
to be used for all late enrollees and by all carriers offering
individual policies of health insurance.
(4) { - Subject to the approval of - } The director { - ,
the committee - } shall develop a list of the specified services
for small employer and portability plans for which carriers may
impose an exclusion period, the duration of the allowable
exclusion period for each specified service and the manner in
which credit will be given for exclusion periods imposed pursuant
to prior health insurance coverage.
SECTION 43. ORS 743.748 is amended to read:
743.748. (1) Each carrier offering a health benefit plan shall
submit to the Director of the Department of Consumer and Business
Services on or before April 1 of each year a report that
contains:
(a) The following information for the preceding year that is
derived from the exhibit of premiums, enrollment and utilization
included in the carrier's annual report:
(A) The total number of members;
(B) The total amount of premiums;
(C) The total amount of costs for claims;
(D) The medical loss ratio;
(E) The average amount of premiums per member per month; and
(F) The percentage change in the average premium per member per
month, measured from the previous year.
(b) The following aggregate financial information for the
preceding year that is derived from the carrier's annual report:
(A) The total amount of general administrative expenses,
including identification of the five largest nonmedical
administrative expenses and the assessment against the carrier
for the Oregon Medical Insurance Pool;
(B) The total amount of the surplus maintained;
(C) The total amount of the reserves maintained for unpaid
claims;
(D) The total net underwriting gain or loss; and
(E) The carrier's net income after taxes.
(c) The retention rate and claims experience of employer groups
within the plan for the preceding year for association health
plans as described in ORS 743.734 (7). This information is not
subject to public disclosure under ORS chapter 192.
(2) A carrier shall electronically submit the information
described in subsection (1) of this section in a format and
according to instructions prescribed by the Department of
Consumer and Business Services by rule { - after obtaining a
recommendation from the Health Insurance Reform Advisory
Committee - } .
(3) The { - advisory committee - } { + department + } shall
evaluate the reporting requirements under subsection (1)(a) of
this section by the following market segments:
(a) Individual health benefit plans;
(b) Health benefit plans for small employers;
(c) Health benefit plans for employers described in ORS
743.733;
(d) Health benefit plans for employers with more than 50
employees; and
(e) Association health plans described in ORS 743.734 (7).
(4) The department shall make the information reported under
this section available to the public through a searchable public
website on the Internet.
SECTION 44. ORS 743.748, as amended by section 10, chapter 752,
Oregon Laws 2007, is amended to read:
743.748. (1) Each carrier offering a health benefit plan shall
submit to the Director of the Department of Consumer and Business
Services on or before April 1 of each year a report that
contains:
(a) The following information for the preceding year that is
derived from the exhibit of premiums, enrollment and utilization
included in the carrier's annual report:
(A) The total number of members;
(B) The total amount of premiums;
(C) The total amount of costs for claims;
(D) The medical loss ratio;
(E) The average amount of premiums per member per month; and
(F) The percentage change in the average premium per member per
month, measured from the previous year.
(b) The following aggregate financial information for the
preceding year that is derived from the carrier's annual report:
(A) The total amount of general administrative expenses,
including identification of the five largest nonmedical
administrative expenses and the assessment against the carrier
for the Oregon Medical Insurance Pool;
(B) The total amount of the surplus maintained;
(C) The total amount of the reserves maintained for unpaid
claims;
(D) The total net underwriting gain or loss; and
(E) The carrier's net income after taxes.
(2) A carrier shall electronically submit the information
described in subsection (1) of this section in a format and
according to instructions prescribed by the Department of
Consumer and Business Services by rule { - after obtaining a
recommendation from the Health Insurance Reform Advisory
Committee - } .
(3) The { - advisory committee - } { + department + } shall
evaluate the reporting requirements under subsection (1)(a) of
this section by the following market segments:
(a) Individual health benefit plans;
(b) Health benefit plans for small employers;
(c) Health benefit plans for employers described in ORS
743.733; and
(d) Health benefit plans for employers with more than 50
employees.
(4) The department shall make the information reported under
this section available to the public through a searchable public
website on the Internet.
SECTION 45. ORS 743.751 is amended to read:
743.751. (1) Except to determine the application of a
preexisting { - conditions provision - } { + condition
exclusion + } for a late enrollee { + who is 19 years of age or
older + }, a carrier offering group health benefit plans shall
not use health statements when offering such plans to a group of
two or more prospective certificate holders and shall not use any
other method to determine the actual or expected health status of
eligible prospective enrollees. Nothing in this section shall
prevent a carrier from using health statements or other
information after enrollment for the purpose of providing
services or arranging for the provision of services under a
health benefit plan or from obtaining aggregate group information
related to historical medical claims expenses and health behavior
surveys for rating purposes.
(2) Subsection (1) of this section applies only to group health
benefit plans that are not small employer health benefit plans.
SECTION 46. ORS 743.752 is amended to read:
743.752. (1) Except in the case of a late enrollee and as
otherwise provided in this section, a carrier offering a group
health benefit plan to a group of two or more prospective
certificate holders shall not decline to offer coverage to any
eligible prospective enrollee and shall not impose different
terms or conditions on the coverage, premiums or contributions of
any enrollee in the group that are based on the actual or
expected health status of the enrollee.
(2) A carrier that elects to discontinue offering all of its
group health benefit plans under ORS 743.754 (6)(e), elects to
discontinue renewing all such plans or elects to discontinue
offering and renewing all such plans is prohibited from offering
health benefit plans in the group market in this state for a
period of five years from one of the following dates:
(a) The date of notice to the Director of the Department of
Consumer and Business Services pursuant to ORS 743.754 (6)(e); or
(b) If notice is not provided under paragraph (a) of this
subsection, from the date on which the director provides notice
to the carrier that the director has determined that the carrier
has effectively discontinued offering group health benefit plans
in this state.
(3) Subsection (1) of this section applies only to group health
benefit plans that are not small employer health benefit plans.
(4) Nothing in this section shall prohibit an employer from
providing different group health benefit plans to various
categories of employees as defined by the employer nor prohibit
an employer from providing health benefit plans through different
carriers so long as the employer's categories of employees are
established in a manner that does not relate to the actual or
expected health status of the employees or their dependents { +
and does not discriminate in favor of highly compensated
individuals + }.
(5) A multiple employer welfare arrangement, professional or
trade association, or other similar arrangement established or
maintained to provide benefits to a particular trade, business,
profession or industry or their subsidiaries, shall not issue
coverage to a group or individual that is not in the same trade,
business, profession or industry or their subsidiaries as that
covered by the arrangement. The arrangement shall accept all
groups and individuals in the same trade, business, profession or
industry or their subsidiaries that apply for coverage under the
arrangement and that meet the requirements for membership in the
arrangement. For purposes of this subsection, the requirements
for membership in an arrangement shall not include any
requirements that relate to the actual or expected health status
of the prospective enrollee.
SECTION 47. ORS 743.754 is amended to read:
743.754. The following requirements apply to all group health
benefit plans { + other than small employer health benefit
plans + } covering two or more certificate holders:
(1) A preexisting { - conditions provision in a group health
benefit plan - } { + condition exclusion + } shall apply only
to a condition for which medical advice, diagnosis, care or
treatment was recommended or received during the six-month period
immediately preceding the enrollment date of an enrollee or late
enrollee. As used in this section, the enrollment date of an
enrollee shall be the earlier of the effective date of coverage
or the first day of any required group eligibility waiting period
and the enrollment date of a late enrollee shall be the effective
date of coverage.
(2) A preexisting { - conditions provision in a group health
benefit plan - } { + condition exclusion may not apply to a
person under 19 years of age and + }shall { - terminate its
effect - } { + expire + }as follows:
(a) For an enrollee { + , on the earlier of + } { - not later
than the first of - } the following dates:
(A) Six months { - following - } { + after + } the
enrollee's effective date of coverage; or
(B) Twelve months { - following - } { + after + } the start
of any required group eligibility waiting period.
(b) For a late enrollee, not later than 12 months
{ - following - } { + after + } the late enrollee's effective
date of coverage.
(3) In applying a preexisting { - conditions provision - }
{ + condition exclusion + } to an enrollee or late
enrollee { + who is 19 years of age or older + }, except as
provided in this subsection, all
{ - group benefit - } plans shall reduce the duration of the
provision by an amount equal to the enrollee's or late enrollee's
aggregate periods of creditable coverage if the most recent
period of creditable coverage is ongoing or ended within 63 days
{ - of - } { + after + } the enrollment date in the new
{ - group health benefit - } plan. The crediting of prior
coverage in accordance with this subsection shall be applied
without regard to the specific benefits covered during the prior
period. This subsection does not preclude, within a { - group
health benefit - } plan, application of:
(a) An affiliation period that does not exceed two months for
an enrollee or three months for a late enrollee; or
(b) An exclusion period for specified covered services
applicable to all individuals enrolling for the first time in the
{ - group health benefit - } plan.
(4) Late enrollees { + who are 19 years of age or older + }
may be
{ - excluded from coverage - } { + denied enrollment + } for
up to 12 months or may be subjected to a preexisting
{ - conditions provision - } { + condition exclusion + } for
up to 12 months. If both { - an exclusion from coverage
period - } { + a denial of enrollment + } and a preexisting
{ - conditions provision - } { + condition exclusion + } are
applicable to a late enrollee, the combined period shall not
exceed 12 months.
(5) { - All group health benefit plans shall contain special
enrollment periods - } { + Each plan shall contain a special
enrollment period + } during which eligible employees and
dependents may enroll for coverage, as provided in 42 U.S.C.
300gg as amended and in effect on { - July 1, 1997 - } { +
February 17, 2009 + }.
(6) Each { - group health benefit - } plan shall be
renewable with respect to all eligible enrollees at the option of
the policyholder { - except - } { + unless + }:
(a) { - For nonpayment of - } { + The policyholder fails to
pay + } the required premiums { - by the policyholder - } .
(b) { - For fraud or misrepresentation of - } The
policyholder or, with respect to coverage of individual
enrollees, { - the enrollees or their representatives - } { +
an enrollee or a representative of an enrollee engages in fraud
or makes an intentional misrepresentation of a material fact as
prohibited by the terms of the plan + }.
(c) { - When - } The number of enrollees covered under the
plan is less than the number or percentage of enrollees required
by participation requirements under the plan.
(d) { - For noncompliance with the carrier's employer - }
{ + The policyholder fails to comply with the + } contribution
requirements under the { - health benefit - } plan.
(e) { - When - } The carrier discontinues offering or
renewing, or offering and renewing, all of its group { - health
benefit - } plans in this state or in a specified service area
within this state. In order to discontinue plans under this
paragraph, the carrier:
(A) Must give notice of the decision to { - the Director
of - } the Department of Consumer and Business Services and to
all policyholders covered by the plans;
(B) May not cancel coverage under the plans for 180 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in the entire state or,
except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel coverage under the plans for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in a specified service area
because of an inability to reach an agreement with the health
care providers or organization of health care providers to
provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and
renewing, all { - health benefit - } plans issued by the
carrier in the group market in this state or in the specified
service area.
(f) { - When - } The carrier discontinues offering and
renewing a group { - health benefit - } plan in a specified
service area within this state because of an inability to reach
an agreement with the health care providers or organization of
health care providers to provide services under the plan within
the service area. In order to discontinue a plan under this
paragraph, the carrier:
(A) Must give notice of the decision to the { - director - }
{ + department + } and to all policyholders covered by the
plan;
(B) May not cancel coverage under the plan for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph; and
(C) Must offer in writing to each policyholder covered by the
plan, all other group health benefit plans { + that the
policyholder is legally eligible to purchase and + } that the
carrier offers in the specified service area. The carrier shall
offer the plans at least 90 days prior to discontinuation.
(g) { - When - } The carrier discontinues offering or
renewing, or offering and renewing, a { - health benefit - }
plan for all groups in this state or in a specified service area
within this state, other than a plan discontinued under paragraph
(f) of this subsection. With respect to plans that are being
discontinued, the carrier must:
(A) Offer in writing to each policyholder covered by the plan,
one or more health benefit plans { + that the policyholder is
legally eligible to purchase and + } that the carrier offers in
the specified service area.
(B) Offer the plans at least 90 days prior to discontinuation.
(C) Act uniformly without regard to the claims experience of
the affected policyholders or the health status of any current or
prospective enrollee.
(h) { - When - } The Director { + of the Department of
Consumer and Business Services + } orders the carrier to
discontinue coverage in accordance with procedures specified or
approved by the director upon finding that the continuation of
the coverage would:
(A) Not be in the best interests of the enrollees; or
(B) Impair the carrier's ability to meet contractual
obligations.
(i) { - When, - } In the case of a { - group health
benefit - } plan that delivers covered services through a
specified network of health care providers, there is no longer
any enrollee who lives, resides or works in the service area of
the provider network.
(j) { - When, - } In the case of a { - health benefit - }
plan that is offered in the group market only through one or more
bona fide associations, the membership of an employer in the
association ceases and the termination of coverage is not related
to the health status of any enrollee.
{ - (k) For misuse of a provider network provision. As used
in this paragraph, 'misuse of a provider network provision' means
a disruptive, unruly or abusive action taken by an enrollee that
threatens the physical health or well-being of health care staff
and seriously impairs the ability of the carrier or its
participating providers to provide services to an enrollee. An
enrollee under this paragraph retains the rights of an enrollee
under ORS 743.804. - }
{ - (L) - } { + (7) + } A carrier may modify a { - group
health benefit - } plan at the time of coverage renewal. The
modification is not a discontinuation of the plan under
{ - paragraphs (e) and (g) of this - } subsection { + (6)(e)
and (g) of this section + }.
{ - (7) - } { + (8) + } Notwithstanding any provision of
subsection (6) of this section to the contrary, { + a carrier
may rescind + } a { - group health benefit - } plan { + , or
the coverage of an enrollee under a plan, + }
{ - may be rescinded by a carrier for fraud, material
misrepresentation or concealment by a policyholder and the
coverage of an enrollee may be rescinded for fraud, material
misrepresentation or concealment by the enrollee. - } { + if
the enrollee:
(a) Performs an act, practice or omission that constitutes
fraud; or
(b) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the plan. + }
{ - (8) - } { + (9) + } A carrier that continues to offer
coverage in the group market in this state is not required to
offer coverage in all of the carrier's group { - health
benefit - } plans. If a carrier, however, elects to continue a
plan that is closed to new policyholders instead of offering
alternative coverage in its other group { - health benefit - }
plans, the coverage for all existing policyholders in the closed
plan is renewable in accordance with subsection (6) of this
section.
{ - (9) This section applies only to group health benefit
plans that are not small employer health benefit plans. - }
{ + (10) A health benefit plan may not impose lifetime dollar
limits on the essential health benefits prescribed by the United
States Secretary of Health and Human Services pursuant to 42
U.S.C. 300gg-11. + }
SECTION 48. ORS 743.758 is amended to read:
743.758. The Department of Consumer and Business Services may
adopt rules incorporating, implementing and administering the
Health Insurance Portability and Accountability Act of 1996
(P.L. 104-191) { + , the Patient Protection and Affordable Care
Act (P.L. 111-148) as amended by the Health Care and Education
Reconciliation Act (P.L. 111-152) + } and federal regulations
that are issued in conjunction with the { - Act - } { +
Acts + }, to the extent that such federal law and regulations
{ - are not inconsistent with - } { + do not preempt + } any
provision of Oregon law.
SECTION 49. ORS 743.760 is amended to read:
743.760. (1) As used in this section:
(a) 'Carrier' means an insurer authorized to issue a policy of
health insurance in this state. 'Carrier' does not include a
multiple employer welfare arrangement.
(b)(A) 'Eligible individual' means an individual who:
(i) Has left coverage that was continuously in effect for a
period of 180 days or more under one or more Oregon group health
benefit plans, has applied for portability coverage not later
than the 63rd day after termination of group coverage issued by
an Oregon carrier and is an Oregon resident at the time of such
application; or
(ii) { - On or after January 1, 1998, - } Meets the
eligibility requirements of 42 U.S.C. 300gg-41, { - as amended
and in effect on January 1, 1998, - } has applied for
portability coverage not later than the 63rd day after
termination of group coverage issued by an Oregon carrier and is
an Oregon resident at the time of such application.
(B) Except as provided in subsection (12) of this section, '
eligible individual' does not include an individual who remains
eligible for the individual's prior group coverage or would
remain eligible for prior group coverage in a plan under the
federal Employee Retirement Income Security Act of 1974, as
amended, were it not for action by the plan sponsor relating to
the actual or expected health condition of the individual, or who
is covered under another health benefit plan at the time that
portability coverage would commence or is eligible for the
federal Medicare program.
(c) 'Portability health benefit plans' and 'portability plans'
mean health benefit plans for eligible individuals that are
required to be offered by all carriers offering group health
benefit plans and that have been approved by the Director of the
Department of Consumer and Business Services in accordance with
this section.
(2)(a) In order to improve the availability and affordability
of health benefit plans for individuals leaving coverage under
group health benefit plans, the { - Health Insurance Reform
Advisory Committee created under ORS 743.745 shall submit to
the - } director { + shall develop + } two portability health
benefit plans pursuant to ORS 743.745. One plan shall be in the
form of insurance and the second plan shall be consistent with
the type of coverage provided by health maintenance
organizations. For each type of portability plan, { - the
committee shall design and submit to - } the director { +
shall establish standards for + }:
(A) A prevailing benefit plan, which shall reflect the benefit
coverages that are prevalent in the group health insurance
market; and
(B) A low cost benefit plan, which shall emphasize
affordability for eligible individuals.
(b) Except as provided in ORS 743.730 to 743.773, no
{ + state + } law requiring the coverage or the offer of
coverage of a health care service or benefit shall apply to
portability health benefit plans.
(3) The { - director shall approve the - } { + standards
for + } portability health benefit plans { - if - } { +
established by + } the director { + under subsection (2) of
this section must + } { - determines that the plans - }
provide for appropriate accessibility and affordability of needed
health care services and comply with all other provisions of this
section.
(4) { - After the director's approval of the portability
plans submitted by the committee under this section, - } Each
carrier offering group health benefit plans shall submit to the
director the policy form or forms containing at least one low
cost benefit and one prevailing benefit portability plan offered
by the carrier that meets the { - required - } standards { +
established by the director under subsection (2) of this
section + }. Each policy form must be submitted as prescribed by
the director and is subject to review and approval pursuant to
ORS 742.003.
(5) { - Within - } { + No later than + } 180 days after
{ - approval by - } the director { - of the - } { +
establishes standards for + } portability plans
{ - submitted by the committee - } , as a condition of
transacting group health insurance in this state, each carrier
offering group health benefit plans shall make available to
eligible individuals the prevailing benefit and low cost benefit
portability plans that have been submitted by the carrier and
approved by the director under subsection (4) of this section.
(6) A carrier offering group health benefit plans shall issue
to an eligible individual who is leaving or has left group
coverage provided by that carrier any portability plan offered by
the carrier if the eligible individual applies for the plan
within 63 days { - of - } { + after + } termination of prior
coverage and agrees to make the required premium payments and to
satisfy the other provisions of the portability plan.
(7) Premium rates for portability plans shall be subject to the
following provisions:
(a) Each carrier must file the geographic average rate for each
of its portability health benefit plans for a rating period with
the director on or before March 15 of each year.
(b) The premium rates charged during the rating period for each
portability health benefit plan shall not vary from the
geographic average rate, except that the premium rate may be
adjusted to reflect differences in benefit design, family
composition and age. Adjustments for age shall comply with the
following:
(A) For each plan, the variation between the lowest premium
rate and the highest premium rate shall not exceed 100 percent of
the lowest premium rate.
(B) Premium variations shall be determined by applying
uniformly the carrier's schedule of age adjustments for
portability plans as approved by the director.
(c) Premium variations between the portability plans and the
rest of the carrier's group plans must be based solely on
objective differences in plan design or coverage and must not
include differences based on the actual or expected health status
of individuals who select portability health benefit plans. For
purposes of determining the premium variations under this
paragraph, a carrier may:
(A) Pool all portability plans with all group health benefit
plans; or
(B) Pool all portability plans for eligible individuals leaving
small employer group health benefit plan coverage with all plans
offered to small employers and pool all portability plans for
eligible individuals leaving other group health benefit plan
coverage with all health benefit plans offered to such other
groups.
(d) A carrier may not increase the rates of a portability plan
issued to { - an enrollee - } { + a policyholder + } more
than once in any 12-month period. Annual rate increases shall be
effective on the anniversary date of the plan issued to the
{ - enrollee - } { + policyholder + }. The percentage increase
in the premium rate charged to { - an enrollee - } { + a
policyholder + } for a new rating period may not exceed the
average increase in the rest of the carrier's applicable group
health benefit plans plus an adjustment for age.
(8) { - No - } { + A + } portability { - plans - }
{ + plan + } under this section may { + not + } contain
preexisting { - conditions provisions, exclusion periods - }
{ + condition exclusions + }, waiting periods or other similar
limitations on coverage.
(9) Portability health benefit plans shall be renewable with
respect to all enrollees at the option of the enrollee { - ,
except - } { + unless + }:
(a) { - For nonpayment of the required premiums by - } The
policyholder { + fails to pay the required premiums + };
(b) { - For fraud or misrepresentation by - } The
policyholder { + engages in fraud or makes an intentional
misrepresentation of a material fact as prohibited by the terms
of the policy + };
(c) { - When - } The carrier elects to discontinue offering
all of its group health benefit plans in accordance with ORS
743.737 and 743.754; or
(d) { - When - } The director orders the carrier to
discontinue coverage in accordance with procedures specified or
approved by the director upon finding that the continuation of
the coverage would:
(A) Not be in the best interests of the enrollees; or
(B) Impair the carrier's ability to meet its contractual
obligations.
(10)(a) { - Each - } { + A + } carrier offering { + a + }
group health benefit
{ - plans - } { + plan + } shall maintain at its principal
place of business a complete and detailed description of its
rating practices and renewal underwriting practices relating to
its portability plans, including information and documentation
that demonstrate that its rating methods and practices are based
upon commonly accepted actuarial practices and are in accordance
with sound actuarial principles.
(b) { - Each such - } { + A + } carrier { + offering a
group health benefit plan + } shall file with the
{ - director - } { + Department of Consumer and Business
Services + } annually on or before March 15 an actuarial
certification that the carrier is in compliance with this section
and that its rating methods are actuarially sound. Each
{ - such - } certification shall be in a form and manner and
shall contain such information as specified by the
{ - director - } { + department + }. A copy of
{ - such - } { + each + } certification shall be retained by
the carrier at its principal place of business.
(c) { - Each such - } { + A + } carrier { + offering a
group health benefit plan + } shall make the information and
documentation described in paragraph (a) of this subsection
available to the { - director - } { + department + } upon
request. Except as provided in ORS 743.018 and except in cases of
violations of the Insurance Code, the information is proprietary
and trade secret information and shall not be subject to
disclosure { - by the director - } to persons outside the
department { - of Consumer and Business Services - } except as
agreed to by the carrier or as ordered by a court of competent
jurisdiction.
(11) A carrier offering { + a + } group health benefit
{ - plans - } { + plan + } shall not provide any financial or
other incentive to any insurance producer that would encourage
the insurance producer to market and sell portability plans of
the carrier on the basis of an eligible individual's anticipated
claims experience.
(12) An individual who is eligible to obtain a portability plan
in accordance with this section may obtain such a plan regardless
of whether the eligible individual qualifies for a period of
continuation coverage under federal law or under ORS 743.600 or
743.610. However, an individual who has elected such continuation
coverage is not eligible to obtain a portability plan until the
continuation coverage has been discontinued by the individual or
has been exhausted.
{ + (13) A carrier may rescind a portability health benefit
plan issued to a policyholder only if the policyholder:
(a) Performs an act, practice or omission that constitutes
fraud; or
(b) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the policy. + }
SECTION 50. ORS 743.761 is amended to read:
743.761. (1) A carrier approved pursuant to subsection (4) of
this section that offers individual health benefit plans may
satisfy the requirements of ORS 743.760 by issuing any individual
health benefit plan offered by the carrier to any eligible
individual as defined in ORS 743.760 who:
(a) Is leaving or has left a group health benefit plan provided
by that carrier;
(b) Applies for the policy; and
(c) Agrees to make the required premium payments and to satisfy
the other provisions of the plan.
(2) All health benefit plans issued pursuant to subsection (1)
of this section shall:
(a) Comply with ORS 743.767 and 743.769; and
(b) Contain no preexisting { - conditions provisions,
exclusion periods - } { + condition exclusions + }, waiting
periods or other similar limitations on coverage.
(3) A carrier offering plans pursuant to this section shall
offer plans that meet the standards and requirements described in
ORS 743.760 (2).
(4) The Director of the Department of Consumer and Business
Services shall adopt standards for minimum participation in the
individual market necessary for a carrier to offer policies under
this section and shall develop a program for approval of carriers
under this section.
SECTION 51. ORS 743.766 is amended to read:
743.766. (1) All carriers { - who - } { + that + } offer
{ + an + } individual health benefit { - plans - } { +
plan + } and evaluate the health status of individuals for
purposes of eligibility shall use the standard health statement
established { - by the Health Insurance Reform Advisory
Committee - } { + under ORS 743.745 + } and may not use any
other method to determine the health status of an individual.
Nothing in this subsection shall prevent a carrier from using
health information after enrollment for the purpose of providing
services or arranging for the provision of services under a
health benefit plan.
(2)(a) If an individual is accepted for coverage under an
individual health benefit plan, the carrier shall not impose
exclusions or limitations { - on coverage greater - } { +
other + } than:
(A) A preexisting { - conditions provision - } { +
condition exclusion + } that complies with the following
requirements:
(i) The { - provision shall apply - } { + exclusion
applies + } only to a condition for which medical advice,
diagnosis, care or treatment was recommended or received during
the six-month period immediately preceding the individual's
effective date of coverage;
{ - and - }
(ii) The { - provision shall terminate its effect - } { +
exclusion expires + } no later than six months
{ - following - } { + after + } the individual's effective
date of coverage; { + and
(iii) Except for grandfathered health plans, the exclusion does
not apply to individuals who are under 19 years of age; + }
(B) An individual coverage waiting period of 90 days; or
(C) An exclusion period for specified covered services
applicable to all individuals enrolling for the first time in the
individual health benefit plan.
(b) Pregnancy may constitute a preexisting condition for
purposes of this section.
(3) If the carrier elects to restrict coverage through the
application of a preexisting { - conditions provision - } { +
condition exclusion + } or an individual coverage waiting period
provision, the carrier shall reduce the duration of the provision
by an amount equal to the individual's aggregate periods of
creditable coverage if the most recent period of creditable
coverage is ongoing or ended within 63 days { - of - } { +
after + } the effective date of coverage in the new individual
health benefit plan. The crediting of prior coverage in
accordance with this subsection shall be applied without regard
to the specific benefits covered during the prior period.
(4) If an eligible prospective enrollee is rejected for
coverage under an individual health benefit plan, the prospective
enrollee shall be eligible to apply for coverage under the Oregon
Medical Insurance Pool.
(5) If a carrier accepts an individual for coverage under an
individual health benefit plan, the carrier shall renew the
policy
{ - except - } { + unless + }:
(a) { - For nonpayment of the required premiums by - } The
policyholder { + fails to pay the required premiums + }.
(b) { - For fraud or misrepresentation by - } The
policyholder { + engages in fraud or makes an intentional
misrepresentation of a material fact as prohibited by the terms
of the policy + }.
(c) { - When - } The carrier discontinues offering or
renewing, or offering and renewing, all of its individual health
benefit plans in this state or in a specified service area within
this state. In order to discontinue the plans under this
paragraph, the carrier:
(A) Must give notice of the decision to the { - Director of
the - } Department of Consumer and Business Services and to all
policyholders covered by the plans;
(B) May not cancel coverage under the plans for 180 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in the entire state or,
except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel coverage under the plans for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in a specified service area
because of an inability to reach an agreement with the health
care providers or organization of health care providers to
provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and
renewing, all health benefit plans issued by the carrier in the
individual market in this state or in the specified service area.
(d) { - When - } The carrier discontinues offering and
renewing an individual health benefit plan in a specified service
area within this state because of an inability to reach an
agreement with the health care providers or organization of
health care providers to provide services under the plan within
the service area. In order to discontinue a plan under this
paragraph, the carrier:
(A) Must give notice of the decision to the { - director - }
{ + department + } and to all policyholders covered by the
plan;
(B) May not cancel coverage under the plan for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph; and
(C) Must offer in writing to each policyholder covered by the
plan, all other individual health benefit plans { + that the
policyholder is legally eligible to purchase and + } that the
carrier offers in the specified service area. The carrier shall
offer the plans at least 90 days prior to discontinuation.
(e) { - When - } The carrier discontinues offering or
renewing, or offering and renewing, an individual health benefit
plan for all individuals in this state or in a specified service
area within this state, other than a plan discontinued under
paragraph (d) of this subsection. With respect to plans that are
being discontinued, the carrier must:
(A) Offer in writing to each policyholder covered by the plan,
one or more individual health benefit plans that the carrier
offers in the specified service area.
(B) Offer the plans at least 90 days prior to discontinuation.
(C) Act uniformly without regard to the claims experience of
the affected policyholders or the health status of any current or
prospective enrollee.
(f) { - When - } The Director { + of the Department of
Consumer and Business Services + } orders the carrier to
discontinue coverage in accordance with procedures specified or
approved by the director upon finding that the continuation of
the coverage would:
(A) Not be in the best interests of the enrollee; or
(B) Impair the carrier's ability to meet its contractual
obligations.
(g) { - When, - } In the case of an individual health
benefit plan that delivers covered services through a specified
network of health care providers, the enrollee no longer lives,
resides or works in the service area of the provider network and
the termination of coverage is not related to the health status
of any enrollee.
(h) { - When, - } In the case of a health benefit plan that
is offered in the individual market only through one or more bona
fide associations, the membership of an individual in the
association ceases and the termination of coverage is not related
to the health status of any enrollee.
{ - (i) For misuse of a provider network provision. As used
in this paragraph, 'misuse of a provider network provision' means
a disruptive, unruly or abusive action taken by an enrollee that
threatens the physical health or well-being of health care staff
and seriously impairs the ability of the carrier or its
participating providers to provide service to an enrollee. An
enrollee under this paragraph retains the rights of an enrollee
under ORS 743.804. - }
{ - (j) - } { + (6) + } A carrier may modify an individual
health benefit plan at the time of coverage renewal. The
modification is not a discontinuation of the plan under
{ - paragraphs (c) and (e) of this - } subsection { + (5)(c)
and (e) of this section + }.
{ - (6) - } { + (7) + } Notwithstanding any other provision
of this section, a carrier may rescind an individual health
benefit plan
{ - for fraud, material misrepresentation or concealment by an
enrollee. - } { + if the policyholder:
(a) Performs an act, practice or omission that constitutes
fraud; or
(b) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the policy. + }
{ - (7) - } { + (8) + } A carrier that withdraws from the
market for individual health benefit plans must continue to renew
its portability health benefit plans that have been approved
pursuant to ORS 743.761.
{ - (8) - } { + (9) + } A carrier that continues to offer
coverage in the individual market in this state is not required
to offer coverage in all of the carrier's individual health
benefit plans. However, if a carrier elects to continue a plan
that is closed to new individual policyholders instead of
offering alternative coverage in its other individual health
benefit plans, the coverage for all existing policyholders in the
closed plan is renewable in accordance with subsection (5) of
this section.
{ + (10) An individual health benefit plan other than a
grandfathered health plan may not impose lifetime dollar limits
on the essential health benefits prescribed by the United States
Secretary of Health and Human Services pursuant to 42 U.S.C.
300gg-11. + }
SECTION 52. ORS 743.767 is amended to read:
743.767. Premium rates for individual health benefit plans
shall be subject to the following provisions:
(1) Each carrier must file the geographic average rate for its
individual health benefit plans for a rating period with the
Director of the Department of Consumer and Business Services on
or before March 15 of each year.
(2) The premium rates charged during a rating period for
individual health benefit plans issued to individuals shall not
vary from the individual geographic average rate, except that the
premium rate may be adjusted to reflect differences in benefit
design, family composition and age. For age adjustments to the
individual plans, a carrier shall apply uniformly its schedule of
age adjustments for individual health benefit plans as approved
by the director.
(3) A carrier may not increase the rates of an individual
health benefit plan more than once in a 12-month period except as
approved by the director. Annual rate increases shall be
effective on the anniversary date of the individual health
benefit plan's issuance. The percentage increase in the premium
rate charged for an individual health benefit plan for a new
rating period may not exceed the sum of the following:
(a) The percentage change in the carrier's geographic average
rate for its individual health benefit plan measured from the
first day of the prior rating period to the first day of the new
period; and
(b) Any adjustment attributable to changes in age and
differences in benefit design and family composition.
(4) Notwithstanding any other provision of this section, a
carrier that imposes an individual coverage waiting period
pursuant to ORS 743.766 may impose a monthly premium rate
surcharge for a period not to exceed six months and in an amount
not to exceed the percentage by which the rates for coverage
under the Oregon Medical Insurance Pool exceed the rates
established by the Oregon Medical Insurance Pool Board as
applicable for individual risks under ORS 735.625. The surcharge
shall be approved by the Director of the Department of Consumer
and Business Services and, in combination with the waiting
period, shall not exceed the actuarial value of a six-month
preexisting
{ - conditions provision - } { + condition exclusion + }.
SECTION 53. ORS 743.801 is amended to read:
743.801. As used in { + this section and + } ORS
{ - 743.801, - } 743.803, 743.804, 743.806, 743.807, 743.808,
743.811, 743.814, 743.817, 743.819, 743.821, 743.823, 743.827,
743.829, 743.831, 743.834, 743.837, 743.839, 743.854, 743.856,
743.857, 743.858, 743.859, 743.861, 743.862, 743.863, 743.864,
743.911, 743.912, 743.913, 743.917, 743.918 { + , + }
{ - and - } 743A.012 { + and 750.333 and section 5 of this
2011 Act + }:
{ + (1) 'Adverse benefit determination' means an insurer's
denial, reduction or termination of a health care item or
service, or an insurer's failure or refusal to provide or to make
a payment in whole or in part for a health care item or service,
that is based on the insurer's:
(a) Denial or termination of enrollment of an individual in a
health benefit plan;
(b) Rescission or cancellation of a policy or certificate;
(c) Imposition of a preexisting condition exclusion as defined
in ORS 743.730, source-of-injury exclusion, network exclusion,
annual benefit limit or other limitation on otherwise covered
items or services;
(d) Determination that a health care item or service is
experimental, investigational or not medically necessary or
appropriate; or
(e) Determination that 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. + }
{ - (1) - } { + (2) + } 'Emergency medical condition' means
a medical condition that manifests itself by acute symptoms of
sufficient severity, including severe pain, that a prudent
layperson possessing an average knowledge of health and medicine
would reasonably expect that failure to receive immediate medical
attention would place the health of a person, or a fetus in the
case of a pregnant woman, in serious jeopardy.
{ - (2) - } { + (3) + } 'Emergency medical screening exam'
means the medical history, examination, ancillary tests and
medical determinations required to ascertain the nature and
extent of an emergency medical condition.
{ - (3) - } { + (4) + } 'Emergency services' means
{ - those health care items and services furnished in an
emergency department and all ancillary services routinely
available to an emergency department to the extent they are
required for the stabilization of a patient. - } { + , with
respect to an emergency medical condition:
(a) An emergency medical screening exam that is within the
capability of the emergency department of a hospital, including
ancillary services routinely available to the emergency
department to evaluate such emergency medical condition; and
(b) Such further medical examination and treatment to stabilize
a patient, to the extent the examination and treatment are within
the capability of the staff and facilities available at a
hospital. + }
{ - (4) - } { + (5) + } 'Enrollee' has the meaning given
that term in ORS 743.730.
{ - (5) - } { + (6) + } 'Grievance' means a written { + or
oral + } complaint submitted by or on behalf of an enrollee
regarding the:
(a) Availability, delivery or quality of health care services,
including a complaint regarding an adverse { + benefit + }
determination made pursuant to utilization review;
(b) Claims payment, handling or reimbursement for health care
services; or
(c) Matters pertaining to the contractual relationship between
an enrollee and an insurer.
{ - (6) - } { + (7) + } 'Health benefit plan' has the
meaning { - provided for - } { + given + } that term in ORS
743.730.
{ - (7) - } { + (8) + } 'Independent practice association'
means a corporation wholly owned by providers, or whose
membership consists entirely of providers, formed for the sole
purpose of contracting with insurers for the provision of health
care services to enrollees, or with employers for the provision
of health care services to employees, or with a group, as
described in ORS 743.522, to provide health care services to
group members.
{ - (8) - } { + (9) + } 'Insurer' { - has the meaning
provided for that term in ORS 731.106. For purposes of ORS
743.801, 743.803, 743.804, 743.806, 743.807, 743.808, 743.811,
743.814, 743.817, 743.819, 743.821, 743.823, 743.827, 743.829,
743.831, 743.834, 743.837, 743.839, 743.854, 743.856, 743.857,
743.858, 743.859, 743.861, 743.862, 743.863, 743.864, 743.911,
743.912, 743.913, 743.917, 743A.012, 750.055 and 750.333,
'insurer' also - } includes a health care service contractor as
defined in ORS 750.005.
{ - (9) - } { + (10) + } 'Managed health insurance' means
any health benefit plan that:
(a) Requires an enrollee to use a specified network or networks
of providers managed, owned, under contract with or employed by
the insurer in order to receive benefits under the plan, except
for emergency or other specified limited service; or
(b) In addition to the requirements of paragraph (a) of this
subsection, offers a point-of-service provision that allows an
enrollee to use providers outside of the specified network or
networks at the option of the enrollee and receive a reduced
level of benefits.
{ - (10) - } { + (11) + } 'Medical services contract' means
a contract between an insurer and an independent practice
association, between an insurer and a provider, between an
independent practice association and a provider or organization
of providers, between medical or mental health clinics, and
between a medical or mental health clinic and a provider to
provide medical or mental health services. 'Medical services
contract' does not include a contract of employment or a contract
creating legal entities and ownership thereof that are authorized
under ORS chapter 58, 60 or 70, or other similar professional
organizations permitted by statute.
{ - (11)(a) - } { + (12)(a) + } 'Preferred provider
organization insurance' means any health benefit plan that:
(A) Specifies a preferred network of providers managed, owned
or under contract with or employed by an insurer;
(B) Does not require an enrollee to use the preferred network
of providers in order to receive benefits under the plan; and
(C) Creates financial incentives for an enrollee to use the
preferred network of providers by providing an increased level of
benefits.
(b) 'Preferred provider organization insurance' does not mean a
health benefit plan that has as its sole financial incentive a
hold harmless provision under which providers in the preferred
network agree to accept as payment in full the maximum allowable
amounts that are specified in the medical services contracts.
{ - (12) - } { + (13) + } '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.
{ - (13) - } { + (14) + } '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 ordinary course of business or practice of a profession.
{ - (14) - } { + (15) + } 'Stabilization' means that,
within reasonable medical probability, no material deterioration
of an emergency medical condition is likely to occur.
{ - (15) - } { + (16) + } 'Utilization review' means a set
of formal techniques used by an insurer or delegated by the
insurer designed to monitor the use of or evaluate the medical
necessity, appropriateness, efficacy or efficiency of health care
services, procedures or settings.
SECTION 54. ORS 743.804 is amended to read:
743.804. All insurers offering a health benefit plan in this
state shall:
{ - (1) Have a written policy that recognizes the rights of
enrollees: - }
{ - (a) To voice grievances about the organization or health
care provided; - }
{ - (b) To be provided with information about the
organization, its services and the providers providing care; - }
{ - (c) To participate in decision making regarding their
health care; and - }
{ - (d) To be treated with respect and recognition of their
dignity and need for privacy. - }
{ - (2) Provide a summary of policies on enrollees' rights
and responsibilities to all participating providers upon request
and to all enrollees either directly or, in the case of group
coverage, to the employer or other policyholder for distribution
to enrollees. - }
{ - (3) Have a timely and organized system for resolving
grievances and appeals. The system shall include: - }
{ - (a) A systematic method for recording all grievances and
appeals, including the nature of the grievances, and significant
actions taken; - }
{ - (b) Written procedures explaining the grievance and
appeal process, including a procedure to assist enrollees in
filing written grievances; - }
{ - (c) Written decisions in plain language justifying
grievance determinations, including appropriate references to
relevant policies, procedures and contract terms; - }
{ - (d) Standards for timeliness in responding to grievances
or appeals that accommodate the clinical urgency of the
situation; - }
{ - (e) Notice in all written decisions prepared pursuant to
this subsection that the enrollee may file a complaint with the
Director of the Department of Consumer and Business Services;
and - }
{ - (f) An appeal process for grievances that includes at
least the following: - }
{ - (A) Three levels of review, the second of which shall be
by persons not previously involved in the dispute and the third
of which shall provide external review pursuant to an external
review program meeting the requirements of ORS 743.857, 743.859
and 743.861; - }
{ - (B) Opportunity for enrollees and any representatives of
the enrollees to appear before a review panel at either the first
or second level of review. Representatives may include health
care providers or any other persons chosen by the enrollee. The
enrollee and insurer shall each provide advance notification of
the number of representatives who will appear before the panel
and the relationship of the representatives to the enrollee or
insurer; and - }
{ - (C) Written decisions in plain language justifying appeal
determinations, including specific references to relevant
provisions of the health benefit plan and related written
corporate practices. - }
{ - (4) If the insurer has a prescription drug formulary,
have: - }
{ - (a) A written procedure by which a provider with
authority to prescribe drugs and medications may prescribe drugs
and medications not included in the formulary. The procedure
shall include the circumstances when a drug or medication not
included in the formulary will be considered a covered benefit;
and - }
{ - (b) A written procedure to provide full disclosure to
enrollees of any cost sharing or other requirements to obtain
drugs and medications not included in the formulary. - }
{ - (5) Furnish to all enrollees either directly or, in the
case of a group policy, to the employer or other policyholder for
distribution to enrollees written general information informing
enrollees about services provided, access to services, charges
and scheduling applicable to each enrollee's coverage,
including: - }
{ - (a) Benefits and services included and how to obtain
them, including any restrictions that apply to services obtained
outside the insurer's network or outside the insurer's service
area, and the availability of continuity of care as required by
ORS 743.854; - }
{ - (b) Provisions for referrals, if any, for specialty care,
behavioral health services and hospital services and how
enrollees may obtain the care or services; - }
{ - (c) Provisions for after-hours and emergency care and how
enrollees may obtain that care, including the insurer's policy,
if any, on when enrollees should directly access emergency care
and use 9-1-1 services; - }
{ - (d) Charges to enrollees, if applicable, including any
policy on cost sharing for which the enrollee is responsible; - }
{ - (e) Procedures for notifying enrollees of: - }
{ - (A) A change in or termination of any benefit; - }
{ - (B) If applicable, termination of a primary care delivery
office or site; and - }
{ - (C) If applicable, assistance available to enrollees
affected by the termination of a primary care delivery office or
site in selecting a new primary care delivery office or site; - }
{ - (f) Procedures for appealing decisions adversely
affecting the enrollee's benefits or enrollment status; - }
{ - (g) Procedures, if any, for changing providers; - }
{ - (h) Procedures for voicing grievances, including the
option of obtaining external review under the insurer's program
established pursuant to ORS 743.857, 743.859 and 743.861; - }
{ - (i) A description of the procedures, if any, by which
enrollees and their representatives may participate in the
development of the insurer's corporate policies and
practices; - }
{ - (j) Summary information on how the insurer makes
decisions regarding coverage and payment for treatment or
services, including a general description of any prior
authorization and utilization review requirements that affect
coverage or payment; - }
{ - (k) A summary of criteria used to determine if a service
or drug is considered experimental or investigational; - }
{ - (L) Information about provider, clinic and hospital
networks, if any, including a list of network providers and
information about how the enrollee may obtain current information
about the availability of individual providers, the hours the
providers are available and a description of any limitations on
the ability of enrollees to select primary and specialty care
providers; - }
{ - (m) A general disclosure of any risk-sharing arrangements
the insurer has with physicians and other providers; - }
{ - (n) A summary of the insurer's procedures for protecting
the confidentiality of medical records and other enrollee
information; - }
{ - (o) A description of any assistance provided to
non-English-speaking enrollees; - }
{ - (p) A summary of the insurer's policies, if any, on drug
prescriptions, including any drug formularies, cost sharing
differentials or other restrictions that affect coverage of drug
prescriptions; - }
{ - (q) Notice of the enrollee's right to file a complaint or
seek other assistance from the Director of the Department of
Consumer and Business Services; and - }
{ - (r) Notice of the information that is available upon
request pursuant to subsection (6) of this section and
information that is available from the Department of Consumer and
Business Services pursuant to ORS 743.804, 743.807, 743.814 and
743.817. - }
{ - (6) Provide the following information upon the request of
an enrollee or prospective enrollee: - }
{ - (a) Rules related to the insurer's drug formulary, if
any, including information on whether a particular drug is
included or excluded from the formulary; - }
{ - (b) Provisions for referrals, if any, for specialty care,
behavioral health services and hospital services and how
enrollees may obtain the care or services; - }
{ - (c) A copy of the insurer's annual report on grievances
and appeals as submitted to the department under subsection (9)
of this section; - }
{ - (d) A description of the insurer's risk-sharing
arrangements with physicians and other providers consistent with
risk-sharing information required by the federal Health Care
Financing Administration pursuant to 42 C.F.R. 417.124 (3)(b) as
in effect on June 18, 1997; - }
{ - (e) A description of the insurer's efforts, if any, to
monitor and improve the quality of health services; - }
{ - (f) Information about any insurer procedures for
credentialing network providers and how to obtain the names,
qualifications and titles of the providers responsible for an
enrollee's care; and - }
{ - (g) A description of the insurer's external review
program established pursuant to ORS 743.857, 743.859 and
743.861. - }
{ - (7) Except as otherwise provided in this subsection,
provide to enrollees, upon request, a written summary of
information that the insurer may consider in its utilization
review of a particular condition or disease to the extent the
insurer maintains such criteria. Nothing in this section shall
require an insurer to advise an enrollee how the insurer would
cover or treat that particular enrollee's disease or condition.
Utilization review criteria that is proprietary shall be subject
to verbal disclosure only. - }
{ - (8) Provide the following information to an enrollee when
the enrollee has filed a grievance: - }
{ - (a) Detailed information on the insurer's grievance and
appeal procedures and how to use them; - }
{ - (b) Information on how to access the complaint line of
the Department of Consumer and Business Services; and - }
{ - (c) Information explaining how an enrollee applies for
external review of the insurer's actions under the external
review program established by the insurer pursuant to ORS
743.857. - }
{ - (9) Provide annual summaries to the Department of
Consumer and Business Services of the insurer's aggregate data
regarding grievances, appeals and applications for external
review in a format prescribed by the department to ensure
consistent reporting on the number, nature and disposition of
grievances, appeals and applications for external review. - }
{ - (10) Ensure that the confidentiality of specified patient
information and records is protected, and to that end: - }
{ - (a) Adopt and implement written confidentiality policies
and procedures; - }
{ - (b) State the insurer's expectations about the
confidentiality of enrollee information and records in medical
service contracts; and - }
{ - (c) Afford enrollees the opportunity to approve or deny
the release of identifiable medical personal information by the
insurer, except as otherwise permitted or required by law. - }
{ - (11) Notify an enrollee of the enrollee's rights under
the health benefit plan at the time that the insurer notifies the
enrollee of an adverse decision. The notification shall
include: - }
{ - (a) Notice of the right of the enrollee to apply for
internal and external review of the adverse decision; - }
{ - (b) A statement whether a decision by an independent
review organization is binding on the insurer and enrollee; - }
{ - (c) A statement that if the decision is not binding on
the insurer and if the insurer does not comply with the decision,
the enrollee may sue the insurer as provided in ORS 743.864;
and - }
{ - (d) Information on filing a complaint with the Director
of the Department of Consumer and Business Services. - }
{ + (1) Provide to all enrollees directly or in the case of a
group policy to the employer or other policyholder for
distribution to enrollees, to all applicants, and to prospective
applicants upon request, the following information:
(a) The insurer's written policy on the rights of enrollees,
including the right:
(A) To participate in decision making regarding the enrollee's
health care.
(B) To be treated with respect and with recognition of the
enrollee's dignity and need for privacy.
(C) To voice grievances about the insurer or health care
provided under the plan.
(D) To be provided with the information described in this
section.
(b) An explanation that is culturally and linguistically
appropriate of the procedures described in subsection (2) of this
section for making coverage determinations and resolving
grievances and appeals, including:
(A) The opportunity for expedited review of an adverse benefit
determination;
(B) A statement that if an insurer does not comply with the
decision of an independent review organization under ORS 743.862,
the enrollee may sue the insurer under ORS 743.864;
(C) The procedure to obtain assistance available from the
insurer, if any, and from the Department of Consumer and Business
Services in filing grievances or appeals; and
(D) A description of the process for filing a complaint with
the department.
(c) A summary of benefits and an explanation of coverage in a
form and manner prescribed by the department by rule.
(d) A summary of the insurer's policies on prescription drugs,
including:
(A) Cost-sharing differentials;
(B) Restrictions on coverage;
(C) Prescription drug formularies;
(D) Procedures by which a provider with prescribing authority
may prescribe drugs not included on the formulary;
(E) Procedures for the coverage of prescription drugs not
included on the formulary; and
(F) A summary of the criteria for determining whether a drug is
experimental or investigational.
(e) A list of network providers and how the enrollee can obtain
current information about the availability of providers, the
hours the providers are available and how to access and schedule
services with providers, including clinic and hospital networks.
(f) Notice of the enrollee's right to select a primary care
provider and specialty care providers.
(g) How to obtain referrals for specialty care in accordance
with ORS 743.856.
(h) Restrictions on services obtained outside of the insurer's
network or service area.
(i) The availability of continuity of care as required by ORS
743.854.
(j) Procedures for accessing after-hours care and emergency
services as required by ORS 743A.012.
(k) Cost-sharing requirements and other charges to enrollees.
(L) Procedures, if any, for changing providers.
(m) Procedures, if any, by which enrollees may participate in
the development of the insurer's corporate policies.
(n) A summary of how the insurer makes decisions regarding
coverage and payment for treatment or services, including a
general description of any prior authorization and utilization
control requirements that affect coverage or payment.
(o) Disclosure of any risk-sharing arrangement the insurer has
with physicians or other providers.
(p) A summary of the insurer's procedures for protecting the
confidentiality of medical records and other enrollee
information.
(q) An explanation of assistance provided to
non-English-speaking enrollees.
(r) Notice of the information available from the department
that is filed by insurers as required under ORS 743.807, 743.814
and 743.817.
(2) Establish procedures for making coverage determinations and
resolving grievances and appeals that provide for:
(a) Timely notice of adverse benefit determinations in a form
and manner approved by the department or prescribed by the
department by rule;
(b) A method for recording all grievances and appeals,
including the nature of the grievance or appeal and significant
action taken;
(c) Written decisions that are culturally and linguistically
appropriate explaining the basis for adverse benefit
determinations, with references to relevant policies, procedures
and contract terms, and that include:
(A) The date of service;
(B) The health care provider;
(C) The amount of the claim;
(D) The diagnosis code and the meaning of the code;
(E) The treatment code and the meaning of the code;
(F) The denial code and the meaning of the code; and
(G) A description of the standard used in denying a claim;
(d) Responding to grievances or appeals in a manner that
accommodates the clinical urgency of the situation;
(e) Three levels of review for group health benefit plans, the
second of which shall be by persons not previously involved in
the dispute, and two levels of review for individual health
benefit plans and portability health benefit plans, with the
final level of review in all cases being an external review that
meets the requirements of ORS 743.857, 743.859 and 743.861 and is
conducted in a manner approved by the department or prescribed by
the department by rule; and
(f) The opportunity for the enrollee to receive continued
coverage under the health benefit plan pending the outcome of the
appeal and, at either the first or second level of internal
review, for the enrollee and any representative chosen by the
enrollee to:
(A) Submit for consideration by the reviewers any written
comments, documents, records and other materials relating to the
adverse benefit determination; and
(B) Receive from the insurer, upon request and free of charge,
reasonable access to and copies of all documents, records and
other information relevant to the adverse benefit determination.
(3) Establish procedures for notifying enrollees of:
(a) A change in or termination of any benefit;
(b) The termination of a primary care delivery office or site;
and
(c) If applicable, assistance available to enrollees affected
by the termination of a primary care delivery office or site in
selecting a new primary care delivery office or site.
(4) Provide the information described in subsection (2) of this
section and ORS 743.859 at each level of review to an enrollee
who is notified of an adverse benefit determination or to an
enrollee who files a grievance or appeal.
(5) Upon the request of an enrollee, applicant or prospective
applicant, provide:
(a) The insurer's annual report on grievances and appeals
submitted to the department under subsection (8) of this section.
(b) A description of the insurer's efforts, if any, to monitor
and improve the quality of health services.
(c) Information about the insurer's procedures for
credentialing network providers.
(6) Provide, upon the request of an enrollee, a written summary
of information that the insurer may consider in its utilization
review of a particular condition or disease, to the extent the
insurer maintains such criteria. Nothing in this subsection
requires an insurer to advise an enrollee how the insurer would
cover or treat that particular enrollee's disease or condition.
Utilization review criteria that are proprietary shall be subject
to oral disclosure only.
(7) Maintain for a period of at least six years written records
that document all grievances and appeals and make the written
records available for examination by the department or by an
enrollee or representative of an enrollee with respect to a
grievance or appeal requested by the enrollee. The written
records must include but are not limited to the following:
(a) Notices and claims associated with each grievance or
appeal.
(b) A general description of the reason for the grievance or
appeal.
(c) The date the grievance or appeal was received by the
insurer.
(d) The date the grievance or appeal was reviewed or the date
of any review meeting held concerning the grievance or appeal.
(e) The resolution of the grievance or appeal at each level of
review.
(f) The name of the covered person for whom the grievance or
appeal was filed.
(8) Provide an annual summary to the department of the
insurer's aggregate data regarding grievances, appeals and
applications for external review in a format prescribed by the
department to ensure consistent reporting on the number, nature
and disposition of grievances, appeals and applications for
external review.
(9) Allow the exercise of any rights described in this section
by a person with the consent of the enrollee or, if the enrollee
is unable to provide informed consent, allow the exercise of any
rights described in this section by a family member of the
enrollee, the enrollee's health care provider or any person
authorized by law to provide consent. + }
SECTION 55. ORS 743.806 is amended to read:
743.806. All utilization review performed pursuant to a medical
services contract to which an insurer is not a party shall comply
with the following:
(1) The criteria used in the review process and the method of
development of the criteria shall be made available for review to
a party to such medical services contract upon request.
(2) A doctor of medicine or osteopathy licensed under ORS
chapter 677 shall be responsible for all final recommendations
regarding the necessity or appropriateness of services or the
site at which the services are provided and shall consult as
appropriate with medical and mental health specialists in making
such recommendations.
(3) Any patient or provider who has had a request for treatment
or payment for services denied as not medically necessary or as
experimental shall be provided an opportunity for a timely appeal
before an appropriate medical consultant or peer review
committee { + or for review as provided in ORS 743.804, 743.857
and 743.861 + }.
(4) A provider request for prior authorization of nonemergency
service must be answered within two business days, and qualified
health care personnel must be available for same-day telephone
responses to inquiries concerning certification of continued
length of stay.
SECTION 56. ORS 743.807 is amended to read:
743.807. (1) All insurers offering a health benefit plan in
this state that provide utilization review or have utilization
review provided on their behalf shall file an annual summary with
the Department of Consumer and Business Services that describes
all utilization review policies, including delegated utilization
review functions, and documents the insurer's procedures for
monitoring of utilization review activities.
(2) All utilization review activities conducted pursuant to
subsection (1) of this section shall comply with the following:
(a) The criteria used in the utilization review process and the
method of development of the criteria shall be made available for
review to contracting providers upon request.
(b) A doctor of medicine or osteopathy licensed under ORS
chapter 677 shall be responsible for all final recommendations
regarding the necessity or appropriateness of services or the
site at which the services are provided and shall consult as
appropriate with medical and mental health specialists in making
such recommendations.
(c) Any { - patient - } { + enrollee + } or provider who
has had a request for treatment or payment for services denied as
not medically necessary or as experimental shall be provided an
opportunity for a timely appeal before an appropriate medical
consultant or peer review committee { + or for review as
provided in ORS 743.804, 743.857 and 743.861 + }.
(d) A provider request for prior authorization of nonemergency
service must be answered within two business days, and qualified
health care personnel must be available for same-day telephone
responses to inquiries concerning certification of continued
length of stay.
SECTION 57. ORS 743.845 is amended to read:
743.845. (1) { - For purposes of this section: - }
{ - (a) 'Pregnancy care' means the care necessary to support
a healthy pregnancy and care related to labor and delivery. - }
{ - (b) - } { + As used in this section, + } 'women's
health care provider' means an obstetrician or gynecologist,
physician assistant specializing in women's health, advanced
registered nurse practitioner specialist in women's health or
certified nurse midwife, practicing within the applicable lawful
scope of practice.
(2) Every health insurance policy that covers hospital, medical
or surgical expenses and requires an enrollee to designate a
participating primary care provider shall permit a female
enrollee to designate a women's health care provider as the
enrollee's primary care provider if:
(a) The women's health care provider meets the standards
established by the insurer in collaboration with interested
parties, including but not limited to the Oregon section of the
American College of Obstetricians and Gynecologists; and
(b) The women's health care provider requests that the insurer
make the provider available for designation as a primary care
provider.
(3) If a female enrollee has designated a primary care provider
who is not a women's health care provider, an insurance policy as
described in subsection (2) of this section shall permit the
enrollee to have direct access to a women's health care provider
{ - for the following services: - } { + , without a referral or
prior authorization, for obstetrical or gynecological care by a
participating health care professional who specializes in
obstetrics or gynecology. + }
{ - (a) At least one annual preventative women's health
examination; - }
{ - (b) Medically necessary follow-up visits resulting from a
preventative women's health examination. A health plan may
require the women's health care provider to notify and consult
with the enrollee's primary care provider; and - }
{ - (c) Pregnancy care. - }
(4) The standards established by the insurer under subsection
(2) of this section shall not prohibit an insurer from
establishing the maximum number of participating primary care
providers and participating women's health care providers
necessary to serve a defined population or geographic service
area.
SECTION 58. ORS 743.857 is amended to read:
743.857. (1) An insurer offering health benefit plans in this
state shall have an external review program that meets the
requirements of this section and ORS { - 743.859 and - }
743.861. Each insurer shall provide the external review through
an independent review organization that is under contract with
the Director of the Department of Consumer and Business Services
to provide external review. Each health benefit plan must allow
an enrollee, by applying to the insurer { + or the director + },
to obtain review by an independent review organization of a
dispute relating to an adverse { - decision - } { + benefit
determination + } by the insurer { - 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. - }
{ - (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. - }
(2) An insurer shall incur all costs of its external review
program. The insurer may not establish or charge a fee payable by
enrollees for conducting external review.
(3) When an enrollee applies for external review, the
{ - insurer shall request the director to - } { + director
shall + } appoint an independent review organization. When an
independent review organization is appointed, the insurer shall
forward all medical records and other relevant materials to the
independent review organization { - and - } { + no later than
six days after the appointment. The insurer + } shall produce
additional information as requested by the independent review
organization to the extent that the information is reasonably
available to the insurer. { - The insurer shall furnish all
such records, materials and information in a timely manner in
order to enable a timely decision by the independent review
organization. The director may establish timelines for the
purpose of this subsection. - } { + An insurer's failure to
furnish records, information and materials to the independent
review organization in a timely manner is grounds for an
immediate reversal of the adverse benefit determination.
(4) An enrollee may submit additional information to the
independent review organization no later than five days after the
enrollee's receipt of notification of the appointment of the
independent review organization and the organization must
consider the information in its review.
(5) The insurer and the director shall expedite the external
review:
(a) If the adverse benefit determination concerns an admission,
the availability of care, a continued stay or a health care
service for a medical condition for which the enrollee received
emergency services and has not been discharged from a health care
facility; or + }
{ - (4) - } { + (b) + } { - An insurer shall expedite an
enrollee's case - } If a provider with an established clinical
relationship to the enrollee certifies in writing and provides
supporting documentation that the ordinary time period for
external review would seriously jeopardize the life or health of
the enrollee or the enrollee's ability to regain maximum
function.
SECTION 59. ORS 743.859 is amended to read:
743.859. { - (1) - } An insurer of a health benefit plan
shall include in the plan the following statements, in boldfaced
type or otherwise emphasized:
{ - (a) - } { + (1) + } A statement of the right of
enrollees to apply for external review by an independent review
organization; and
{ - (b) A statement of whether the insurer agrees to be bound
by decisions of independent review organizations. - }
{ - (2) If an insurer states in the health benefit plan as
provided in subsection (1) of this section that the insurer is
not bound by the decisions of independent review organizations,
the plan and the written information provided by the plan must
prominently disclose that: - }
{ - (a) The insurer is not bound by the decisions of
independent review organizations; - }
{ - (b) The insurer may follow nonetheless a decision by an
independent review organization; and - }
{ - (c) - } { + (2) A statement that + } if the insurer
does not follow a decision of an independent review organization,
the enrollee has the right to sue the insurer.
{ - (3) If an insurer states in the health benefit plan as
provided in subsection (1) of this section that the insurer is
bound by the decisions of independent review organizations, the
plan must prominently disclose that fact. The plan must also
state that the insurer agrees to act in accordance with the
decision of the independent review organization notwithstanding
the definition of medical necessity in the plan. - }
SECTION 60. ORS 743.861 is amended to read:
743.861. (1) An enrollee shall apply in writing for external
review of an adverse { - decision - } { + benefit
determination + } by the insurer of a health benefit plan not
later than the 180th day after receipt of the insurer's final
written decision following its internal review through its
grievance and appeal process under ORS 743.804. An enrollee is
eligible for external review only if the enrollee has satisfied
the following requirements:
(a) The enrollee must have signed a waiver granting the
independent review organization access to the medical records of
the enrollee.
(b) The enrollee must have exhausted the plan's internal
grievance procedures established pursuant to ORS 743.804 { + or
be considered to have exhausted the plan's internal grievance
procedures according to rules adopted by the Department of
Consumer and Business Services + }. The insurer may waive the
requirement of compliance with the internal grievance procedures
and have a dispute referred directly to external review upon the
enrollee's consent.
(2) An enrollee who applies for external review of an adverse
{ - decision - } { + benefit determination + } shall provide
complete and accurate information to the independent review
organization { - in a timely manner - } { + as provided in
ORS 743.857 + }.
SECTION 61. ORS 743.862 is amended to read:
743.862. (1) An independent review organization shall perform
the following duties when appointed under ORS 743.857 to review a
dispute under a health benefit plan between an insurer and an
enrollee:
(a) Decide whether the dispute { - is covered by the
conditions established in ORS 743.857 for external review - }
{ + pertains to an adverse benefit determination + } and notify
the enrollee and insurer in writing of the decision. If the
decision is against the enrollee, the independent review
organization shall notify the enrollee of the right to file a
complaint with or seek other assistance from the { - Director
of the - } Department of Consumer and Business Services and the
availability of other assistance as specified by the
{ - director - } { + department + }.
(b) Appoint a reviewer or reviewers as determined appropriate
by the independent review organization.
(c) Notify the enrollee of information that the enrollee is
required to provide and any additional information the enrollee
may provide, and when the information must be submitted { + as
provided in ORS 743.857 + }.
(d) Notify the insurer of additional information the
independent review organization requires and when the information
must be submitted { + as provided in ORS 743.857 + }.
(e) Decide the dispute relating to the adverse
{ - decision - } { + benefit determination + } of the insurer
{ - under ORS 743.857 (1) - } and issue the decision in
writing.
(2) A decision by an independent review organization shall be
based on expert medical judgment after consideration of the
enrollee's medical record, the recommendations of each of the
enrollee's providers, relevant medical, scientific and
cost-effectiveness evidence and standards of medical practice in
the United States. An independent review organization must make
its decision in accordance with the coverage described in the
health benefit 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 the standards of
the insurer are unreasonable or are inconsistent with sound
medical practice.
(3) When review is expedited, the independent review
organization shall issue a decision not later than the third day
after the date on which the enrollee applies to the insurer for
an expedited review { + or the Director of the Department of
Consumer and Business Services orders an expedited review + }.
(4) When a review is not expedited, the independent review
organization shall issue a decision not later than the 30th day
after the enrollee applies to the insurer for a review { + or
the director orders a review + }.
(5) An independent review organization shall file synopses of
its decisions with the director according to the format and other
requirements established by the director. The synopses shall
exclude information that is confidential, that is otherwise
exempt from disclosure under ORS 192.501 and 192.502 or that may
otherwise allow identification of an enrollee. The director shall
make the synopses public.
SECTION 62. ORS 743.863 is amended to read:
743.863. (1) If an insurer { - has agreed under the
provisions of a health benefit plan to be bound by the decision
of an independent review organization and the insurer fails to
comply with such a decision - } { + fails to comply with the
decision of an independent review organization under ORS
743.862 + }, the Director of the Department of Consumer and
Business Services shall impose on the insurer a civil penalty of
not less than $100,000 and not more than $1 million.
(2) A decision of an independent review organization is
admissible in any legal proceeding involving the insurer or the
enrollee and involving the disputed issues subject to external
review.
(3) The sanctions under subsection (1) of this section and the
remedies under subsection (2) of this section are in addition to
and not in lieu of other sanctions, rights and remedies provided
by law or contract.
SECTION 63. ORS 743.864 is amended to read:
743.864. (1) An enrollee who is the subject of a decision of an
independent review organization has a private right of action
against the insurer for damages arising from an adverse
{ - decision - } { + benefit determination + } by the insurer
that is subject to external review if { - : - }
{ - (a) The insurer states in the health benefit plan in
which the enrollee is enrolled that the insurer is not bound by
the decisions of an independent review organization; and - }
{ - (b) - } the insurer fails to comply with the decision.
(2) The Legislative Assembly intends that there is no private
right of action under subsection (1) of this section if a court
finds { - either subsection (1)(a) or (b) - } { + subsection
(1) + } of this section to be unconstitutional or otherwise void.
SECTION 64. ORS 743.878 is amended to read:
743.878. { - (1) - } An insurer offering a health benefit
plan as defined in ORS 743.730 must submit to the Director of the
Department of Consumer and Business Services:
{ - (a) - } { + (1) + } Upon request by the director, the
methodology used to determine the insurer's allowable charges for
out-of-network procedures and services or, if the insurer uses a
third party to determine the charges, the methodology used by the
third party to determine allowable charges;
{ - (b) - } { + (2) + } For approval, a written explanation
of the method used by the insurer to determine the allowable
charge, that is in plain language and that must be provided upon
request to enrollees directly, or, in the case of group coverage,
to the employer or other policyholder for distribution to
enrollees; and
{ - (c) - } { + (3) + } Information prescribed by the
director as necessary to assess the effect of the disclosure
requirements in ORS 743.874 and 743.876 on the individual and
group health insurance markets.
{ - (2) The director shall consider the recommendations of
the Health Insurance Reform Advisory Committee in prescribing the
information required for submission under subsection (1)(c) of
this section. - }
SECTION 65. ORS 743.913 is amended to read:
743.913. (1) An insurer that fails to pay a claim to a provider
within the timelines established in ORS 743.911 shall pay simple
interest of 12 percent per annum on the unpaid amount of the
claim that is due and owing, accruing from the date after the
payment was due until the claim is paid. Interest on any overdue
payment for a claim begins to accrue on the 31st day after:
(a) The date on which the insurer received the claim; or
(b) The date the insurer receives the requested additional
information.
(2) The interest is payable with the payment of the claim. An
insurer is not required to pay interest that is in the amount of
$2 or less on any claim.
(3) The availability of interest under subsection (1) of this
section is in addition to and not in lieu of administrative
actions and penalties that may be imposed by the Director of the
Department of Consumer and Business Services under the Insurance
Code { + or federal health insurance laws + }.
SECTION 66. ORS 743A.080 is amended to read:
743A.080. { + (1) As used in this section, 'pregnancy care '
means the care necessary to support a healthy pregnancy and care
related to labor and delivery.
(2) + } All health benefit plans as defined in ORS 743.730 must
provide payment or reimbursement for expenses associated with
pregnancy care { - , as defined by ORS 743.845, - } and
childbirth. Benefits provided under this section shall be
extended to all enrollees, enrolled spouses and enrolled
dependents.
SECTION 67. ORS 743A.090 is amended to read:
743A.090. (1) All individual and group health insurance
policies providing hospital, medical or surgical expense benefits
that include coverage for a family member of the insured shall
also provide that the health insurance benefits applicable for
children in the family shall be payable with respect to:
(a) A { - newly born - } child of the insured from the
moment of birth; and
(b) An adopted child effective upon placement for adoption.
(2) The coverage of { - newly born - } { + natural + } and
adopted children required by subsection (1) of this section shall
consist of coverage { + of preventive health services and
treatment + } of injury or sickness, including the necessary care
and treatment of medically diagnosed congenital defects and birth
abnormalities.
(3) If payment of a specific premium is required to provide
coverage for a child, the policy may require that notification of
the birth of the child or of the placement for adoption of the
child and payment of the premium be furnished the insurer within
31 days after the date of birth or date of placement in order to
have the coverage extended beyond the 31-day period.
(4) { - The following requirements apply to coverage of an
adopted child required by subsection (1)(b) of this section: - }
{ - (a) - } In any case in which a policy provides coverage
for dependent children of participants or beneficiaries, the
policy shall provide benefits to dependent children placed with
participants or beneficiaries for adoption under the same terms
and conditions as apply to the natural, dependent children of the
participants and beneficiaries, regardless of whether the
adoption has become final.
{ - (b) A policy may not restrict coverage of any dependent
child adopted by a participant or beneficiary, or placed with a
participant or beneficiary for adoption, solely on the basis of a
preexisting condition of the child at the time that the child
would otherwise become eligible for coverage under the plan if
the adoption or placement for adoption occurs while the
participant or beneficiary is eligible for coverage under the
plan. - }
(5) As used in this section:
(a) 'Child' means, in connection with any adoption, or
placement for adoption of the child, an individual who { - has
not attained 18 years of age - } { + is under 18 years of age
+ }as of the date of the adoption or placement for adoption { +
and who is under 26 years of age as of the date of the provision
of a benefit under the policy + }.
(b) 'Placement for adoption' means the assumption and retention
by a person of a legal obligation for total or partial support of
a child in anticipation of the adoption of the child. The
child's placement with a person terminates upon the termination
of such legal obligations.
(6) The provisions of ORS 743A.001 do not apply to this
section.
SECTION 68. ORS 743A.110 is amended to read:
743A.110. (1) All insurers offering a health benefit plan as
defined in ORS 743.730 shall provide payment, coverage or
reimbursement for the following mastectomy-related services as
determined by the attending physician and enrollee to be part of
the enrollee's course or plan of treatment:
(a) All stages of reconstruction of the breast on which a
mastectomy was performed, including but not limited to nipple
reconstruction, skin grafts and stippling of the nipple and
areola;
(b) Surgery and reconstruction of the other breast to produce a
symmetrical appearance;
(c) Prostheses;
(d) Treatment of physical complications of the mastectomy,
including lymphedemas; and
(e) Inpatient care related to the mastectomy and
post-mastectomy services.
(2) An insurer providing coverage under subsection (1) of this
section shall provide written notice describing the coverage to
the enrollee at the time of enrollment in the health benefit plan
and annually thereafter.
(3) A health benefit plan must provide a single determination
of prior authorization for all mastectomy-related services
covered under subsection (1) of this section that are part of the
enrollee's course or plan of treatment.
(4) When an enrollee requests an external review of an adverse
{ - decision - } { + benefit determination as defined in ORS
743.801 + } by the insurer regarding services described in
subsection (1) of this section, the insurer { + or the Director
of the Department of Consumer and Business Services + } must
expedite the enrollee's case pursuant to ORS 743.857
{ - (4) - } { + (5) + }.
(5) The coverage required under subsection (1) of this section
is subject to the same terms and conditions in the plan that
apply to other benefits under the plan.
(6) This section is exempt from ORS 743A.001.
SECTION 69. ORS 744.718 is amended to read:
744.718. (1) The Director of the Department of Consumer and
Business Services shall suspend, revoke or refuse to renew a
license of a third party administrator if the director finds that
the third party administrator:
(a) Is in an unsound financial condition;
(b) Is using such methods or practices in the conduct of
business so as to render further transaction of business by the
third party administrator in this state hazardous or injurious to
insured persons or to the public; or
(c) Has failed to pay any judgment rendered against the third
party administrator in this state within 60 days after the
judgment has become final.
(2) The director may suspend, revoke, refuse to issue or refuse
to renew a license of a third party administrator if the director
finds one or more of the following with respect to a third party
administrator or an applicant for a license therefor:
(a) Falsification by the applicant or licensee of an
application for the license or renewal thereof, or engagement in
any dishonest act in relation to the application;
(b) Dishonesty, fraud or gross negligence in the transaction of
insurance or in the conduct of business as a third party
administrator;
(c) Conduct resulting in a conviction of a felony under the
laws of any state or of the United States, to the extent that
such conduct may be considered under ORS 670.280;
(d) Conviction of any crime, an essential element of which is
dishonesty or fraud, under the laws of any state or of the United
States;
(e) Refusal to renew or cancellation, revocation or suspension
of authority to transact insurance or business as a third party
administrator or similar entity in another state;
(f) Failure to pay a civil penalty imposed by final order of
the director or to carry out terms of probation set by the
director;
(g) Refusal to be examined or to produce accounts, records or
files for examination, refusal by any officers to give
information with respect to the affairs of the third party
administrator or refusal to perform any other legal obligation as
to the examination when required by the director;
(h) Affiliation with or under the same general management or
interlocking directorate or ownership as another administrator or
insurer that unlawfully transacts business in this state;
(i) Failure at any time to meet any qualification for which
issuance of the license could have been refused had the failure
then existed and been known to the director; or
(j) Violation of any rule or order of the director or any
provision of the Insurance Code { + or federal health insurance
laws + }.
(3) The director may suspend or refuse to renew a license
immediately and without hearing if the director determines that
one or more of the following circumstances exist:
(a) The third party administrator is insolvent;
(b) A proceeding for receivership, conservatorship or
rehabilitation or other delinquency proceeding regarding the
third party administrator has been commenced in any state; or
(c) The financial condition or business practices of the third
party administrator otherwise pose an imminent threat to the
public health, safety or welfare of the residents of this state.
(4) A third party administrator holding a license that has not
been renewed or has been revoked shall surrender the license to
the director at the director's request.
(5) The director may take any other administrative action
authorized under the Insurance Code { + or federal health
insurance laws + } in addition to or in lieu of the actions
authorized under this section.
SECTION 70. ORS 746.650 is amended to read:
746.650. { + Except as otherwise provided in ORS 743.804,
743.806, 743.857 and 743.861: + }
(1) In the event of an adverse underwriting decision, the
insurer or insurance producer responsible for the decision must:
(a) Either provide the consumer proposed for coverage with the
specific reason or reasons for the adverse underwriting decision
in writing or advise the consumer that upon written request the
consumer may receive the specific reason or reasons in writing;
and
(b) Provide the consumer proposed for coverage with a summary
of the rights established under subsection (2) of this section
and ORS 746.640 and 746.645.
(2) Upon receipt of a written request within 90 business days
from the date of the mailing of notice or other communication of
an adverse underwriting decision to a consumer proposed for
coverage, the insurer or insurance producer shall furnish to the
consumer within 21 business days from the date of receipt of the
written request:
(a) The specific reason or reasons for the adverse underwriting
decision, in writing, if this information was not initially
furnished in writing pursuant to subsection (1) of this section;
(b) The specific items of personal information and privileged
information that support these reasons, subject to the following:
(A) The insurer or insurance producer is not required to
furnish specific items of privileged information if the insurer
or insurance producer has a reasonable suspicion, based upon
specific information available for review by the Director of the
Department of Consumer and Business Services, that the consumer
proposed for coverage has engaged in criminal activity, fraud,
material misrepresentation or material nondisclosure; and
(B) Specific items of individually identifiable health
information supplied by a health care provider shall be disclosed
either directly to the consumer about whom the information
relates or to a health care provider designated by the consumer
and licensed to provide health care with respect to the condition
to which the information relates, whichever the insurer or
insurance producer prefers; and
(c) The names and addresses of the institutional sources that
supplied the specific items of information described in paragraph
(b) of this subsection. However, the identity of any health care
provider must be disclosed either directly to the consumer or to
the designated health care provider, whichever the insurer or
insurance producer prefers.
(3) The obligations imposed by this section upon an insurer or
insurance producer may be satisfied by another insurer or
insurance producer authorized to act on its behalf.
(4) When an adverse underwriting decision results solely from
an oral request or inquiry, the explanation of reasons and
summary of rights required by subsection (1) of this section may
be given orally.
(5) Notwithstanding subsection (1) of this section, when an
adverse underwriting decision is based in whole or in part on
credit history or insurance score, the insurer or insurance
producer responsible for the decision must provide the consumer
proposed for coverage with the specific reason or reasons for the
adverse underwriting decision in writing. The notice must include
the following:
(a) A summary of no more than four of the most significant
credit reasons for the adverse underwriting decision, listed in
decreasing order of importance, that clearly identifies the
specific credit history or insurance score used to make the
adverse underwriting decision. An insurer or insurance producer
may not use 'poor credit history' or a similar phrase as a reason
for an adverse underwriting decision.
(b) The name, address and telephone number, including a
toll-free telephone number, of the consumer reporting agency that
provided the information for the consumer report.
(c) A statement that the consumer reporting agency used by the
insurer or insurance producer to obtain the credit history of the
consumer did not make the adverse underwriting decision and is
unable to provide the consumer with specific reasons why the
insurer or insurance producer made an adverse underwriting
decision.
(d) Information on the right of the consumer:
(A) To obtain a free copy of the consumer's consumer report
from the consumer reporting agency described in paragraph (b) of
this subsection, including the deadline, if any, for obtaining a
copy; and
(B) To dispute the accuracy or completeness of any information
in a consumer report furnished by the consumer reporting agency.
(6) Notwithstanding subsection (1) of this section, an insurer
or insurance producer responsible for an adverse underwriting
decision that is based in whole or in part on credit history or
insurance score must provide the notice required by subsection
(5) of this section only when the insurer or insurance producer
makes the initial adverse underwriting decision regarding a
consumer.
(7) Notwithstanding subsection (1) of this section, when an
adverse underwriting decision relating to homeowner insurance is
based in whole or in part on a loss history report, the insurer
or insurance producer responsible for the decision must provide
the consumer proposed for coverage with the specific reason or
reasons for the adverse underwriting decision in writing. The
notice must include the following:
(a) A description of a specific claim or claims that are the
basis for the specific loss history report used to make the
adverse underwriting decision.
(b) The name, address and telephone number, including a
toll-free telephone number, of the consumer reporting agency that
provided the information for the loss history report.
(c) A statement that the consumer reporting agency used by the
insurer or insurance producer to obtain the loss history report
of the consumer did not make the adverse underwriting decision
and is unable to provide the consumer with specific reasons why
the insurer or insurance producer made an adverse underwriting
decision.
(d) Information on the right of the consumer:
(A) To obtain a free copy of the consumer's loss history report
from the consumer reporting agency described in paragraph (b) of
this subsection, including the deadline, if any, for obtaining a
copy; and
(B) To dispute the accuracy or completeness of any information
in a loss history report furnished by the consumer reporting
agency.
(8) When an adverse underwriting decision relating to homeowner
insurance is based in part on credit history and in part on a
loss history report, the insurer or insurance producer
responsible for the adverse underwriting decision may provide the
notices required by subsections (5) and (7) of this section in a
single notice.
SECTION 71. ORS 750.055 is amended to read:
750.055. (1) The following provisions of the Insurance Code
apply to health care service contractors to the extent not
inconsistent with the express provisions of ORS 750.005 to
750.095:
(a) ORS 705.137, 705.139, 731.004 to 731.150, 731.162, 731.216
to 731.362, 731.382, 731.385, 731.386, 731.390, 731.398 to
731.430, 731.428, 731.450, 731.454, 731.488, 731.504, 731.508,
731.509, 731.510, 731.511, 731.512, 731.574 to 731.620, 731.592,
731.594, 731.640 to 731.652, 731.730, 731.731, 731.735, 731.737,
731.750, 731.752, 731.804, 731.844 to 731.992 and 731.870.
(b) ORS 732.215, 732.220, 732.230, 732.245, 732.250, 732.320,
732.325 and 732.517 to 732.592, not including ORS 732.582.
(c) ORS 733.010 to 733.050, 733.080, 733.140 to 733.170,
733.210, 733.510 to 733.680 and 733.695 to 733.780.
(d) ORS chapter 734.
(e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065, 742.150
to 742.162, 742.400, 742.520 to 742.540, 743.010, 743.013,
743.018 to 743.030, 743.050, 743.100 to 743.109, 743.402,
743.472, 743.492, 743.495, 743.498, 743.522, 743.523, 743.524,
743.526, 743.527, 743.528, 743.529, 743.549 to 743.552, 743.560,
743.600 to 743.610, 743.650 to 743.656, 743.804, 743.807,
743.808, 743.814 to 743.839, 743.842, 743.845, 743.847, 743.854,
743.856, 743.857, 743.858, 743.859, 743.861, 743.862, 743.863,
743.864, 743.911, 743.912, 743.913, 743.917, 743A.010, 743A.012,
743A.020, 743A.036, 743A.048, 743A.058, 743A.062, 743A.064,
743A.066, 743A.068, 743A.070, 743A.080, 743A.084, 743A.088,
743A.090, 743A.100, 743A.104, 743A.105, 743A.110, 743A.140,
743A.141, 743A.144, 743A.148, 743A.160, 743A.164, 743A.168,
743A.170, 743A.175, 743A.184, 743A.188, 743A.190 and
743A.192 { + and section 5 of this 2011 Act + }.
(f) The provisions of ORS chapter 744 relating to the
regulation of insurance producers.
(g) ORS 746.005 to 746.140, 746.160, 746.220 to 746.370,
746.600, 746.605, 746.607, 746.608, 746.610, 746.615, 746.625,
746.635, 746.650, 746.655, 746.660, 746.668, 746.670, 746.675,
746.680 and 746.690.
(h) ORS 743A.024, except in the case of group practice health
maintenance organizations that are federally qualified pursuant
to Title XIII of the Public Health Service Act unless the patient
is referred by a physician associated with a group practice
health maintenance organization.
(i) ORS 735.600 to 735.650.
(j) ORS 743.680 to 743.689.
(k) ORS 744.700 to 744.740.
(L) ORS 743.730 to 743.773.
(m) ORS 731.485, except in the case of a group practice health
maintenance organization that is federally qualified pursuant to
Title XIII of the Public Health Service Act and that wholly owns
and operates an in-house drug outlet.
(2) For the purposes of this section, health care service
contractors shall be deemed insurers.
(3) Any for-profit health care service contractor organized
under the laws of any other state that is not governed by the
insurance laws of the other state is subject to all requirements
of ORS chapter 732.
(4) The Director of the Department of Consumer and Business
Services may, after notice and hearing, adopt reasonable rules
not inconsistent with this section and ORS 750.003, 750.005,
750.025 and 750.045 that are deemed necessary for the proper
administration of these provisions.
SECTION 72. ORS 750.313 is amended to read:
750.313. (1) The Director of the Department of Consumer and
Business Services shall issue a certificate of multiple employer
welfare arrangement to a multiple employer welfare arrangement by
and through its board of trustees if, upon completion of the
application for the certificate and upon investigation and review
of all information acquired by the director, the director does
all of the following:
(a) Approves the application for the certificate.
(b) Determines that the person applying for the certificate
satisfies the requirements in ORS 750.305, 750.307 and 750.309
for qualifying for and holding a certificate of multiple employer
welfare arrangement and satisfies all other applicable
requirements in the Insurance Code { + and federal health
insurance laws + }.
(2) The director shall take all necessary action and shall
either issue or refuse to issue a certificate within a reasonable
time after the completion of the application for the certificate.
SECTION 73. ORS 750.333 is amended to read:
750.333. (1) The following provisions of the Insurance Code
apply to trusts carrying out a multiple employer welfare
arrangement:
(a) ORS 731.004 to 731.150, 731.162, 731.216 to 731.268,
731.296 to 731.316, 731.324, 731.328, 731.378, 731.386, 731.390,
731.398, 731.406, 731.410, 731.414, 731.418 to 731.434, 731.454,
731.484, 731.486, 731.488, 731.512, 731.574 to 731.620, 731.640
to 731.652 and 731.804 to 731.992.
(b) ORS 733.010 to 733.050, 733.140 to 733.170, 733.210,
733.510 to 733.680 and 733.695 to 733.780.
(c) ORS chapter 734.
(d) ORS 742.001 to 742.009, 742.013, 742.061 and 742.400.
(e) ORS 743.028, 743.053, 743.524, 743.526, 743.527, 743.528,
743.529, 743.530, 743.560, 743.562, 743.600, 743.601, 743.602,
743.610, 743.730 to 743.773 (except 743.760 to 743.773), 743.801,
743.804, 743.807, 743.808, 743.814 to 743.839, 743.842, 743.845,
743.847, 743.854, 743.856, 743.857, 743.858, 743.859, 743.861,
743.862, 743.863, 743.864, 743.912, 743.917, 743A.012, 743A.020,
743A.052, 743A.064, 743A.080, 743A.100, 743A.104, 743A.110,
743A.144, 743A.170, 743A.175, 743A.184 and 743A.192 { + and
section 5 of this 2011 Act + }.
(f) ORS 743A.010, 743A.014, 743A.024, 743A.028, 743A.032,
743A.036, 743A.040, 743A.048, 743A.058, 743A.066, 743A.068,
743A.070, 743A.084, 743A.088, 743A.090, 743A.105, 743A.140,
743A.141, 743A.148, 743A.168, 743A.180, 743A.188 and 743A.190.
Multiple employer welfare arrangements to which ORS 743.730 to
743.773 apply are subject to the sections referred to in this
paragraph only as provided in ORS 743.730 to 743.773.
(g) Provisions of ORS chapter 744 relating to the regulation of
insurance producers and insurance consultants, and ORS 744.700 to
744.740.
(h) ORS 746.005 to 746.140, 746.160 and 746.220 to 746.370.
(i) ORS 731.592 and 731.594.
(j) ORS 731.870.
(2) For the purposes of this section:
(a) A trust carrying out a multiple employer welfare
arrangement shall be considered an insurer.
(b) References to certificates of authority shall be considered
references to certificates of multiple employer welfare
arrangement.
(c) Contributions shall be considered premiums.
(3) The provision of health benefits under ORS 750.301 to
750.341 shall be considered to be the transaction of health
insurance.
SECTION 74. Section 4, chapter 75, Oregon Laws 2010, is amended
to read:
{ + Sec. 4. + } (1) An insurer who elects to offer discounted
rates for a health insurance plan utilizing electronic
administration shall include the schedule of discounts for
utilization of electronic administration as part of a small
employer group health insurance or individual health insurance
rate filing. The rate discounts may be graduated and must be
proportionate to the amount of administrative cost savings the
insurer anticipates as a result of the use of electronic
transactions described in section { + 3, chapter 75, Oregon Laws
2010 + } { - 3 of this 2010 Act - } .
(2) Discounted rates allowed under this section shall be
applied uniformly to all similarly situated small employer group
or individual health insurance purchasers of an insurer.
(3) Discounts in premium rates under this section are not
premium rate variations for purposes of ORS 743.737 { - (8) - }
{ + (9) + } or 743.767.
SECTION 75. { + Sections 1, 3 and 5 of this 2011 Act, the
amendments to statutes and session laws by sections 6 to 36 and
38 to 74 of this 2011 Act and the repeal of section 12, chapter
752, Oregon Laws 2007, by section 37 of this 2011 Act apply to
policies or certificates issued or renewed on or after September
23, 2010. + }
SECTION 76. { + The Health Insurance Reform Advisory Committee
is abolished. + }
SECTION 77. { + This 2011 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2011 Act takes effect on
its passage. + }
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