Oregon Administrative Code

836-052-0133 Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010 (1) The following standards in this rule are applicable to all …

836-052-0134 Minimum Benefit Standards for Policies or Certificates Issued for Delivery Prior to July 1, 1992 (1) A policy or certificate may not be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless it meets or exceed…

836-052-0136 Standard Medicare Supplement Benefit Plans for 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery on or After July 1, 1992 and with an Effective Date of Coverage Prior to June 1, 2010 (1) An issuer shall make available to …

836-052-0138 Open Enrollment (1)(a) An issuer may not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this state, nor discriminate in the pricing of a policy or certificate because of the health status, claims…

836-052-0139 Medicare Select Policies and Certificates (1) This section applies to Medicare Select policies and certificates, as defined in this rule. (2) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of thi…

836-052-0140 Standards for Claims Payment (1) An issuer must comply with Section 1882(c)(3) of the Social Security Act, as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Public Law No. 100-203, by: (a) Accepting a notice from a Medi…

836-052-0141 Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates with an Effective Date of Coverage on or After June 1, 2010 The following standards are applicable to all Medicare supplement policies or certif…

836-052-0142 Guaranteed Issue for Eligible Persons (1) Guaranteed issue: (a) Eligible persons are those individuals described in section (2) of this rule who seek to enroll under the policy during the period specified in section (3) of this rule and who submit evidence of the dat…

836-052-0143 Annual Opportunity to Select Another Medicare Supplement Policy or Certificate (1) For the purposes of this rule, for 1990, 2010, and 2020 Medicare Supplement Plans, “same or lesser benefits” means a policy or certificate of the same or lower benefit level as indicat…

836-052-0144 Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or after January 1, 2020. The Medicare Access and CHIP Reauthorization Act of …

836-052-0145 Loss Ratio Standards and Refund or Credit of Premium (1) The following provisions of this section establish loss ratio standards: (a) A Medicare supplement policy form or certificate form shall not be delivered or issued for delivery unless the policy form or certifi…

836-052-0151 Filing and Approval of Policies and Certificates and Premium Rates (1) An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this state unless the policy form or certificate form has been filed with and approved by the Director in…

836-052-0156 Permitted Compensation Arrangements (1) An issuer or other entity may provide commission or other compensation to an insurance producer or other representative for the sale of a Medicare supplement policy or certificate only if the first year commission or other firs…

836-052-0160 Required Disclosure Provisions (1) The following provisions apply to all Medicare supplement policies and certificates: (a) Each Medicare supplement policy and certificate shall include a renewal or continuation provision. The language or specifications of the provis…

836-052-0165 Requirements for Application Forms, Replacement Coverage (1) Application forms shall include the statements and questions set forth in this section designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare s…

836-052-0170 Filing Requirements for Advertising An issuer shall provide to the Director a copy of any Medicare supplement advertisement intended for use in this state, whether through the written, radio or television medium, for review or approval by the Director to the extent i…

836-052-0175 Standards for Marketing (1) An issuer, directly or through its producers, shall: (a) Establish marketing procedures to assure that any comparison of policies by its insurance producers will be fair and accurate; (b) Establish marketing procedures to assure excessive …

836-052-0180 Appropriateness of Recommended Purchase and Excessive Insurance (1) In recommending the purchase or replacement of any Medicare supplement policy or certificate, an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or repl…

836-052-0185 Reporting of Multiple Policies (1) On or before March 1 of each year, each issuer shall report to the Director the following information for every individual resident of this state for which the issuer has in force more than one Medicare supplement insurance policy o…

836-052-0190 Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies and Certificates (1) If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the repla…

836-052-0192 Prohibition Against Use of Genetic Information and Requests for Genetic Testing (1) This section applies to all policies with policy years beginning on or after May 21, 2009. (2) An issuer of a Medicare supplement policy or certificate shall not: (a) Deny or conditio…

836-052-0194 Separability If any provision of OAR 836-052-0103 to 836-052-0194 or the application thereof to any person or circumstance is held to be invalid for any reason, the remainder of 836-052-0103 to 836-052-0194 shall not be affected thereby. Statutory/Other Authority: OR…

836-052-0225 Durational Limits for Health Maintenance Organizations Text in ORMS History: Reverted to ID 9-1988, f. 6-9-88, cert. ef. 7-1-88 ID 4-1998(Temp), f. & cert. ef. 2-13-98 thru 8-10-98 ID 9-1988, f. 6-9-88, cert. ef. 7-1-88

836-052-0230 Provider Services Limits for Insurers and Health Care Contractors Text in ORMS History: Reverted to ID 9-1988, f. 6-9-88, cert. ef. 7-1-88 ID 4-1998(Temp), f. & cert. ef. 2-13-98 thru 8-10-98 ID 9-1988, f. 6-9-88, cert. ef. 7-1-88

836-052-0500 Statutory Authority; Applicability (1) OAR 836-052-0500 to 836-052-0786 are adopted pursuant to the requirements and authority of ORS 731.244,742.003, 742.005, 742.023, 743.013, 743.655, 743.656 and 746.240. (2) Except as otherwise specifically provided, OAR 836-052-…

836-052-0508 Definitions For the purpose of OAR 836-052-0500 to 836-052-0790: (1) The following have the meanings given those terms in ORS 743.652: (a) “Applicant;” (b) “Benefit trigger;” (c) “Certificate;” (d) “Group long term care insurance;” (e) “Long term care insurance;” (f)…

836-052-0516 Policy Definitions A long-term care insurance policy delivered or issued for delivery in this state shall not use the terms set forth in this rule unless the terms are defined in the policy according to the definitions in this rule and satisfy the requirements in OAR…

836-052-0526 Policy Practices and Provisions (1) Renewability. The terms "guaranteed renewable" and "noncancellable" shall not be used in any individual long-term care insurance policy without further explanatory language in accordance with the disclosure requirements of OAR 836-…

836-052-0531 Long Term Care Insurance Partnership Program (1) As used in this rule, "qualified long term care insurance partnership policy" or "partnership policy" means a long term care insurance policy that meets all of the following requirements: (a) The policy was issued on o…

836-052-0546 Required Policy Provisions (1) Renewability. Each individual long-term care insurance policy shall contain a renewability provision. The following requirements apply to such a provision: (a) The provision shall be appropriately captioned, shall appear on the first pa…

836-052-0556 Required Disclosure of Rating Practices to Consumers (1) This rule applies as follows: (a) Except as provided in subsection (b) of this section, this rule applies to any long term care policy or certificate issued in this state on or after March 1, 2006. (b) For cert…

836-052-0566 Initial Rate Filing Requirements (1)(a) Except as provided in subsection (b) of this section, this rule applies to any long-term care insurance policy issued in this state on or after March 1, 2006. (b) Sections (2)(b)(D) and (3) of this rule apply to any long-term c…

836-052-0576 Prohibition Against Post-Claims Underwriting, Applications (1) Each application for a long-term care insurance policy, rider or certificate, except those that are guaranteed issue, shall contain clear and unambiguous questions designed to ascertain the health conditi…

836-052-0586 Minimum Standards for Home Health and Community Care Benefits in Long-Term Care Insurance Policies (1) A long-term care insurance policy, certificate or rider that provides benefits for home care services or community care services may not limit or exclude those bene…

836-052-0596 Standards for Covered Services This rule establishes standards for covered services for the purpose of payment of benefits pursuant to ORS 743.656. An insurer shall not define the covered services more restrictively than the following minimum standards, or similar st…

836-052-0606 Use and Definition of “Home” or Similar Wording A long-term care insurance policy that defines “home” or uses similar wording to refer to the residence of the insured shall define or use wording that means or refers to the principal place of residence for the insured…

836-052-0616 Requirement to Offer Inflation Protection (1) An insurer may not offer a long-term care insurance policy unless the insurer also offers to the policyholder, in addition to any other inflation protection offered by the insurer, the option to purchase a policy that pro…

836-052-0626 Requirements for Application Forms and Replacement Coverage (1) An application form for long-term care insurance shall include the questions set forth in this section designed to elicit information as to whether, as of the date of the application, the applicant has a…

836-052-0636 Reporting Requirements (1) Every insurer shall maintain records for each insurance producer of that insurance producer's amount of replacement sales as a percent of the insurance producer's total annual sales and the amount of lapses of long-term care insurance polic…

836-052-0637 Annual Rate Certification Requirements (1) This rule applies to any long-term care policy issued in this state on or after January 1, 2016. (2) The following annual submission requirements apply subsequent to initial rate filings for individual long-term care insuran…

836-052-0639 Training for Insurance Producers (1) When the provider of a training course notifies an insurance producer that the insurance producer has successfully completed the training course and passed the examination, the insurance producer shall send the notice of completio…

836-052-0646 Benefits Provided Through Advancement of Life Insurance Proceeds (1) When long term care benefits are provided through early payment of a portion of a life insurance policy death benefit, the insurer may make no more than a pro rata reduction in the life insurance po…

836-052-0656 Reserve Standards (1)(a) Each insurer shall use the following standards for determining policy reserves for long-term care insurance: When long-term care benefits are provided through the acceleration of benefits under a group or individual life insurance policy or a…

836-052-0666 Loss Ratio (1) This rule applies to all long-term care insurance policies, certificates and riders except those that are subject to OAR 836-052-0566 and 836-052-0676. (2) Benefits under long-term care insurance policies and riders shall be deemed reasonable in relati…

836-052-0676 Premium Rate Schedule Increases (1) This rule applies as follows: (a) Except as provided in subsection (b) of this section, this rule applies to any long-term care insurance policy or certificate issued in this state on or after March 1, 2006 and prior to January 1, …

836-052-0680 Premium Rate Schedule Increases for Policies Subject to Loss Ratio Limits Related to Original Filings (1) This rule applies as follows: (a) Except as provided in section (1)(b) of this rule, this rule applies to any long-term care policy or certificate issued in this…

836-052-0686 Filing Requirements for Out-of-State Group Policies Each insurer providing group long-term care insurance benefits to a resident of this state under an exempt master group policy pursuant to ORS 731.486 issued outside of this state shall file, for informational purpo…

836-052-0696 Filing Requirements for Advertising At the request of the Director, every insurer, health care service plan or other entity providing long-term care insurance or benefits in this state shall provide to the Director a copy of any long-term care insurance advertisement…

836-052-0706 Standards for Marketing (1) Every insurer, health care service plan or other entity marketing long-term care insurance coverage in this state, directly or through its insurance producers, shall: (a) Establish marketing procedures and insurance producer training requi…

836-052-0716 Disclosure Statement (1) An insurer offering long-term care insurance coverage in this state shall deliver a disclosure statement as provided in this rule to the insured under a long-term care insurance policy, rider or certificate or separately but at the same time …