Oregon Administrative Code

836-052-0726 Suitability (1) This rule does not apply to life insurance policies that accelerate benefits for long-term care. (2) Each insurer, health care service plan or other entity shall: (a) Develop and use suitability standards to determine whether the purchase or replaceme…

836-052-0736 Prohibition Against Preexisting Conditions, Waiting Periods and Probationary Periods in Replacement Policies and Certificates (1) If a long-term care insurance policy replaces another long-term care insurance policy, the replacing insurer shall waive any time periods…

836-052-0738 Availability of New Services or Providers (1) An insurer shall notify policyholders of the availability of a new long term policy series that provides coverage for new long term care services or providers that are material in nature and not previously available throu…

836-052-0740 Right to Reduce Coverage and Lower Premiums (1) Every long term care insurance policy and certificate must include a provision that allows the policyholder or certificate holder to reduce coverage and lower the policy or certificate premium in at least one of the fol…

836-052-0746 Nonforfeiture Benefit Requirement (1) This rule does not apply to life insurance policies or riders containing accelerated long-term care benefits. (2) To comply with the requirement to offer a nonforfeiture benefit pursuant to the provisions of ORS 743.664: (a) A lo…

836-052-0756 Standards for Benefit Triggers (1) A long-term care insurance policy shall condition the payment of benefits on a determination of the insured's ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits shall n…

836-052-0766 Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts (1) For purposes of this rule, the following definitions apply: (a) "Qualified long-term care services" means services that meet the requirements of Section 7702(c)(1) of the I…

836-052-0768 Appealing An Insurer’s Determination That The Benefit Trigger Is Not Met (1) For purposes of this rule, “authorized representative” means a person who is authorized to act as the covered person’s personal representative within the meaning of 45 CFR 164.502(g) promulg…

836-052-0770 Prompt Payment of Clean Claims (1) For purposes of this rule: (a) “Claim” means a request for payment of benefits under an in-force policy, regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met. (…

836-052-0776 Standard Format Outline of Coverage (1) This rule implements, interprets and makes specific the provisions of ORS 743.655(7) in prescribing a standard format and the content of an outline of coverage. The format for the outline of coverage shall be as provided by the…

836-052-0786 Requirement to Deliver Shopper’s Guide (1) A long-term care insurance Shopper's Guide in a form approved by the Director shall be provided to all prospective applicants of a long term care insurance policy, certificate or rider as provided in this rule. (2) For the p…

836-052-0790 Disclosure of Benefits Paid (1) Each insurer shall provide at a minimum the following information at least quarterly to each insured, or a designee of the insured, who is currently receiving, or has received during that quarter, any benefits under a qualified long te…

836-052-0800 Purpose; Applicability OAR 836-052-0800 to 836-052-0860 are adopted for the purpose of carrying out ORS 743.526, 743.560, 743.562 and 743.565. Statutory/Other Authority: ORS 731.244, 743.526, 743.560 & 743.562 Statutes/Other Implemented: ORS 743.526, 743.560 & 743.56…

836-052-0810 Replacement Upon Termination For purposes of the notice requirement under ORS 743.560, replacement of the terminated group health insurance coverage occurs when all classes of persons covered by the terminated policy are eligible for coverage: (1) Under a group healt…

836-052-0840 Termination of Coverage For purposes of ORS 743.560 and 743.562, termination of coverage under a group health insurance policy includes the amendment or reissuance of a policy to delete one or more classes of certificate holders from coverage. Statutory/Other Authori…

836-052-0850 Multiple Employer Trusts (1) For purposes of ORS 743.560 and 743.562, a multiple employer trust is a trust to which a group health insurance policy has been issued, that is established and controlled by the insurer issuing the group health insurance policy. (2) Termi…

836-052-0860 Form of Notice to Group Policyholder (1) The form of the notice required by ORS 743.560 shall be as established in this rule. The form shall be printed in 12 point type, one point leaded, and shall provide at least the following: (a) The date of the notice; (b) A sta…

836-052-1000 Prosthetic and Orthotic Devices (1) For purposes of this rule, the term device has the meaning given under ORS 743A.145. (2) The list of devices that must be covered under ORS 743A.145, includes: (a) Any device for which the Centers for Medicare and Medicaid Services…

836-053-0000 Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53 (1) Except as provided in section (3) of this rule, the January 1, 2014 amendment to rules in OAR chapter 836, division 53 as amended effective January 1, 2014 apply to health benefit plans i…

836-053-0001 Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements (1) A modification of a health benefit plan not subject to the levels of coverage defined in 42 U.S.C. 18022(d) is defined in this rule for the purposes of: (a) ORS 743.737 and 743.754,…

836-053-0002 Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements (1) A modification of a health benefit plan subject to the levels of coverage defined in 42 U.S.C. 18022(d) is defined in this rule for the purposes of: (a) ORS 743B.013, regarding small…

836-053-0003 Prohibition of Exclusion Period for Pregnancy A carrier may not impose an exclusion period or a waiver in a health benefit plan for pregnancy and childbirth expenses, for which coverage is required by ORS 743A.080. Statutory/Other Authority: ORS 731.244 Statutes/Othe…

836-053-0004 Compliance with Federal and State Law Upon contract issuance or renewal, any insurer offering a health benefit plan must update the plans of the insurer as necessary to comply with state and federal law. Statutory/Other Authority: ORS 731.244 Statutes/Other Implement…

836-053-0005 Prescription Drug Identification Cards (1) This rule establishes minimum standards for prescription drug identification cards or other technologies that are required by ORS 743.788 to be issued by carriers, administrators of health benefit plans, third party administ…

836-053-0006 Issuance of Group Health Benefit Coverage to Employer Association (1) As used in this rule, the term “employer association” refers to an association or other group of employers that sponsors, or wishes to sponsor one or more fully insured group health benefit plan fo…

836-053-0007 Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements (1) Before an insurer may issue coverage to an association, trust, discretionary group or Multiple Employer Welfare Arrangement (MEWA) not already appr…

836-053-0008 Essential Health Benefits for Plan Years 2014, 2015 and 2016 (1) This rule applies to plan years beginning January 1, 2014 through December 31, 2016. (2) As used in the Insurance Code for plan years beginning January 1, 2014 through December 31, 2016 only: (a) “Base …

836-053-0009 Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016 (1) This rule applies to plan years beginning January 1, 2014 through December 31, 2016. (2) As used in this rule, “coverage” includes medically necessary benefits, services, pr…

836-053-0011 Standard Bronze Plan Health Savings Account Eligible Requirement (1) If a plan or product is HSA eligible under applicable federal law, the insurer or health care service contractor shall clearly indicate on any applicable plan and benefits template or other plan or …

836-053-0012 Essential Health Benefits for Plan Years Beginning on and after January 1, 2017 (1) This rule applies to plan years beginning on and after January 1, 2017. (2) As used in the Insurance Code and OAR chapter 836: (a) “Applied behavior analysis” has that meaning given i…

836-053-0013 Oregon Standard Bronze and Silver Health Benefit Plans (1) This rule applies to plan years beginning on and after January 1, 2017. (2) As used in this rule, "coverage" includes medically necessary benefits, services, prescription drugs and medical devices. "Coverage"…

836-053-0014 Standards and Process for Shortened Period of Market Prohibition (1) In order to be eligible for consideration by the director for a shortened period of prohibition under ORS 743B.012, 743B.104 or 743B.126 , a carrier must have met at least one of the following condi…

836-053-0015 Definition of Small Employer (1) This rule establishes the methodology for defining a small employer to be used in any instance in which the definition set forth in ORS 743B.005 would apply and in rules of the Department of Consumer and Business Services implementing…

836-053-0017 Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022 (1) In addition to any other benefits required under state or federal law, a health benefit plan required to provide essential health benefits within the meaning of ORS 731.0…

836-053-0019 Purpose; Statutory Authority; Enforcement (1) OAR 836-053-0010 to 836-053-0070 are adopted for the purpose of implementing ORS 743B.003 to 743B.013 and 743B.100, pursuant to the authority of ORS 731.244, 743B.003 to 743B.013 and 743B.100. (2) Violation of any provisi…

836-053-0021 Plans Offered to Oregon Small Employers (1) A small employer carrier shall issue a plan to a small employer if the employee eligibility criteria established by the small employer meet the requirements of this section. A carrier must follow the methodology and address…

836-053-0027 Copayments for Certain Primary Care Visits (1) As used in this section, “primary care” means outpatient behavioral health services, non-specialty medical services or the coordination of health care for the purpose of: (a) Promoting or maintaining behavioral and physi…

836-053-0028 Primary Care Provider Assignment Methodology (1) As used in these rules: (a) “Enrollee” means an employee, dependent of the employee or an individual otherwise eligible for a group or individual health benefit plan who has enrolled for coverage under the terms of the…

836-053-0030 Marketing of a Health Benefit Plan to Small Employers (1) A carrier may offer different small employer health benefit plans in different geographic areas. The bronze and silver plan required to be offered under ORS 743B.130 and a point-of-service plan required under …

836-053-0050 Trade Practices Relating to Small Employer Health Benefit Plans (1) When offering plans to small employers, a carrier must briefly describe the variety of small employer plans and plan options that are available from the carrier and must specify that: (a) Nongrandfat…

836-053-0063 Rating for Nongrandfathered Small Group Plans The following provisions relating to rating apply to nongrandfathered health benefit plans offered to small employers: (1) A small employer carrier shall file a single geographic average rate for each nongrandfathered hea…

836-053-0065 Rating for Grandfathered Small Group Plans The following provisions relating to rating apply to grandfathered health benefit plans offered to small employers: (1) A small employer carrier shall file a single geographic average rate for each grandfathered health benef…

836-053-0066 Rating for Transitional Health Benefit Plans Offered to Small Employers For purposes of rating, a transitional health benefit plan offered to small employers: (1) Is subject to the requirements of OAR 836-053-0065 that apply to grandfathered health benefit plans offe…

836-053-0070 Multiple Employer Welfare Arrangements For purposes of determining whether a multiple employer welfare arrangement is exempt from the requirements of the Insurance Code that apply to a small employer carrier, the director must consider the following factors: (1) Whet…

836-053-0100 Work Related Injuries or Disease A carrier may not impose an exclusion or waiver in a health benefit plan for coverage of any service otherwise provided under the plan solely on the basis that the service is provided for a work-related injury or occupational disease.…

836-053-0105 Coordination of Payment for Interim Medical Services (1) As used in this section: (a) “Expedited preauthorization” means a determination by an insurer prior to provision of interim medical services that the insurer will provide reimbursement for the services. (b) “He…

836-053-0211 Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan (1) As used in this rule, an “enrollee” includes an employee covered under a group health benefit plan and a dependent of an…

836-053-0221 Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans (1) For every group health benefit plan, a carrier that chooses to enforce participation, contribution or eligibility requirements must…

836-053-0230 Underwriting (1) Every group health benefit plan issued by a carrier must specify all of the participation, contribution and eligibility requirements that have been agreed upon by the carrier and the covered group, and the carrier must apply those requirements unifor…

836-053-0300 Purpose; Statutory Authority; Applicability of Network Adequacy Requirements (1) OAR 836-053-0300 to 836-053-0355 are adopted for the purpose of implementing ORS 743B.505. (2) The requirements set forth in OAR 836-053-0310 to 836-053-0355 apply to all carriers offeri…