Oregon Administrative Code

836-053-0310 Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0355 As used in OAR 836-053-0300 to 836-053-0355: (1) “Enrollee” means an employee, dependent of the employee or an individual otherwise eligible for a group or individual health benefit plan who has enroll…

836-053-0320 Annual Report Requirements for Network Adequacy (1) An insurer offering individual or small group health benefits plans must submit its annual report for each network required under ORS 743B.505 no later than March 31 of each year. (2) Beginning March 31, 2020, the a…

836-053-0325 Network Adequacy Reporting Requirements (1) By March 31 of each year, a carrier must submit a network adequacy report for each provider network used in connection with a health benefit plan offered or renewed in this state, demonstrating compliance with the requireme…

836-053-0330 Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements (1) Beginning with plan year 2020, an insurer electing to demonstrate compliance with network adequacy requirements established in ORS 743B.505 by submitting for ea…

836-053-0335 Nationally Recognized Standard for Annual Network Adequacy Evaluation (1) For purposes of the annual evaluation of network adequacy required by ORS 743B.505, the department adopts the nationally recognized standard for network adequacy, defined as the federal network…

836-053-0340 Factor-Based Evidence of Compliance with Network Adequacy Requirements (1) An insurer electing to demonstrate compliance with network adequacy requirements required under ORS 743.505B via the factor-based approach shall submit evidence of compliance to the Director b…

836-053-0345 Quantitative Network Adequacy Access Standards (1) Carriers must meet the following minimum quantitative access benchmarks as adopted in OAR 836-053-0335, consistent with the network adequacy standards for Qualified Health Plans set forth in 45 C.F.R. § 156.230, as i…

836-053-0350 Provider Directory Requirements for Network Adequacy (1)(a) A carrier shall post electronically a current, accurate and complete provider directory for each of its network plans with the information and search functions, as described in section (2) of this rule. (b) …

836-053-0355 Behavioral Health Network Composition and Reporting For the purpose of evaluating the sufficiency of a carrier’s network of behavioral health providers under ORS 743B.505(4)(b), the carrier must annually submit, as part of its network adequacy report, a behavioral he…

836-053-0410 Purpose; Statutory Authority; Enforcement (1) OAR 836-053-0410 to 836-053-0465 are adopted under the authority of ORS 743B.330, 743B.126 and 743B.310 for the purpose of implementing ORS 743B.022, 743B.125, 743B.126 and 743B.310 relating to individual health benefit p…

836-053-0415 Cancellation of an Individual Health Benefit Plan Coverage The notice requirements of ORS 743.499 and 743.894 are triggered at the time an insurer takes administrative action to terminate coverage. Statutory/Other Authority: ORS 743.499, 743.769 & 743.894 Statutes/Ot…

836-053-0418 Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic As used in 2017 Or Laws, ch 719, §2, “Insurer” includes: (1) Any person with a certificate of authority to transact insurance in Oregon; (2) A health care service contractor a…

836-053-0431 Underwriting, Enrollment and Benefit Design (1) A carrier must offer all of its approved nongrandfathered individual health benefit plans and plan options, including individual plans offered through associations, to all individuals eligible for such plans on a guaran…

836-053-0435 Health Benefit Plan Coverage of Well-woman Preventive Care Services Effective September 1, 2024, health benefit plan policies or certificates issued, renewed, modified or extended on or after September 1, 2024 must provide coverage without cost sharing for well-woman car…

836-053-0441 Gender Affirming Treatment (1) For purposes of this rule: (a) “Gender-affirming treatment” has the meaning given to that term under ORS 743A.325; and (b) “Accepted standards of care” includes, at a minimum, the World Professional Association for Transgender Health’s …

836-053-0444 Purpose and Statutory Authority (1) The purpose of OAR 836-053-0444 to 836-053-0461 is to implement the requirements in ORS 743B.292, which ground ambulance service organizations from balance billing health benefit plan enrollees, requires ground ambulance service or…

836-053-0447 Definitions As used in OAR 836-053-0444 to 836-053-0461: (1) “Enrollee” has the meaning given that term in ORS 743B.005. (2) “Established local rate” means the rate established where the health care services originated for the provision of ground ambulance services t…

836-053-0451 Balance Billing Prohibition and Consumer Cost-Sharing for Ground Ambulance Services (1) A ground ambulance services organization may not bill an enrollee for covered ground ambulance services if the enrollee has paid the in-network cost-sharing amount specified in th…

836-053-0454 Payments to Ground Ambulance Services Organizations (1) The allowed amount paid to a ground ambulance services organization for covered ground ambulance services under a health benefit plan must be one of the following amounts: (a)(A) The rate established by the loca…

836-053-0457 Ground Ambulance Service Organization Rate Reporting to the Department (1) Each ground ambulance service organization that has established local rates for ground ambulance services provided in their geographic area must submit the established local rates in an electr…

836-053-0461 Self-Funded Group Health Plan, Public Employees' Benefit Board and Oregon Educators Benefit Board, Election to Participate (1) A self-funded group health plan, the Public Employees’ Benefit Board, and the Oregon Educators Benefit Board may elect to participate in the…

836-053-0465 Rating for Individual Health Benefit Plans (1) Individual health benefit plans must be rated in accordance with the geographic areas specified in OAR 836-053-0065. A carrier must file a single geographic average rate for each health benefit plan that is offered to in…

836-053-0472 Statutory Authority and Implementation (1) OAR 836-053-0473 and 836-053-0475 are adopted under the authority of ORS 731.244, 743.018, 743.019, and 743.020 to aid in giving effect to provisions of ORS Chapters 742,743 and 743B relating to the filing of rates and polic…

836-053-0473 Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans (1) Every insurer that offers a health benefit plan for small employers or an individual health benefit plan must file the information specified in section (2) of this rule when …

836-053-0474 Process For Rate Filing for Individual and Small Employer Health Benefit Plans (1)(a) Within 10 days after receiving a proposed table or schedule of premium rate filing, the director shall determine whether the proposed table or schedule of premium rate filing is com…

836-053-0475 Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan (1) The materials submitted under OAR 836-053-0473 must include information sufficient to allow the director to evaluate the proposed schedule or table of prem…

836-053-0480 Consumer Friendly Summary Document for Rate Filings (1) This rule applies to plan years beginning on and after January 1, 2026. (2) Every insurer that offers a health benefit plan for small employers or an individual health benefit plan must file with each rate filin…

836-053-0510 Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage (1) A carrier may use the health statement entitled, “Oregon Standard Health Statement” set forth on the website of the Department of Consumer and Business Services at dfr.oregon…

836-053-0600 Purpose; Statutory Authority; Applicability (1) OAR 836-053-0600 to 836-053-0615 are adopted for the purpose of implementing sections 2, 3 and 12, chapter 470, Oregon Laws 2015. (2) The requirements set forth in OAR 836-053-0600 to 836-053-0615 apply to carriers and …

836-053-0605 Definitions for OAR 836-053-0600 to 836-053-0615 As used in OAR 836-053-0600 to 836-053-0615: (1) The definitions set forth in Section 2, chapter 470; Oregon Laws 2015 apply to the use of those terms in these rules. (2) “Enrollee” includes a person covered under a he…

836-053-0610 Carrier Response to Request for Confidentiality (1) A carrier or third party administrator must do all of the following: (a) Allow enrollees to submit the standardized form entitled “Oregon Confidential Communication Request” set forth on the Division of Financial Re…

836-053-0615 Carrier Reporting Requirements (1) In order to comply with the requirements of section 3, chapter 470, Oregon Laws 2015, not later than December 1, 2015, carriers and third party administrators shall submit the following to the Department of Consumer and Business Ser…

836-053-0825 Rescission of a Group Health Benefit Plan (1) For purposes of ORS 743B.013 and ORS 743B.105, “representative” means a person who, with specific authority from the employer or plan sponsor to do so, binds the employer or plan sponsor to a contract for health benefit p…

836-053-0830 Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy (1) The notice required by ORS 743B.310(2) to the individual whose coverage is rescinded must be in writing and include all of the following: (a) Clear identification of the alleged…

836-053-0835 Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy (1) Subject to the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, P.L. 99-272, April 7, 1986, and ORS 743.601 and ORS 743.610, for purposes …

836-053-0851 Purpose; Authority; Applicability; and Enforcement OAR 836-053-0851 to 836-053-0862 apply to insurers issuing continuation coverage as required under ORS 743.610 and are adopted under the authority of ORS 731.244, 743.601 and 743.610. Statutory/Other Authority: ORS 7…

836-053-0857 Definitions (1) As used in ORS 743.601, “enrollee” has the same meaning as “covered person” as defined in ORS 743.610. (2) As used in ORS 743.610: (a) “Claim” means a request for payment of medical treatment, services, drugs, equipment, or other medical benefit under…

836-053-0863 Notifications (1) For purposes of the notice required by ORS 743.610(10), an insurer must use the notice set forth on the website for the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. An insurer: (a) May incor…

836-053-0900 Purpose; Statutory Authority OAR 836-053-0900 and 836-053-0910 are adopted under the authority of ORS 731.244 for the purpose of carrying out ORS 743.730 to 743.773 and providing rate filing requirements and procedures for small employer and individual health benefit…

836-053-0910 Rate Filing (1) A carrier must file with the director of the Department of Consumer and Business Services the appropriate checklists and certification statements as established in OAR 836-010-0011. (2) A carrier may not: (a) Offer a small group or individual health b…

836-053-1000 Statutory Authority and Implementation (1) OAR 836-053-1000 to 836-053-1200 are adopted under the authority of ORS 731.244, 743.814 and 743.819, for the purpose of implementing ORS 743.804, 743.807, 743.814, 743.817, 743.819, 743.821, 743.829, 743.837 and 743A.012. (…

836-053-1010 Insurer Policies (1) The written policy recognizing the rights of enrollees, which is required of an insurer by ORS 743.804, must be an official corporate policy of the insurer. (2) An insurer must provide a written summary of the policy required by ORS 743.804 to: (…

836-053-1020 Drug Formularies (1) For purposes of OAR 836-053-0000 to 836-053-1200: (a) "Open formulary" means a method used by an insurer to provide prescription drug benefits in which all prescribed FDA approved prescription drug products are covered except for any drug product…

836-053-1030 Written Information to Enrollees (1) Each insurer must furnish written information to policyholders that is required by ORS 743.804, including but not limited to information relating to enrollee rights and responsibilities, including the right to appeal adverse benef…

836-053-1033 Cultural and Linguistic Appropriateness (1) All notices and communications required to be provided by an insurer to enrollees under ORS 743.804 and 743.857 must be provided in a manner that is culturally and linguistically appropriate, as required by ORS 743.804. For…

836-053-1035 Summary of Benefits and Explanation of Coverage The summary of benefits and explanations of coverage required by ORS 743.804 must be provided in a manner and form consistent with the requirements of 45 CFR 147.200. Statutory/Other Authority: ORS 731.244 & 743.804 Sta…

836-053-1060 Definitions For purposes of grievance procedures under OAR 836-053-1000 to 836-053-1200 and ORS 743.804: (1) "Complaint" means an expression of dissatisfaction directly to an insurer that is about a specific problem encountered by an enrollee or about a decision by a…

836-053-1070 Reporting of Grievances and Prior Authorization; Format and Contents (1)(a) To comply with the requirements in ORS 743B.250, on or before June 30 of each calendar year, an insurer must submit information pertaining to grievances and appeals in the previous calendar y…

836-053-1080 Tracking Grievances and Prior Authorization Requests An insurer must record data relating to all grievances, significant actions taken from each initial grievance filing through the appeals process, applications for external review as required by ORS 743B.250, and pr…

836-053-1090 Assistance in Filing Grievances For the purpose of providing assistance to enrollees in filing written grievances, as required by ORS 743.804, an insurer must promptly: (1) Provide information regarding the use of the insurer’s grievance process to an enrollee who wa…