Chapter 743B — Chapter 743B

ORS 743B.001 Definitions. As used in this section and ORS 743.008, 743.029, 743.035, 743A.112, 743A.190, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204, 743B.220, 743B.225, 743B.227, 743B.250, 743B.252, 743B.253, 743B.254, 743B.255, 743B.256, 743B.257, 743B.258, 743B.310, 743B.400, 743B.403, 743B.405, 743B.420, 743B.422, 743B.423, 743B.424, 743B.425, 743B.430, 743B.445, 743B.450, 743B.451, 743B.452, 743B.453, 743B.454, 743B.505, 743B.550, 743B.555, 743B.602 and 743B.603

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ORS 743B.003 Purposes. The purposes of ORS 743.004, 743.022, 743.535, 743B.003 to 743B.127 and 743B.800 are

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ORS 743B.005 Definitions. For purposes of ORS 743.004, 743.007, 743.022, 743.416, 743.417, 743.535, 743A.101, 743B.003 to 743B.127, 743B.109, 743B.128, 743B.250 and 743B.323

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ORS 743B.010 Issuance of group health benefit plan to affiliated group of employers; determination of number of employees for purpose of determining eligibility as small employer. (1) If an affiliated group of employers is treated as a single employer under section 414(b), (c), (m) or (o) 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

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ORS 743B.011 Group health benefit plans subject to provisions of specified laws; exemptions. (1) Except as provided in subsection (2) of this section, every health benefit plan shall be subject to the provisions of ORS 743B.010 to 743B.013, 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

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ORS 743B.012 Requirement to offer all health benefit plans to small employers; offering of plan by carriers; exceptions. (1) As a condition of transacting business in the small employer health insurance market in this state, a carrier shall offer small employers all of the carrier’s health benefit plans, approved by the Department of Consumer and Business Services for use in the small employer market, for which the small employer is eligible

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ORS 743B.013 Requirements for small employer health benefit plans. (1) A health benefit plan issued to a small employer

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ORS 743B.020 Eligible employees and small employers; rules. (1) The Department of Consumer and Business Services shall adopt by rule a method for determining whether

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ORS 743B.100 Department’s authority to regulate market. (1) In order to ensure the broadest availability of small employer and individual health benefit plans, the Department of Consumer and Business Services may approve market conduct and other requirements for carriers and insurance producers, including

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ORS 743B.102 Certifications and disclosure of coverage. All carriers that offer individual or group health benefit plans shall provide certifications and disclosure of coverage in accordance with 42 U.S.C. 300gg(e) and 300gg-43 as amended and in effect on July 1, 1997. [Formerly 743.749]

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ORS 743B.103 Use of health-related information. (1) A carrier may not

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ORS 743B.104 Coverage in group health benefit plans; consideration of prospective enrollee health status restricted; effect of discontinuing offer of plans; exceptions; coverage by multiple employer welfare arrangements. (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

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ORS 743B.105 Requirements for group health benefit plans other than small employer plans. The following requirements apply to all group health benefit plans other than small employer health benefit plans covering two or more certificate holders

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ORS 743B.109 Short term health insurance policies; rules. (1) An insurer offering a short term health insurance policy in this state shall include in any policy document, application materials or advertisements related to the policy a notice informing an insured or prospective insured under the policy that

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ORS 743B.110 Implementation of federal laws; rules. 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 Acts. [Formerly 743.758]

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ORS 743B.120 [Formerly 743.764; 2017 c.152 §10; renumbered 743A.262 in 2017]

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ORS 743B.125 Individual health benefit plans; waiting or exclusion periods; preexisting condition exclusions; guaranteed issue and renewal. (1) With respect to coverage under an individual health benefit plan, a carrier may not impose a preexisting condition exclusion or an individual coverage waiting period

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ORS 743B.126 Carrier marketing of individual health benefit plans; rules; duties of carrier regarding applications; effect of discontinuing offer of plans. (1) Each carrier shall actively market all individual health benefit plans sold by the carrier that are not grandfathered health plans

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ORS 743B.127 Rules for ORS 743.022, 743B.125 and 743B.126. The Director of the Department of Consumer and Business Services shall adopt all rules necessary for the implementation and administration of ORS 743.022, 743B.125 and 743B.126. [Formerly 743.773]

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ORS 743B.128 Exceptions to requirement to actively market all plans. Notwithstanding ORS 743B.012, 743B.013 and 743B.105, a carrier is not required to actively market

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ORS 743B.129 Shortening period of exclusion following discontinued offering; rules. (1) As used in this section, “procedural requirements” means the processes that the Department of Consumer and Business Services will use to obtain public input such as public hearings, rule comment periods and the electronic distribution of information by the department

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ORS 743B.130 Requirement to offer bronze and silver plans; rules. (1) In each individual or small group market, in which a carrier offers a health benefit plan through or outside of the health insurance exchange described in ORS 741.310, the carrier must offer to residents of this state bronze and silver plans meeting the requirements of subsection (2) of this section and, if offered through the health insurance exchange, certified by the Oregon Health Authority as qualified health plans

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ORS 743B.195 Enforcement of Newborns’ and Mothers’ Health Protection Act of 1996. The Department of Consumer and Business Services shall enforce insurer compliance with the federal Newborns’ and Mothers’ Health Protection Act of 1996. [Formerly 743.823]

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ORS 743B.197 Health Care Consumer Protection Advisory Committee. The Director of the Department of Consumer and Business Services shall appoint a Health Care Consumer Protection Advisory Committee with fair representation of health care consumers, providers and insurers. The committee shall advise the director regarding the implementation of ORS 743.008, 743A.012, 743B.001, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204, 743B.220, 743B.250, 743B.400, 743B.403, 743B.405, 743B.420, 743B.422, 743B.423, 743B.424 and 743B.550 and other issues related to health care consumer protection. [Formerly 743.827; 2017 c.101 §55; 2017 c.384 §11]

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ORS 743B.200 Requirements for insurers offering managed health insurance; quality assessment. Each insurer offering managed health insurance in this state shall

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ORS 743B.202 Requirements for insurers offering managed health or preferred provider organization insurance; rules; opportunity to participate. An insurer offering managed health insurance or preferred provider organization insurance in this state shall

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ORS 743B.204 Required managed health insurance contract provision; enrollee liability. All insurers offering managed health insurance in this state shall include in contracts with providers a provision requiring that in the event the insurer fails to pay for health care services covered by the health benefit plan, the provider shall not bill or otherwise attempt to collect from enrollees for amounts owed by insurers, and enrollees shall not be liable to the provider for any sums owed by the insurer. Nothing in this section shall be construed to in any manner limit the applicability of ORS 750.095 (2). [Formerly 743.821]

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ORS 743B.206 [Formerly 743.831; repealed by 2017 c.101 §53 and 2017 c.384 §13]

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ORS 743B.220 Requirements for insurers that require designation of participating primary care physician; exceptions. (1) All insurers offering a health benefit plan in this state that requires an enrollee to designate a participating primary care physician shall

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ORS 743B.221 (1) As used in this section, “primary care provider” means an individual, clinic or team of health care providers licensed or certified in this state to provide outpatient, nonspecialty medical services or the coordination of health care for the purpose of

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ORS 743B.222 Designation of women’s health care provider as primary care provider; direct access to women’s health care provider. (1) As used in this section, “women’s health care provider” means an obstetrician or gynecologist, physician associate specializing in women’s health, advanced registered nurse practitioner specialist in women’s health, naturopathic physician specializing in women’s health or certified nurse midwife, practicing within the applicable lawful scope of practice

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ORS 743B.225 Continuity of care. (1) As used in this section, “continuity of care” means the feature of a health benefit plan under which an enrollee who is receiving care from an individual provider is entitled to continue with care with the individual provider for a limited period of time after the medical services contract terminates

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ORS 743B.227 Referrals to specialists. (1) If an insurer offers a health benefit plan that requires, as a condition of coverage for specialty care services, a referral by a physician who is authorized under the plan or under the medical services contract between the physician and the insurer to refer an enrollee to specialty care services, the insurer must include the requirements of this section in the plan. The requirements apply only to benefits for which the member is contractually eligible under the plan. The requirements are as follows

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ORS 743B.250 Required notices to applicants and enrollees; grievances, internal appeals and external reviews; reports to department. All insurers offering a health benefit plan in this state shall

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ORS 743B.252 External review; rules. (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 743B.255 and rules adopted by the Director of the Department of Consumer and Business Services to carry out the provisions of this section and ORS 743B.250 and 743B.255. Each insurer shall provide the external review through an independent review organization that is under contract with the director 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 benefit determination by the insurer on one or more of the following

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ORS 743B.253 Director to contract with independent review organizations to provide external review; rules. (1) The Director of the Department of Consumer and Business Services shall contract with independent review organizations as provided in this section for the purpose of providing external review under ORS 743B.252. Contracts shall be let with independent review organizations on a biennial basis. A contract may be renewed if both parties agree

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ORS 743B.254 Required statements regarding external reviews. An insurer offering a health benefit plan shall include in the plan the following statements, in boldfaced type or otherwise emphasized

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ORS 743B.255 Enrollee application for external review; when enrollee deemed to have exhausted internal appeal. (1) An enrollee shall apply in writing for external review of an adverse 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 grievance and internal appeal process under ORS 743B.250

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ORS 743B.256 Duties of independent review organizations; expedited reviews. (1) An independent review organization shall perform the following duties when appointed under ORS 743B.252 to review a dispute under a health benefit plan between an insurer and an enrollee

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ORS 743B.257 Civil penalty for failure to comply by insurer that agreed to be bound by decision. (1) An insurer shall comply in a timely manner with a decision of an independent review organization under ORS 743B.256 that reverses, in whole or in part, an adverse benefit determination. If an insurer fails to comply with the decision, the Director of the Department of Consumer and Business Services may impose on the insurer a civil penalty of not more than $1 million

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ORS 743B.258 Private right of action. (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 benefit determination by the insurer that is subject to external review if the insurer fails to comply with the decision

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ORS 743B.260 Claims and appeals of adverse benefit determinations under disability income insurance policies; rules. (1) As used in this section

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ORS 743B.275 Definitions for ORS 743B.275 to 743B.285. As used in ORS 743B.275 to 743B.285

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ORS 743B.277 Credits to deductibles and out-of-pocket expenses; requirements; process. (1) An insurer offering a health benefit plan as defined in ORS 743B.005 shall credit any amount an enrollee pays directly to a health care provider to the enrollee’s deductible and annual out-of-pocket expenses if

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ORS 743B.280 [Formerly 743B.871; renumbered 743B.275 in 2025]

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ORS 743B.281 Estimate of costs for in-network procedure or service. (1) An insurer offering a health benefit plan as defined in ORS 743B.005 must establish a procedure for providing to an enrollee in the plan a reasonable estimate of an enrollee’s costs for an in-network procedure or service covered by the enrollee’s health benefit plan, in advance of the procedure or service, when an enrollee or an enrollee’s authorized representative provides the following information to the insurer

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ORS 743B.282 Estimate of costs for out-of-network procedure or service. (1) An insurer offering a health benefit plan as defined in ORS 743B.005 must establish a procedure for providing to an enrollee in the plan a reasonable estimate of the enrollee’s costs for an out-of-network procedure or service covered by the enrollee’s health benefit plan, including the difference between the insurer’s allowable charge and the billed charge for the procedure or service, in advance of the procedure or service, when an enrollee or an enrollee’s authorized representative provides the following information to the insurer

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ORS 743B.283 Submission of methodology used to determine insurer’s allowable charges. An insurer offering a health benefit plan as defined in ORS 743B.005 must submit to the Director of the Department of Consumer and Business Services

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ORS 743B.284 Alternative mechanism for disclosure of costs and charges. The Director of the Department of Consumer and Business Services may waive the requirements of ORS 743B.281 or 743B.282 to allow an insurer to use an alternative disclosure mechanism, provided that the mechanism enables enrollees to access information substantially similar to or more extensive than the information disclosed in ORS 743B.281 or 743B.282. [Formerly 743.883]

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ORS 743B.285 Rules. The Director of the Department of Consumer and Business Services shall adopt rules necessary to carry out the purposes of ORS 743B.275 to 743B.285. [Formerly 743.893]

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