Title 56, Insurance

(1) As used in this section: (a) “Enrollee” has the meaning given that term in ORS 743B.005. (b) “Established local rate” means the rate established where the health care services originated for the provision of ground ambulance services through a publicly accessible process that…

(1) The Director of the Department of Consumer and Business Services shall adopt by rule requirements for disclosure by group and individual health insurers to individual and group health insurance policyholders the difference between coverage under the existing policy and covera…

(1) As used in this section, “rescind” means to retroactively cancel or discontinue coverage under a health benefit plan or group or individual health insurance policy for reasons other than failure to timely pay required premiums or required contributions toward the cost of cove…

(1) A group health insurance policy shall contain a provision allowing a minimum grace period of 10 days after the premium due date for payment of premium. (2) An insurer of a group health insurance policy providing coverage for hospital or medical expenses, other than coverage l…

ORS 743B.320 applies to multiple employer trusts when an employer ceases to participate therein. [Formerly 743.562]

(1) Before a health insurer selling an individual policy or group health benefit plan may cancel a policy for nonpayment of premium, the insurer must mail a separate notice to the policyholder informing the policyholder that the premium was not received and that the policy will b…

The Director of the Department of Consumer and Business Services shall adopt rules necessary for the implementation and administration of ORS 743B.323 and the amendments to ORS 743.417, 743.420, 743B.013, 743B.105, 743B.125 and 743B.320 by sections 9 to 14, chapter 943, Oregon La…

(1) As used in this section, “health benefit plan” has the meaning given that term in ORS 743B.005. (2) An insurer shall notify a policyholder in writing if the insurer cancels or does not renew the policyholder’s individual health benefit plan. The notice shall be sent to the po…

(1) Every group health insurance policy delivered or issued for delivery in this state shall contain in substance the following provisions, applicable to the coverage for hospital or medical services or expenses provided under the policy: (a) A provision that, when the premium fo…

(1) Every group health insurance policy that provides coverage for hospital or medical services or expenses shall provide that the insurer shall continue its obligation for benefits under the policy for any person insured under the policy who is hospitalized on the date of termin…

Every policy of group health insurance delivered or issued for delivery in this state shall contain a provision applicable to the coverage for hospital or medical services or expenses provided under the policy that if an employee incurs an injury or illness for which a workers’ c…

(1) A group health insurance policy providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, shall contain a provision that: (a) The surviving spouse of a certificate holder may continue coverage under the p…

(1) As used in subsections (1) to (6) of this section, “plan administrator” means: (a) The person designated as the plan administrator by the instrument under which the group health insurance plan is operated; or (b) If no plan administrator is designated, the plan sponsor. (2) W…

If a legally separated, divorced or surviving spouse elects continuation of coverage under ORS 743B.344 (1) to (6): (1) The monthly premium for the continuation shall not be greater than the amount that would be charged if the legally separated, divorced or surviving spouse were …

(1) As used in this section: (a) “Covered person” means an individual who was a certificate holder under a group health insurance policy: (A) On the day before a qualifying event; and (B) During the three-month period ending on the date of the qualifying event. (b) “Qualified ben…

(1) All clinical decisions regarding length of stay in a health care facility as defined in ORS 442.015, transfer between levels of care and follow-up care shall be the decision of the treating provider in consultation with the patient, as appropriate. (2) An insurer may not term…

No insurer may terminate or otherwise financially penalize a provider for: (1) Providing information to or communicating with a patient in a manner that is not slanderous, defamatory or intentionally inaccurate concerning: (a) Any aspect of the patient’s medical condition; (b) An…

(1) A medical services contract may not require the provider, as an element of the contract or as a condition of compensation for services, to agree: (a) In the event of alleged improper medical treatment of a patient, to indemnify the other party to the medical services contract…

(1) As used in this section: (a) “Contractual discount” means a percentage reduction, required under a contract with an insurer, in a vision care provider’s usual and customary rate for vision care services and materials. (b) “Discount card” means a card or other purchasing mecha…

(1) An insurer shall provide a naturopathic physician the choice of applying to be credentialed by the insurer as a primary care provider or as a specialty care provider. (2) To be credentialed by an insurer as a primary care provider, a naturopathic physician must meet the crede…

Except in the case of misrepresentation, prior authorization determinations shall be subject to the following requirements: (1) Prior authorization determinations relating to benefit coverage and medical necessity shall be binding on the insurer if obtained no more than 60 days p…

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 …

(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, inc…

The provisions of ORS 743B.001, 743B.220, 743B.405 and 743B.422 do not apply to medical services contracts for services to be provided under ORS chapter 656. [Formerly 743.811] Note: See note under 743B.405.

(1) An insurer offering a health benefit plan may not: (a) Require prior authorization: (A) During the first 60 days of treatment, including medication therapy, prescribed for opioid or opiate withdrawal; or (B) For post-exposure prophylactic antiretroviral drugs or preexposure p…

(1) As used in this section: (a) “Behavioral health benefits” means insurance coverage of mental health treatment and services and substance use disorder treatment and services. (b) “Carrier” has the meaning given that term in ORS 743B.005. (c) “Geographic region” means the geogr…

An insurer offering a health benefit plan that requires prior authorization for surgical procedures may not require prior authorization for an additional or related health care procedure that is identified during the authorized surgical procedure if: (1) The provider, while provi…

(1) An insurer offering a health benefit plan in this state that provides utilization review or has utilization review provided on the insurer’s behalf shall utilize a prior authorization application programming interface as described in 45 C.F.R. 156.223(b), as in effect on Febr…

(1) Except as provided in this subsection, when a claim under a health benefit plan is submitted to an insurer by a provider on behalf of an enrollee, the insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the cla…

(1) As used in this section, “refund” means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider. (2) Except in the case of fraud or abuse of billing, and except as provided in subsections (3) a…

(1) An insurer that fails to pay a claim to a provider within the timelines established in ORS 743B.450 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 p…

(1) Except in the case of fraud and except as provided in subsection (3) of this section, a health care provider may not: (a) Request additional payment from a health insurer to satisfy a claim unless the provider: (A) Requests the additional payment in writing on or before the l…

(1) As used in this section: (a) “Complete application” means a provider’s application to a health insurer to become a credentialed provider that includes: (A) Information required by the health insurer; (B) Proof that the provider is licensed by a health professional regulatory …

(1) As used in this section, “dental insurer” means an insurer that offers a policy or certificate of insurance or other contract, that provides only a dental benefit. (2) A dental insurer may pay a claim for reimbursement made by a dental care provider using a credit card or ele…

An insurer offering a health benefit plan, as defined in ORS 743B.005, that reimburses the costs of services provided by a national primary care medical home payment model, conducted by the Center for Medicare and Medicaid Innovation in accordance with 42 U.S.C. 1315a, that inclu…

(1) An insurer may negotiate and enter into contracts for alternative rates of payment with providers to provide services covered by a group health insurance policy and may offer the benefit of such alternative rates to insureds who select such providers. An insurer may utilize s…

(1) As used in this section: (a) “Health benefit plan” has the meaning given that term in ORS 743B.005. (b) “Provider” means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services, including substanc…

(1) For the purposes of this section: (a) “Health insurer” or “insurer” means an employee benefit plan, self-insured plan, managed care organization or group health plan, a third party administrator, fiscal intermediary or pharmacy benefit manager of the plan or organization, or …

The Director of the Department of Consumer and Business Services shall by rule establish guidelines for the coordination of benefits for individual and group health insurance, including: (1) The procedures by which persons insured under the policies are to be made aware of the ex…

As used in this section and ORS 743B.501 to 743B.503: (1)(a) “Contracting entity” means any person that contracts directly with a provider for the delivery of health care services or contracts with a third party for the purpose of selling or making available to the third party th…

(1) A contracting entity that does not have a certificate of authority shall register with the Department of Consumer and Business Services as a contracting entity by submitting the following information to the department in written or electronic form as prescribed by the departm…

(1) A contracting entity or a third party may not contract with another third party to provide access to the health care services and discounted rates of a provider under a provider network contract unless: (a) The third party contract is specifically authorized by the provider n…

(1) A contract between a third party and a contracting entity or between two third parties with respect to a provider network contract must comply with this section and ORS 743B.502. (2)(a) A third party shall inform the contracting entity and providers under a contracting entity…

(1) As used in this section: (a) “Dental insurer” means an insurer that offers a policy or certificate of insurance or other contract, that provides only a dental benefit. (b)(A) “Material modification” includes, but is not limited to, changes to the terms or conditions of a cont…

(1) A carrier offering an individual or group health benefit plan in this state that provides coverage through a specified network of health care providers shall: (a) Contract with or employ a network of providers that is sufficient in number, geographic distribution and types of…

Nothing in ORS 743.008, 743A.012, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204, 743B.250, 743B.400, 743B.403, 743B.420, 743B.423 and 743B.550 shall be construed to require disclosure of information that is otherwise privileged or confidential under any other provision of law.…

(1) As used in this section: (a) “Carrier” has the meaning given that term in ORS 743B.005. (b) “Communication” includes: (A) An explanation of benefits notice; (B) Information about an appointment; (C) A notice of an adverse benefit determination; (D) A carrier’s or third party …

(1) As used in this section: (a) “Health plan” means: (A) A “health benefit plan” as defined in ORS 743B.005; and (B) A self-insured health plan offered by the Oregon Health and Science University. (b) “Synchronization policy” means a procedure for aligning the refill dates of a …

(1) As used in this section: (a) “Beneficiary” means an individual receiving health care that is provided or reimbursed by an entity that provides health care coverage. (b) “Health care coverage” includes any of the following that reimburse the cost of prescription drugs: (A) A h…

(1) As used in this section: (a)(A) “Generic equivalent” means a drug that meets applicable standards of strength, quality and purity according to the United States Pharmacopeia or other nationally recognized compendium and that, compared to a brand name drug: (i) Has an identica…