Title 56, Insurance

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, 7…

The purposes of ORS 743.004, 743.022, 743.535, 743B.003 to 743B.127 and 743B.800 are: (1) To promote the availability of health insurance coverage to groups regardless of their enrollees’ health status or claims experience; (2) To prevent abusive rating practices; (3) To require …

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: (1) “Actuarial certification” means a written statement by a member of the American Academy of Actuaries or other individual accept…

(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 affili…

(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 i…

(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 mark…

(1) A health benefit plan issued to a small employer: (a) Other than a grandfathered health plan, must cover essential health benefits consistent with 42 U.S.C. 300gg-11. (b) May require an affiliation period that does not exceed two months for an enrollee or 90 days for a late e…

(1) The Department of Consumer and Business Services shall adopt by rule a method for determining whether: (a) An employee is an eligible employee as defined in ORS 743B.005; and (b) An employer is a small employer as defined in ORS 743B.005. (2) The method adopted by the departm…

(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: (a) Registration by each car…

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]

(1) A carrier may not: (a) Require an applicant to provide health-related information as a precondition for the issuance of an individual health benefit plan policy; or (b) Deny coverage under an individual health benefit plan policy based on health-related information provided b…

(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 imp…

The following requirements apply to all group health benefit plans other than small employer health benefit plans covering two or more certificate holders: (1) A carrier offering a group health benefit plan may not decline to offer coverage to any eligible prospective enrollee an…

(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: (a) The policy is not subject…

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 Ca…

(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. (2) With respect to individual coverage under a grandfathered health plan, a carrier: (a) May impose an exclu…

(1) Each carrier shall actively market all individual health benefit plans sold by the carrier that are not grandfathered health plans. (2) Except as provided in subsection (3) of this section, no carrier or insurance producer shall, directly or indirectly, discourage an individu…

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]

Notwithstanding ORS 743B.012, 743B.013 and 743B.105, a carrier is not required to actively market: (1) A health benefit plan sold only to a bona fide association, to groups that are not members of the bona fide association; (2) A grandfathered health plan, to a group or individua…

(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. (2) The…

(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 subsec…

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]

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 O…

Each insurer offering managed health insurance in this state shall: (1) Have a quality assessment program that enables the insurer to evaluate, maintain and improve the quality of health services provided to enrollees. The program shall include data gathering that allows the plan…

An insurer offering managed health insurance or preferred provider organization insurance in this state shall: (1) File an annual summary with the Department of Consumer and Business Services that reports on the scope and adequacy of the insurer’s network and the insurer’s ongoin…

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…

(1) All insurers offering a health benefit plan in this state that requires an enrollee to designate a participating primary care physician shall: (a) Permit the enrollee to change participating primary care physicians at will, except that the enrollee may be restricted to making…

(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: (a) Promoting or maint…

(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 cer…

(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 ser…

(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 sp…

All insurers offering a health benefit plan in this state shall: (1) Provide to all enrollees directly or in the case of a group policy to the employer or other policyholder for distribution to enrollees, to all applicants, and to prospective applicants upon request, the followin…

(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 …

(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…

An insurer offering a health benefit plan shall include in the plan the following statements, in boldfaced type or otherwise emphasized: (1) A statement of the right of an enrollee to apply for external review by an independent review organization; (2) A statement that an enrolle…

(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 …

(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: (a) Decide whether the dispute pertains to an adverse benefit determination and notify t…

(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 Consume…

(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…

(1) As used in this section: (a) “Adverse benefit determination” means a denial, reduction, termination of or failure to provide or pay, in whole or in part, for a benefit, including: (A) A denial, reduction, termination of or failure to provide or pay for a benefit that is based…

As used in ORS 743B.275 to 743B.285: (1) “In-network” means performed by a provider or provider group that has directly contracted with the insurer. (2) “Out-of-network” means performed by a provider or provider group that has not contracted or has indirectly contracted with the …

(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: (a) The health care item or service is medically necessary and c…

(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 advan…

(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, inc…

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: (1) Upon request by the director, the methodology used to determine the insurer’s allowable charges for out-of-network procedures …

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 …

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] Note: See note under 743B.275.

(1) As used in this section: (a) “Emergency services” has the meaning given that term in ORS 743A.012. (b) “Enrollee” means: (A) An individual who is enrolled in a health benefit plan or a covered dependent or beneficiary of the individual; or (B) A subscriber to a health care se…

(1) As used in this section: (a) “In-network provider” means an individual or facility that contracts with a health benefit plan or health care service contractor to provide health care services to an individual insured under the health benefit plan or health care service contrac…

An insurer offering a policy or certificate of health insurance may not prohibit a hospital, as a condition of reimbursing a claim for hospital services, from paying or waiving all or a portion of a copayment or deductible owed by an insured under the policy or certificate. [2019…