Chapter 322
Oregon Laws 2011
AN ACT
SB 91
Relating to
health benefit plans; creating new provisions; and amending ORS 743.730.
Be It Enacted by the People of the State of Oregon:
SECTION 1. Sections 2, 3 and 4 of
this 2011 Act are added to and made a part of ORS 743.730 to 743.773.
SECTION 2. The Director of the
Department of Consumer and Business Services shall prescribe by rule the:
(1) Requirements for a bronze plan to
ensure that a bronze plan offered in this state is actuarially equivalent to 60
percent of the full actuarial value of benefits included in the essential
health benefits package prescribed by the United States Secretary of Health and
Human Services under 42 U.S.C. 18022(a).
(2) Requirements for a silver plan to
ensure that a silver plan offered in this state is actuarially equivalent to 70
percent of the full actuarial value of benefits included in the essential
health benefits package prescribed by the United States Secretary of Health and
Human Services under 42 U.S.C. 18022(a).
(3) Form, level of coverage and
benefit design for the bronze and silver plans to be used by carriers in the
individual and small group market in this state.
SECTION 3. As a condition of
transacting business in the health benefit plan market in this state, a carrier
shall offer to residents of this state bronze and silver plans approved by the
Department of Consumer and Business Services as meeting the requirements of
section 2 of this 2011 Act in each individual and small group market in which
the carrier offers a health benefit plan through the Oregon Health Insurance
Exchange or outside of the exchange.
SECTION 4. A carrier may offer a
catastrophic plan only through the Oregon Health Insurance Exchange and only to
an individual who:
(1) Is under 30 years of age at the
beginning of the plan year; or
(2) Is exempt from any state or
federal penalties imposed for failing to maintain minimal essential coverage
during the plan year.
SECTION 5. ORS 743.730 is amended to
read:
743.730. For purposes of ORS 743.730
to 743.773:
(1) “Actuarial certification” means a
written statement by a member of the American Academy of Actuaries or other
individual acceptable to the Director of the Department of Consumer and
Business Services that a carrier is in compliance with the provisions of ORS
743.736, 743.760 or 743.761, based upon the person’s examination, including a
review of the appropriate records and of the actuarial assumptions and methods
used by the carrier in establishing premium rates for small employer and
portability health benefit plans.
(2) “Affiliate” of, or person “affiliated”
with, a specified person means any carrier who, directly or indirectly through
one or more intermediaries, controls or is controlled by or is under common
control with a specified person. For purposes of this definition, “control” has
the meaning given that term in ORS 732.548.
(3) “Affiliation period” means, under
the terms of a group health benefit plan issued by a health care service
contractor, a period:
(a) That is applied uniformly and
without regard to any health status related factors to an enrollee or late
enrollee in lieu of a preexisting conditions provision;
(b) That must expire before any
coverage becomes effective under the plan for the enrollee or late enrollee;
(c) During which no premium shall be
charged to the enrollee or late enrollee; and
(d) That begins on the enrollee’s or
late enrollee’s first date of eligibility for coverage and runs concurrently
with any eligibility waiting period under the plan.
(4) “Basic health benefit plan” means
a health benefit plan [for small
employers] that provides bronze plan coverage and that is required
to be offered by all small employer carriers and approved by the Director of
the Department of Consumer and Business Services in accordance with ORS
743.736.
(5) “Bona fide association” means an
association that meets the requirements of 42 U.S.C. [300gg-11] 300gg-91 as amended and in effect on [July 1, 1997] March 23, 2010.
(6) “Bronze plan” means a health
benefit plan that meets the criteria for a bronze plan prescribed by the
director by rule pursuant to section 2 of this 2011 Act.
[(6)]
(7) “Carrier” means any person who provides health benefit plans in this
state, including a licensed insurance company, a health care service
contractor, a health maintenance organization, an association or group of
employers that provides benefits by means of a multiple employer welfare
arrangement or any other person or corporation responsible for the payment of
benefits or provision of services.
(8) “Catastrophic plan” means a
health benefit plan that meets the requirements for a catastrophic plan under
42 U.S.C. 18022(e) and that is offered through the Oregon Health Insurance
Exchange.
[(7)]
(9) “Committee” means the Health Insurance Reform Advisory Committee
created under ORS 743.745.
[(8)]
(10) “Creditable coverage” means prior health care coverage as defined
in 42 U.S.C. 300gg as amended and in effect on [July 1, 1997] February 27, 2010, and includes coverage
remaining in force at the time the enrollee obtains new coverage.
[(9)
“Department” means the Department of Consumer and Business Services.]
[(10)]
(11) “Dependent” means the spouse or child of an eligible employee, subject
to applicable terms of the health benefit plan covering the employee.
[(11)
“Director” means the Director of the Department of Consumer and Business
Services.]
(12) “Eligible employee” means an
employee of a small employer who works on a regularly scheduled basis, with a
normal work week of 17.5 or more hours. The employer may determine hours worked
for eligibility between 17.5 and 40 hours per week subject to rules of the
carrier. “Eligible employee” does not include employees who work on a
temporary, seasonal or substitute basis. Employees who have been employed by
the small employer for fewer than 90 days are not eligible employees unless the
small employer so allows.
(13) “Employee” means any individual
employed by an employer.
(14) “Enrollee” means an employee,
dependent of the employee or an individual otherwise eligible for a group,
individual or portability health benefit plan who has enrolled for coverage
under the terms of the plan.
(15) “Exchange” means the Oregon
Health Insurance Exchange established pursuant to section 17, chapter 595, Oregon
Laws 2009.
[(15)]
(16) “Exclusion period” means a period during which specified treatments or
services are excluded from coverage.
[(16)]
(17) [“Financially impaired” means a
member that]”Financial impairment” means that a carrier is not
insolvent and is:
(a) Considered by the director [of the Department of Consumer and Business
Services] to be potentially unable to fulfill its contractual obligations;
or
(b) Placed under an order of
rehabilitation or conservation by a court of competent jurisdiction.
[(17)(a)]
(18)(a) “Geographic average rate” means the arithmetical average of the
lowest premium and the corresponding highest premium to be charged by a carrier
in a geographic area established by the director for the carrier’s:
(A) [Small employer] Group health benefit plans offered to small
employers;
(B) Individual health benefit plans;
or
(C) Portability health benefit plans.
(b) “Geographic average rate” does not
include premium differences that are due to differences in benefit design or
family composition.
[(18)]
(19) “Group eligibility waiting period” means, with respect to a group
health benefit plan, the period of employment or membership with the group that
a prospective enrollee must complete before plan coverage begins.
[(19)(a)]
(20)(a) “Health benefit plan” means any hospital expense, medical expense
or hospital or medical expense policy or certificate, health care service
contractor or health maintenance organization subscriber contract, any plan
provided by a multiple employer welfare arrangement or by another benefit
arrangement defined in the federal Employee Retirement Income Security Act of
1974, as amended.
(b) “Health benefit plan” does not
include coverage for accident only, specific disease or condition only, credit,
disability income, coverage of Medicare services pursuant to contracts with the
federal government, Medicare supplement insurance policies, coverage of CHAMPUS
services pursuant to contracts with the federal government, benefits delivered
through a flexible spending arrangement established pursuant to section 125 of
the Internal Revenue Code of 1986, as amended, when the benefits are provided
in addition to a group health benefit plan, long term care insurance, hospital
indemnity only, short term health insurance policies (the duration of which
does not exceed six months including renewals), student accident and health
insurance policies, dental only, vision only, a policy of stop-loss coverage
that meets the requirements of ORS 742.065, coverage issued as a supplement to
liability insurance, insurance arising out of a workers’ compensation or
similar law, automobile medical payment insurance or insurance under which
benefits are payable with or without regard to fault and that is statutorily
required to be contained in any liability insurance policy or equivalent
self-insurance.
(c) Nothing in this subsection shall
be construed to regulate any employee welfare benefit plan that is exempt from
state regulation because of the federal Employee Retirement Income Security Act
of 1974, as amended.
[(20)]
(21) “Health statement” means any information that is intended to inform
the carrier or insurance producer of the health status of an enrollee or
prospective enrollee in a health benefit plan. “Health statement” includes the
standard health statement developed by the Health Insurance Reform Advisory
Committee.
[(21)]
(22) “Implementation of chapter 836, Oregon Laws 1989” means that the
Health Services Commission has prepared a priority list, the Legislative
Assembly has enacted funding of the list and all necessary federal approval,
including waivers, has been obtained.
[(22)]
(23) “Individual coverage waiting period” means a period in an individual
health benefit plan during which no premiums may be collected and health
benefit plan coverage issued is not effective.
[(23)]
(24) “Initial enrollment period” means a period of at least 30 days
following commencement of the first eligibility period for an individual.
[(24)]
(25) “Late enrollee” means an individual who enrolls in a group health
benefit plan subsequent to the initial enrollment period during which the
individual was eligible for coverage but declined to enroll. However, an
eligible individual shall not be considered a late enrollee if:
(a) The individual qualifies for a
special enrollment period in accordance with 42 U.S.C. 300gg as amended and in
effect on July 1, 1997;
(b) The individual applies for
coverage during an open enrollment period;
(c) A court has ordered that coverage
be provided for a spouse or minor child under a covered employee’s health
benefit plan and request for enrollment is made within 30 days after issuance
of the court order;
(d) The individual is employed by an
employer who offers multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period; or
(e) The individual’s coverage under
Medicaid, Medicare, CHAMPUS, Indian Health Service or a publicly sponsored or
subsidized health plan, including but not limited to the medical assistance
program under ORS chapter 414, has been involuntarily terminated within 63 days
of applying for coverage in a group health benefit plan.
(26) “Minimal essential coverage”
has the meaning given that term in section 5000A(f) of the Internal Revenue
Code.
[(25)]
(27) “Multiple employer welfare arrangement” means a multiple employer
welfare arrangement as defined in section 3 of the federal Employee Retirement
Income Security Act of 1974, as amended, 29 U.S.C. 1002, that is subject to ORS
750.301 to 750.341.
[(26)]
(28) “Oregon Medical Insurance Pool” means the pool created under ORS
735.610.
[(27)]
(29) “Preexisting conditions provision” means a health benefit plan
provision applicable to an enrollee or late enrollee that excludes coverage for
services, charges or expenses incurred during a specified period immediately
following enrollment for a condition for which medical advice, diagnosis, care
or treatment was recommended or received during a specified period immediately
preceding enrollment. For purposes of ORS 743.730 to 743.773:
(a) Pregnancy does not constitute a
preexisting condition except as provided in ORS 743.766;
(b) Genetic information does not
constitute a preexisting condition in the absence of a diagnosis of the
condition related to such information; and
(c) A preexisting conditions provision
shall not be applied to a newborn child or adopted child who obtains coverage
in accordance with ORS 743A.090.
[(28)]
(30) “Premium” includes insurance premiums or other fees charged for a health
benefit plan, including the costs of benefits paid or reimbursements made to or
on behalf of enrollees covered by the plan.
[(29)]
(31) “Rating period” means the 12-month calendar period for which premium
rates established by a carrier are in effect, as determined by the carrier.
(32) “Silver plan” means an
individual or small group health benefit plan that meets the criteria for a
silver plan prescribed by the director by rule pursuant to section 2 of this
2011 Act.
[(30)(a)]
(33)(a) “Small employer” means an employer that employed an average of at
least two but not more than 50 employees on business days during the preceding
calendar year, the majority of whom are employed within this state, and that
employs at least two eligible employees on the date on which coverage takes
effect under a health benefit plan issued by a small employer carrier.
(b) Any person that is treated as a
single employer under subsection (b), (c), (m) or (o) of section 414 of the
Internal Revenue Code of 1986 shall be treated as one employer for purposes of
this subsection.
(c) The determination of whether an
employer that was not in existence throughout the preceding calendar year is a
small employer shall be based on the average number of employees that it is
reasonably expected the employer will employ on business days in the current
calendar year.
[(31)]
(34) “Small employer carrier” means any carrier that offers health benefit
plans covering eligible employees of one or more small employers. A fully
insured multiple employer welfare arrangement otherwise exempt under ORS
750.303 (4) may elect to be a small employer carrier governed by the provisions
of ORS 743.733 to 743.737.
SECTION 6. Sections 2, 3 and 4 of this 2011 Act and the amendments to ORS 743.730
by section 5 of this 2011 Act become operative on January 2, 2014.
SECTION 7. The Director of the
Department of Consumer and Business Services may take any action before the
operative date specified in section 6 of this 2011 Act that is necessary to
enable the director to exercise, on and after the operative date specified in
section 6 of this 2011 Act, all of the duties, functions and powers conferred
on the director by this 2011 Act.
Approved by
the Governor June 14, 2011
Filed in the
office of Secretary of State June 14, 2011
Effective date
January 1, 2012
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