Chapter 741 — Health Insurance Exchange

 

2017 EDITION

 

 

HEALTH INSURANCE EXCHANGE

 

INSURANCE

 

ADMINISTRATION OF HEALTH INSURANCE EXCHANGE

 

(Generally)

 

741.001     Health insurance exchange; legislative intent

 

741.002     Duties, powers and functions of Department of Consumer and Business Services; rules

 

741.003     Duties and powers of director

 

741.004     Health Insurance Exchange Advisory Committee

 

741.008     Criminal records check; fingerprints required; persons subject to requirement

 

(Financing Operations of Exchange)

 

741.102     Health Insurance Exchange Fund

 

741.105     Charges and fees to be paid by insurers and state programs; rules

 

(Audits and Reports)

 

741.220     Financial and performance audits of health insurance exchange accounts; report of audit

 

741.222     Annual reports to Legislative Assembly

 

HEALTH INSURANCE EXCHANGE

 

(Definitions)

 

741.300     Definitions

 

(Operation of Exchange)

 

741.310     Requirements for purchase of insurance through exchange and for participation of insurers in exchange

 

741.340     Health benefit plans offered through exchange

 

741.342     Small Business Health Options Program

 

741.381     Application of antitrust laws

 

741.390     False or misleading filings prohibited

 

741.400     Service of eligibility notices; when notice becomes final order; opportunity to contest actual receipt of notice

 

(Collection and Disclosure

of Information by Exchange)

 

741.500     Required documentation; rules

 

741.510     Confidential information; public officer privilege; permitted uses of confidential information

 

741.520     Agreements with other agencies regarding sharing and use of confidential information; contents

 

741.540     Complaints and investigations confidential; permitted disclosures

 

MISCELLANEOUS

 

(Grace Period)

 

741.800     Insurer to notify health care provider of qualified health plan coverage

 

741.801     Insurer to notify health care provider that enrollee is in grace period; effect of failure to provide notice

 

741.802     Department to produce written informational materials

 

(Penalties)

 

741.900     Civil penalties

 

 

ADMINISTRATION OF HEALTH INSURANCE EXCHANGE

 

(Generally)

 

      741.001 Health insurance exchange; legislative intent. It is the intent of the Legislative Assembly that the health insurance exchange be administered in such a manner as to:

      (1) Incorporate the goals of improving the lifelong health of all Oregonians, increasing the quality, reliability and availability of health insurance for all Oregonians and lowering or containing the cost of health insurance so that health insurance is affordable to everyone.

      (2) Promote the public interest and for the benefit of the people and businesses that obtain health insurance coverage for themselves, their families and their employees through the exchange.

      (3) Empower Oregonians by giving them the information and tools they need to make health insurance choices that meet their needs and values.

      (4) Improve health care quality and public health, mitigate health disparities linked to race, ethnicity, primary language and similar factors, control costs and ensure access to affordable, equitable and high-quality health care throughout this state.

      (5) Be accountable to the public.

      (6) Encourage the development of new health insurance products that offer innovative:

      (a) Benefit packages for the coverage of health care services;

      (b) Health care delivery systems; and

      (c) Payment mechanisms. [2011 c.415 §2; 2015 c.3 §16]

 

      741.002 Duties, powers and functions of Department of Consumer and Business Services; rules. (1) The duties of the Department of Consumer and Business Services include:

      (a) Administering a health insurance exchange in accordance with federal law to make qualified health plans available to individuals and groups throughout this state.

      (b) Providing information in writing, through an Internet-based clearinghouse and through a toll-free telephone line, that will assist individuals and small businesses in making informed health insurance decisions and that may include:

      (A) The rating assigned to each health plan and the rating criteria that were used;

      (B) Quality and enrollee satisfaction survey results; and

      (C) The comparative costs, benefits, provider networks of health plans and other useful information.

      (c) Establishing and maintaining an electronic calculator that allows individuals and employers to determine the cost of coverage after deducting any applicable tax credits or cost-sharing reduction.

      (d) Operating a call center for answers to questions from individuals seeking enrollment in a qualified health plan or in the state medical assistance program.

      (e) Providing information about the eligibility requirements and the application processes for the state medical assistance program.

      (2) The department shall:

      (a) Screen, certify and recertify health plans as qualified health plans according to the requirements, standards and criteria adopted by the department under ORS 741.310 and ensure that qualified health plans provide choices of coverage.

      (b) Decertify or suspend, in accordance with ORS chapter 183, the certification of a health plan that fails to meet federal and state standards in order to exclude the health plan from participation in the exchange.

      (c) Promote fair competition of carriers participating in the exchange by certifying multiple health plans as qualified under ORS 741.310.

      (d) Assign ratings to health plans in accordance with criteria established by the United States Secretary of Health and Human Services and by the department.

      (e) Establish open and special enrollment periods for all enrollees, and monthly enrollment periods for Native Americans in accordance with federal law.

      (f) Assist individuals and groups to enroll in qualified health plans, including defined contribution plans as defined in section 414 of the Internal Revenue Code and, if appropriate, collect and remit premiums for such individuals or groups.

      (g) Facilitate community-based assistance with enrollment in qualified health plans by awarding grants to entities that are certified as navigators as described in 42 U.S.C. 18031(i).

      (h) Provide employers with the names of employees who end coverage under a qualified health plan during a plan year.

      (i) Certify the eligibility of an individual for an exemption from the individual responsibility requirement of section 5000A of the Internal Revenue Code.

      (j) Provide information to the federal government necessary for individuals who are enrolled in qualified health plans through the exchange to receive tax credits and reduced cost-sharing.

      (k) Provide to the federal government any information necessary to comply with federal requirements including:

      (A) Information regarding individuals determined to be exempt from the individual responsibility requirement of section 5000A of the Internal Revenue Code;

      (B) Information regarding employees who have reported a change in employer; and

      (C) Information regarding individuals who have ended coverage during a plan year.

      (L) Take any other actions necessary and appropriate to comply with the federal requirements for a health insurance exchange.

      (m) Work in coordination with the Oregon Health Authority and the Oregon Health Policy Board in carrying out its duties.

      (3) The department may adopt rules necessary to carry out its duties and functions under ORS 741.001 to 741.540.

      (4) The department may contract or enter into an intergovernmental agreement with the federal government to perform any of the duties and functions described in ORS 741.001 to 741.540.

      (5) The department may assign contracts to the Oregon Health Authority if necessary for the authority to administer the state medical assistance program. [2011 c.415 §3; 2012 c.38 §1; 2012 c.107 §88; 2015 c.3 §17]

 

      741.003 Duties and powers of director. (1) The health insurance exchange is under the supervision of the Director of the Department of Consumer and Business Services.

      (2) The director has such powers as are necessary to carry out ORS 741.001 to 741.540.

      (3) The director may employ, supervise and terminate the employment of such staff as the director deems necessary. The director shall prescribe their duties and fix their compensation. An employee of the department, other than the director, who has management responsibilities or decision-making authority with respect to the administration of the health insurance exchange may not also have management responsibilities or decision-making authority with respect to reviewing rates, assessing provider network adequacy, approving forms, determining financial solvency or enforcing other legal requirements applicable to insurers offering health insurance, as defined in ORS 731.162, in this state. Employees administering the exchange may not be individuals who are:

      (a) Employed by, consultants to or members of a board of directors of:

      (A) An insurer or third party administrator;

      (B) An insurance producer; or

      (C) A health care provider, health care facility or health clinic;

      (b) Members, board members or employees of a trade association of:

      (A) Insurers or third party administrators; or

      (B) Health care providers, health care facilities or health clinics; or

      (c) Health care providers, unless they receive no compensation for rendering services as health care providers and do not have ownership interests in professional health care practices. [Formerly 741.201]

 

      741.004 Health Insurance Exchange Advisory Committee. (1) The Health Insurance Exchange Advisory Committee is created to advise the Director of the Department of Consumer and Business Services in the development and implementation of the policies and operational procedures governing the administration of a health insurance exchange in this state including, but not limited to, all of the following:

      (a) The amount of the assessment imposed on insurers under ORS 741.105.

      (b) The implementation of a Small Business Health Options Program in accordance with 42 U.S.C. 18031.

      (c) The processes and procedures to enable each insurance producer to be authorized to act for all of the insurers offering health benefit plans through the health insurance exchange.

      (d) The affordability of health benefit plans offered by employers under section 5000A(e)(1) of the Internal Revenue Code.

      (e) Outreach strategies for reaching minority and low-income communities.

      (f) Solicitation of customer feedback.

      (g) The affordability of health benefit plans offered through the exchange.

      (2) The committee consists of 15 members. Thirteen members shall be appointed by the Governor and are subject to confirmation by the Senate in the manner prescribed in ORS 171.562 and 171.565. The appointed members serve at the pleasure of the Governor. The Director of the Department of Consumer and Business Services and the Director of the Oregon Health Authority shall serve as ex officio members of the committee.

      (3) The 13 members appointed by the Governor must represent the interests of:

      (a) Insurers;

      (b) Insurance producers;

      (c) Navigators, in-person assisters, application counselors and other individuals with experience in facilitating enrollment in qualified health plans;

      (d) Health care providers;

      (e) The business community, including small businesses and self-employed individuals;

      (f) Consumer advocacy groups, including advocates for enrolling hard-to-reach populations;

      (g) Enrollees in health benefit plans; and

      (h) State agencies that administer the medical assistance program under ORS chapter 414.

      (4) The Director of the Department of Consumer and Business Services may solicit recommendations from the committee and the committee may initiate recommendations on its own.

      (5) The committee shall provide annual reports to the Legislative Assembly, in the manner provided in ORS 192.245, of the findings and recommendations the committee considers appropriate, including a report on the:

      (a) Adequacy of assessments for reserve programs and administrative costs;

      (b) Implementation of the Small Business Health Options Program;

      (c) Number of qualified health plans offered through the exchange;

      (d) Number and demographics of individuals enrolled in qualified health plans;

      (e) Advance premium tax credits provided to enrollees in qualified health plans; and

      (f) Feedback from the community about satisfaction with the operation of the exchange and qualified health plans offered through the exchange.

      (6) The members of the committee shall be appointed for a term of two years and shall serve without compensation, but shall be entitled to travel expenses in accordance with ORS 292.495. The committee may hire, subject to the approval of the Director of the Department of Consumer and Business Services, such experts as the committee may require to discharge its duties. All expenses of the committee shall be paid out of the Health Insurance Exchange Fund established in ORS 741.102.

      (7) The employees of the Department of Consumer and Business Services are directed to assist the committee in the performance of its duties under subsection (1) of this section and, to the extent permitted by laws relating to confidentiality, to furnish such information and advice as the members of the committee consider necessary to perform their duties under subsection (1) of this section. [2015 c.3 §13]

 

      741.005 [1955 c.737 §2; repealed by 1967 c.359 §704]

 

      741.008 Criminal records check; fingerprints required; persons subject to requirement. The Department of Consumer and Business Services shall conduct a state or nationwide criminal records check under ORS 181A.195 on, and for that purpose may require the fingerprints of, a person who:

      (1) Is employed by or applying for employment with the department in a position related to the administration of the health insurance exchange; or

      (2) Is, or will be, providing services to the department in a position related to the administration of the health insurance exchange:

      (a) In which the person is providing information technology services and has control over, or access to, information technology systems that would allow the person to harm the information technology systems or the information contained in the systems;

      (b) In which the person has access to information that is confidential or for which state or federal laws, rules or regulations prohibit disclosure;

      (c) That has payroll functions or in which the person has responsibility for receiving, receipting or depositing money or negotiable instruments, for billing, collections or other financial transactions or for purchasing or selling property or has access to property held in trust or to private property in the temporary custody of the department;

      (d) That has mailroom duties as a primary duty or job function;

      (e) In which the person has responsibility for auditing the department;

      (f) That has personnel or human resources functions as a primary responsibility;

      (g) In which the person has access to Social Security numbers, dates of birth or criminal background information; or

      (h) In which the person has access to tax or financial information about individuals or business entities. [Formerly 741.255]

 

      741.010 [Repealed by 1967 c.359 §704]

 

      741.020 [Amended by 1961 c.466 §7; 1961 c.562 §6; repealed by 1967 c.359 §704]

 

      741.022 [1955 c.737 §10; 1963 c.349 §8; 1967 c.359 §426; renumbered 743.402]

 

      741.025 [2011 c.415 §4; 2014 c.78 §§3,4; repealed by 2015 c.3 §58]

 

      741.027 [2011 c.415 §6; 2012 c.38 §17; 2012 c.107 §94; repealed by 2015 c.3 §58]

 

      741.028 [1955 c.737 §11; repealed by 1967 c.359 §704]

 

      741.029 [2011 c.415 §7; repealed by 2015 c.3 §58]

 

      741.030 [Amended by 1955 c.409 §5; 1959 c.338 §5; repealed by 1967 c.359 §704]

 

      741.031 [2011 c.415 §8; repealed by 2015 c.3 §58]

 

      741.040 [Repealed by 1967 c.359 §704]

 

      741.050 [Repealed by 1955 c.737 §13]

 

      741.060 [Repealed by 1955 c.737 §13]

 

      741.070 [Repealed by 1955 c.737 §13]

 

      741.080 [Repealed by 1955 c.737 §13]

 

      741.090 [Repealed by 1955 c.737 §13]

 

      741.100 [Repealed by 1967 c.359 §704]

 

      741.101 [2011 c.415 §18; 2012 c.38 §2; 2012 c.107 §89; repealed by 2015 c.3 §59]

 

(Financing Operations of Exchange)

 

      741.102 Health Insurance Exchange Fund. The Health Insurance Exchange Fund is established in the State Treasury, separate and distinct from the General Fund. Interest earned by the Health Insurance Exchange Fund shall be credited to the fund. The Health Insurance Exchange Fund consists of moneys received by the Department of Consumer and Business Services under ORS 741.001 to 741.540. Moneys in the fund are continuously appropriated to the department for carrying out the purposes of ORS 741.001 to 741.540. [2015 c.3 §14; 2015 c.3 §15]

 

      741.105 Charges and fees to be paid by insurers and state programs; rules. (1) The Department of Consumer and Business Services shall establish, by rule, an administrative charge. The department shall impose and collect the charge from all insurers and state programs participating in the health insurance exchange. The Health Insurance Exchange Advisory Committee shall advise the department in establishing the administrative charge. The charge must be in an amount sufficient to cover the costs of grants to navigators, in-person assisters and application counselors certified under ORS 741.002 and to pay the administrative and operational expenses of the department in carrying out ORS 741.001 to 741.540. The charge shall be paid in a manner and at intervals prescribed by the department.

      (2) Each insurer’s charge shall be based on the number of individuals, excluding individuals enrolled in state programs, who are enrolled in health plans offered by the insurer through the exchange. The assessment on each state program shall be based on the number of individuals enrolled in state programs offered through the exchange. The charge may not exceed:

      (a) Five percent of the premium or other monthly charge for each enrollee if the number of enrollees receiving coverage through the exchange is at or below 175,000;

      (b) Four percent of the premium or other monthly charge for each enrollee if the number of enrollees receiving coverage through the exchange is above 175,000 and at or below 300,000; and

      (c) Three percent of the premium or other monthly charge for each enrollee if the number of enrollees receiving coverage through the exchange is above 300,000.

      (3)(a) If charges collected under subsection (1) of this section exceed the amounts needed for the administrative and operational expenses of the department in administering the health insurance exchange, the excess moneys collected may be held and used by the department to offset future net losses.

      (b) The maximum amount of excess moneys that may be held under this subsection is the total administrative and operational expenses of administering the health insurance exchange anticipated by the department for a six-month period. Any moneys received that exceed the maximum shall be applied by the department to reduce the charges imposed by this section.

      (4) Charges shall be based on annual statements and other reports submitted by insurers and state programs as prescribed by the department.

      (5) In addition to charges imposed under subsection (1) of this section, to the extent permitted by federal law the department may impose a fee on insurers and state programs participating in the exchange to cover the cost of commissions of insurance producers that are certified by the department or by the United States Department of Health and Human Services to facilitate the participation of individuals and employers in the exchange.

      (6)(a) The Department of Consumer and Business Services shall establish and amend the charges and fees under this section in accordance with ORS 183.310 to 183.410.

      (b) If the department intends to increase an administrative charge or fee, the notice of intended action required by ORS 183.335 shall be sent, if the Legislative Assembly is not in session, to the interim committees of the Legislative Assembly related to health, to the Joint Interim Committee on Ways and Means and to each member of the Legislative Assembly. The Director of the Department of Consumer and Business Services shall appear at the next meetings of the interim committees of the Legislative Assembly related to health and the next meetings of the Joint Interim Committee on Ways and Means that occur after the notice of intended action is sent and fully explain the basis and rationale for the proposed increase in the administrative charges or fees.

      (c) If the Legislative Assembly is in session, the department shall give the notice of intended action to the committees of the Legislative Assembly related to health and to the Joint Committee on Ways and Means and shall appear before the committees to fully explain the basis and rationale for the proposed increase in administrative charges or fees.

      (7) All charges and fees collected under this section shall be deposited in the Health Insurance Exchange Fund. [2011 c.415 §17; 2012 c.38 §4; 2012 c.107 §91; 2015 c.3 §18]

 

      Note: Section 36a, chapter 3, Oregon Laws 2015, provides:

      Sec. 36a. (1) As used in this section, “Small Business Health Options Program” has the meaning given that term in ORS 741.300.

      (2) If the Department of Consumer and Business Services submits a request to the Oregon Department of Administrative Services to procure an information technology product or service for creating an Internet portal for the Small Business Health Options Program and the anticipated cost exceeds $1 million:

      (a) The department shall, if the Legislative Assembly is not in session, notify the interim committees of the Legislative Assembly related to health, the Joint Interim Committee on Ways and Means and each member of the Legislative Assembly. The Director of the Department of Consumer and Business Services shall appear at the next meetings of the interim committees of the Legislative Assembly related to health and the next meetings of the Joint Interim Committee on Ways and Means to fully explain the need for the product or service.

      (b) If the Legislative Assembly is in session, the department shall notify the committees of the Legislative Assembly related to health and the Joint Committee on Ways and Means and the director shall appear before the committees to fully explain the need for the product or service. [2015 c.3 §36a]

 

      741.110 [1955 c.737 §3; repealed by 1967 c.359 §704]

 

      741.120 [1955 c.737 §4; 1967 c.359 §427; renumbered 743.405]

 

      741.130 [1955 c.737 §5; repealed by 1967 c.359 §704]

 

      741.140 [1955 c.737 §6; repealed by 1967 c.359 §704]

 

      741.145 [1955 c.737 §12; repealed by 1967 c.359 §704]

 

      741.150 [1955 c.737 §7; repealed by 1967 c.359 §704]

 

      741.160 [1955 c.737 §8; repealed by 1967 c.359 §704]

 

      741.170 [1955 c.737 §9; 1967 c.359 §455; renumbered 743.489]

 

      741.180 [1965 c.35 §2; 1967 c.359 §456; renumbered 743.492]

 

      741.190 [1965 c.573 §2; 1967 c.359 §457; renumbered 743.495]

 

      741.200 [1965 c.573 §3; 1967 c.359 §458; renumbered 743.498]

 

      741.201 [2011 c.415 §9; 2012 c.38 §5; 2012 c.107 §92; 2015 c.3 §19; renumbered 741.003 in 2015]

 

(Audits and Reports)

 

      741.220 Financial and performance audits of health insurance exchange accounts; report of audit. (1) The Department of Consumer and Business Services shall keep an accurate accounting of the operation and all activities, receipts and expenditures of the department with respect to the health insurance exchange.

      (2) The Secretary of State shall conduct an annual financial audit of the department’s revenues and expenditures in carrying out ORS 741.001 to 741.540. The audit shall include but is not limited to:

      (a) A review of the sources and uses of the moneys in the Health Insurance Exchange Fund;

      (b) A review of charges and fees imposed and collected pursuant to ORS 741.105; and

      (c) A review of premiums collected and remitted.

      (3) Every two years, the Secretary of State shall conduct a performance audit of the exchange.

      (4) The Director of the Department of Consumer and Business Services and employees of the department shall cooperate with the Secretary of State in the audits and reviews conducted under subsections (2) and (3) of this section.

      (5) The audits shall be conducted using generally accepted accounting principles and any financial integrity requirements of federal authorities.

      (6) The cost of the audits required by subsections (2) and (3) of this section shall be paid by the department.

      (7) The Secretary of State shall issue a report to the Governor, the President of the Senate, the Speaker of the House of Representatives, the Oregon Health Authority, the Oregon Health Policy Board and appropriate federal authorities on the results of each audit conducted pursuant to this section, including any recommendations for corrective actions. The report shall be available for public inspection, in accordance with the Secretary of State’s established rules and procedures governing public disclosure of audit documents.

      (8) To the extent the audit requirements under this section are similar to any audit requirements imposed on the department by federal authorities, the Secretary of State and the department shall make reasonable efforts to coordinate with the federal authorities to promote efficiency and the best use of resources in the timing and provision of information.

      (9) Not later than the 90th day after the Secretary of State completes and delivers an audit report issued under subsection (7) of this section, the director shall notify the Secretary of State in writing of the corrective actions taken or to be taken, if any, in response to any recommendations in the report. The Secretary of State may extend the 90-day period for good cause. [2011 c.415 §21; 2012 c.38 §6; 2012 c.107 §93; 2015 c.3 §20]

 

      741.222 Annual reports to Legislative Assembly. (1) The Director of the Department of Consumer and Business Services shall report to the Legislative Assembly each year on:

      (a) The financial condition of the health insurance exchange, including actual and projected revenues and expenses of the administrative operations of the exchange and commissions paid to insurance producers out of fees collected under ORS 741.105 (5);

      (b) The implementation of the Small Business Health Options Program;

      (c) The development of the information technology system for the exchange; and

      (d) Any other information requested by the leadership of the Legislative Assembly.

      (2) The director shall provide to the Legislative Assembly, the Governor, the Oregon Health Authority and the Oregon Health Policy Board, not later than April 15 of each year:

      (a) A report covering the activities and operations of the Department of Consumer and Business Services in administering the health insurance exchange during the previous year of operations;

      (b) A statement of the financial condition, as of December 31 of the previous year, of the Health Insurance Exchange Fund;

      (c) A description of the role of insurance producers in the exchange; and

      (d) Recommendations, if any, for additional groups to be eligible to purchase qualified health plans through the exchange under ORS 741.310. [2011 c.415 §22; 2012 c.38 §18; 2012 c.107 §95; 2013 c.368 §§1,3; 2015 c.3 §§21,22]

 

      741.250 [2011 c.415 §19; 2012 c.38 §7; 2012 c.107 §68; repealed by 2015 c.3 §58]

 

      741.255 [2011 c.415 §20; 2015 c.3 §23; renumbered 741.008 in 2015]

 

HEALTH INSURANCE EXCHANGE

 

(Definitions)

 

      741.300 Definitions. As used in ORS 741.001 to 741.540:

      (1) “Coordinated care organization” has the meaning given that term in ORS 414.025.

      (2) “Essential health benefits” has the meaning given that term in ORS 731.097.

      (3) “Health benefit plan” has the meaning given that term in ORS 743B.005.

      (4) “Health care service contractor” has the meaning given that term in ORS 750.005.

      (5) “Health insurance” has the meaning given that term in ORS 731.162, excluding disability income insurance.

      (6) “Health insurance exchange” or “exchange” means an American Health Benefit Exchange as described in 42 U.S.C. 18031, 18032, 18033 and 18041.

      (7) “Health plan” means health insurance, a health benefit plan or health care coverage offered by an insurer.

      (8) “Insurer” means an insurer as defined in ORS 731.106 that offers health insurance, a health care service contractor, a prepaid managed care health services organization or a coordinated care organization.

      (9) “Insurance producer” has the meaning given that term in ORS 731.104.

      (10) “Prepaid managed care health services organization” has the meaning given that term in ORS 414.025.

      (11) “State program” means a program providing medical assistance, as defined in ORS 414.025, and any self-insured health benefit plan or health plan offered to employees by the Public Employees’ Benefit Board or the Oregon Educators Benefit Board.

      (12) “Qualified health plan” means a health benefit plan available for purchase through the health insurance exchange.

      (13) “Small Business Health Options Program” or “SHOP” means a health insurance exchange for small employers as described in 42 U.S.C. 18031. [2011 c.415 §1; 2013 c.681 §10; 2015 c.3 §24; 2015 c.792 §9]

 

(Operation of Exchange)

 

      741.310 Requirements for purchase of insurance through exchange and for participation of insurers in exchange. (1)(a) Individuals and families may purchase qualified health plans through the health insurance exchange.

      (b) The following groups may purchase qualified health plans through the Small Business Health Options Program:

      (A) Employers with no more than 100 employees; and

      (B) Districts and eligible employees of districts that are subject to ORS 243.886, unless their participation is precluded by federal law.

      (2)(a) Only individuals who purchase health plans through the exchange may be eligible to receive premium tax credits under section 36B of the Internal Revenue Code and reduced cost-sharing under 42 U.S.C. 18071.

      (b) Only employers that purchase health plans through the SHOP may be eligible to receive small employer health insurance credits under section 45R of the Internal Revenue Code.

      (3) Only an insurer that has a certificate of authority to transact insurance in this state and that meets applicable federal requirements for participating in the exchange may offer a qualified health plan through the exchange. Any qualified health plan must be certified under ORS 741.002. Coordinated care organizations that do not have a certificate of authority to transact insurance may serve only medical assistance recipients through the exchange and may not offer qualified health plans.

      (4)(a) The Department of Consumer and Business Services shall adopt by rule uniform requirements, standards and criteria for the certification of qualified health plans, including requirements that a qualified health plan provide, at a minimum, essential health benefits and have acceptable consumer and provider satisfaction ratings.

      (b) The department may limit the number of qualified health plans that may be offered through the exchange as long as the same limit applies to all insurers.

      (5) The department shall certify as qualified a dental only health plan as permitted by federal law.

      (6) The department, in collaboration with the Oregon Health Authority and the Department of Human Services, shall coordinate the application and enrollment processes for the exchange and the state medical assistance program.

      (7) The Department of Consumer and Business Services may establish risk mediation programs within the exchange.

      (8) The department shall establish by rule a process for certifying insurance producers to facilitate the transaction of insurance through the exchange, in accordance with federal standards and policies.

      (9) The department shall ensure that an insurer charges the same premiums for plans sold through the exchange as for identical plans sold outside of the exchange.

      (10) The department is authorized to enter into contracts for the performance of the department’s duties, functions or operations with respect to the exchange, including but not limited to contracting with:

      (a) Insurers that meet the requirements of subsections (3) and (4) of this section, to offer qualified health plans through the exchange; and

      (b) Navigators, in-person assisters and application counselors certified by the department under ORS 741.002.

      (11)(a) The department shall consult with stakeholders, including but not limited to representatives of school administrators, school board members, school employees and the Oregon Educators Benefit Board, regarding the plans that may be offered through the exchange to districts and eligible employees of districts under subsection (1)(b)(B) of this section and the insurers that may offer the plans.

      (b) The board and the department shall each adopt rules to ensure that:

      (A) Any plan offered under subsection (1)(b)(B) of this section is underwritten by an insurer using a single risk pool composed of all eligible employees who are enrolled or who will be enrolled in the plan both through the exchange and by the board; and

      (B) In every plan offered under subsection (1)(b)(B) of this section, the coverage is comparable to plans offered by the board.

      (12) The department is authorized to apply for and accept federal grants, other federal funds and grants from nongovernmental organizations for purposes of developing, implementing and administering the exchange. Moneys received under this subsection shall be deposited in the Health Insurance Exchange Fund. [2011 c.415 §11; 2011 c.415 §12; 2012 c.38 §§10,11; 2012 c.107 §§96,97; 2013 c.421 §§1,2; 2015 c.3 §25; 2015 c.792 §§10,11]

 

      741.340 Health benefit plans offered through exchange. The Oregon Health Authority, in developing and offering the health benefit package required by ORS 413.011 (1)(j), may not establish policies or procedures that discourage insurers from offering more comprehensive health benefit plans that provide greater consumer choice at a higher cost. The health benefit package approved by the Oregon Health Policy Board shall:

      (1) Promote the provision of services through an integrated health home model that reduces unnecessary hospitalizations and emergency department visits.

      (2) Require little or no cost sharing for evidence-based preventive care and services, such as care and services that have been shown to prevent acute exacerbations of disease symptoms in individuals with chronic illnesses.

      (3) Create incentives for individuals to actively participate in their own health care and to maintain or improve their health status.

      (4) Require a greater contribution by an enrollee to the cost of elective or discretionary health services.

      (5) Include a defined set of health care services that are affordable, financially sustainable and based upon the prioritized list of health services developed and updated by the Health Evidence Review Commission under ORS 414.690. [Formerly 413.064]

 

      741.342 Small Business Health Options Program. Health benefit plans offered through a Small Business Health Options Program, as defined in ORS 741.300, are subject to ORS 743.004, 743.022, 743.535 and 743B.003 to 743B.127 and to other provisions of the Insurance Code applicable to small employer group health insurance. [2015 c.3 §36]

 

      Note: 741.342 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 741 or any series therein. See Preface to Oregon Revised Statutes for further explanation.

 

      741.381 Application of antitrust laws. The activities of insurers working under the direction of the Oregon Health Authority and the Department of Consumer and Business Services pursuant to ORS 413.011 (1)(j) or participating in the health insurance exchange administered under ORS 741.002 do not constitute a conspiracy or restraint of trade or an illegal monopoly, nor are they carried out for the purposes of lessening competition or fixing prices arbitrarily. [Formerly 413.075; 2012 c.38 §19; 2015 c.3 §26]

 

      741.390 False or misleading filings prohibited. A person may not file or cause to be filed with the Department of Consumer and Business Services any article, certificate, report, statement, application or any other information related to the health insurance exchange required or permitted by the department to be filed, that is known by the person to be false or misleading in any material respect. [2011 c.415 §24; 2015 c.3 §28]

 

      741.400 Service of eligibility notices; when notice becomes final order; opportunity to contest actual receipt of notice. (1) The Department of Consumer and Business Services may serve by regular mail or, if requested by the recipient, by electronic mail a notice described in ORS 183.415 of the department’s determination of:

      (a) A person’s eligibility to purchase or to continue to purchase a qualified health plan through the health insurance exchange;

      (b) A person’s eligibility for a premium tax credit for purchasing a qualified health plan or the amount of the person’s premium tax credit; or

      (c) A person’s eligibility for cost-sharing reductions for qualified health plans and the amount of the person’s cost-sharing reduction.

      (2) The legal presumption described in ORS 40.135 (1)(q) does not apply to a notice that is served by regular or electronic mail in accordance with subsection (1) of this section.

      (3) Except as provided in subsection (4) of this section, a contested case notice served in accordance with subsection (1) of this section that complies with ORS 183.415 but for service by regular or electronic mail becomes a final order against a party and is not subject to ORS 183.470 (2), upon the earlier of the following:

      (a) If the party fails to request a hearing, the day after the date prescribed in the notice as the deadline for requesting a hearing.

      (b) The date the department or the Office of Administrative Hearings mails an order dismissing a hearing request because:

      (A) The party withdraws the request for hearing; or

      (B) Neither the party nor the party’s representative appears on the date and at the time set for hearing.

      (4) The department shall prescribe by rule a period of not less than 60 days after a notice becomes a final order under subsection (3) of this section within which a party may request a hearing under this subsection. If a party requests a hearing within the period prescribed under this subsection, the department shall do one of the following:

      (a) If the department finds that the party did not receive the written notice and did not have actual knowledge of the notice, refer the request for hearing to the Office of Administrative Hearings for a contested case proceeding on the merits of the department’s intended action described in the notice.

      (b) Refer the request for hearing to the Office of Administrative Hearings for a contested case proceeding to determine whether the party received the written notice or had actual knowledge of the notice. The department must show that the party had actual knowledge of the notice or that the department mailed the notice to the party’s correct address or sent an electronic notice to the party’s correct electronic mail address.

      (5) If a party informs the department that the party did not receive a notice served by regular or electronic mail in accordance with subsection (1) of this section, the department shall advise the party of the right to request a hearing under subsection (4) of this section. [2013 c.678 §2; 2015 c.3 §29]

 

      741.405 [1961 c.182 §3; repealed by 1967 c.359 §704]

 

      741.410 [1955 c.125 §2; repealed by 1961 c.182 §14]

 

      741.415 [1961 c.182 §2; repealed by 1967 c.359 §704]

 

      741.420 [1961 c.182 §4; repealed by 1967 c.359 §704]

 

      741.425 [1961 c.182 §5; 1967 c.359 §474; renumbered 743.573]

 

      741.430 [1961 c.182 §6; repealed by 1967 c.359 §704]

 

      741.435 [1961 c.182 §7; repealed by 1967 c.359 §704]

 

      741.440 [1961 c.182 §8; repealed by 1967 c.359 §704]

 

      741.445 [1961 c.182 §9; repealed by 1967 c.359 §704]

 

      741.450 [1961 c.182 §10; repealed by 1967 c.359 §704]

 

      741.455 [1961 c.182 §11; 1967 c.359 §566; renumbered 744.575]

 

      741.460 [1961 c.182 §12; repealed by 1967 c.359 §704]

 

      741.465 [1961 c.182 §13; repealed by 1967 c.359 §704]

 

(Collection and Disclosure of Information by Exchange)

 

      741.500 Required documentation; rules. (1)(a) The Department of Consumer and Business Services shall adopt by rule the information that must be documented in order for a person to qualify for:

      (A) Health plan coverage through the health insurance exchange;

      (B) Premium tax credits; and

      (C) Cost-sharing reductions.

      (b) The documentation specified by the department under this subsection shall include but is not limited to documentation of:

      (A) The identity of the person;

      (B) The status of the person as a United States citizen, or lawfully admitted noncitizen, and a resident of this state;

      (C) Information concerning the income and resources of the person as necessary to establish the person’s financial eligibility for coverage, for premium tax credits and for cost-sharing reductions, which may include income tax return information and a Social Security number; and

      (D) Employer identification information and employer-sponsored health insurance coverage information applicable to the person.

      (2) The department shall adopt by rule the information that must be documented in order to determine whether the person is exempt from a requirement to purchase or be enrolled in a health plan under section 5000A of the Internal Revenue Code or other federal law.

      (3) The department shall implement systems that provide electronic access to, and use, disclosure and validation of data needed to administer the exchange, to comply with federal data access and data exchange requirements and to streamline and simplify exchange processes.

      (4) Information and data that the department obtains under this section may be exchanged with other state or federal health insurance exchanges, with state or federal agencies and, subject to ORS 741.510, for the purpose of carrying out exchange responsibilities, including but not limited to:

      (a) Establishing and verifying eligibility for:

      (A) A state medical assistance program;

      (B) The purchase of health plans through the exchange; and

      (C) Any other programs that are offered through the exchange;

      (b) Establishing and verifying the amount of a person’s federal tax credit, cost-sharing reduction or premium assistance;

      (c) Establishing and verifying eligibility for exemption from the requirement to purchase or be enrolled in a health plan under section 5000A of the Internal Revenue Code or other federal law;

      (d) Complying with other federal requirements; or

      (e) Improving the operations of the exchange and for program analysis. [2011 c.415 §14; 2015 c.3 §30]

 

      741.505 [1963 c.349 §2; repealed by 1967 c.359 §704]

 

      741.510 Confidential information; public officer privilege; permitted uses of confidential information. (1) Except as provided in subsection (3) of this section, documents, materials or other information that is in the possession or control of the Department of Consumer and Business Services for the purpose of carrying out ORS 741.002, 741.310 and 741.500 or complying with federal health insurance exchange requirements, and that is protected from disclosure by state or federal law, remains confidential and is not subject to disclosure under ORS 192.311 to 192.478 or subject to subpoena or discovery or admissible into evidence in any private civil action in which the department is not a named party. The department may use confidential documents, materials or other information without further disclosure in order to carry out the duties described in ORS 741.002, 741.310 and 741.500 or to take any legal or regulatory action authorized by law.

      (2) Documents, materials and other information to which subsection (1) of this section applies is subject to the public officer privilege described in ORS 40.270.

      (3) The Director of the Department of Consumer and Business Services may:

      (a) Authorize the sharing of confidential documents, materials or other information that is subject to subsection (1) of this section within the department and subject to any conditions on further disclosure, for the purpose of carrying out the duties and functions of the department under ORS 741.002, 741.310 and 741.500 or complying with federal health insurance exchange requirements.

      (b) Authorize the sharing of confidential documents, materials or other information that is subject to subsection (1) of this section or that is otherwise confidential under ORS 192.345 or 192.355 with other state or federal health insurance exchanges or regulatory authorities, the Oregon Health Authority, the Department of Revenue, law enforcement agencies and federal authorities, if required or authorized by state or federal law and if the recipient agrees to maintain the confidentiality of the documents, materials or other information.

      (c) Receive documents, materials or other information, including documents, materials or other information that is otherwise confidential, from other state or federal health insurance exchanges or regulatory authorities, the Oregon Health Authority, the Department of Revenue, law enforcement agencies or federal authorities. The Department of Consumer and Business Services shall maintain the confidentiality requested by the sender of the documents, materials or other information received under this section as necessary to comply with the laws of the jurisdiction from which the documents, materials or other information was received and originated.

      (4) The disclosure of documents, materials or other information to the Department of Consumer and Business Services under this section, or the sharing of documents, materials or other information as authorized in subsection (3) of this section, does not waive any applicable privileges or claims of confidentiality in the documents, materials or other information.

      (5) This section does not prohibit the department from releasing to a database or other clearinghouse service maintained by federal authorities a final, adjudicated order, including a certification, recertification, suspension or decertification of a qualified health plan under ORS 741.002, if the order is otherwise subject to public disclosure. [2011 c.415 §15; 2015 c.3 §31]

 

      741.515 [1963 c.349 §1; repealed by 1967 c.359 §704]

 

      741.520 Agreements with other agencies regarding sharing and use of confidential information; contents. (1) The Director of the Department of Consumer and Business Services may enter into agreements governing the sharing and use of information consistent with this section and ORS 741.510 with other state or federal health insurance exchanges or regulatory authorities, the Oregon Health Authority, the Department of Revenue, law enforcement agencies or federal authorities.

      (2) An agreement under this section must specify the duration of the agreement, the purpose of the agreement, the methods that may be employed for terminating the agreement and any other necessary and proper matters.

      (3) An agreement under this section does not relieve the director of any obligation or responsibility imposed by law.

      (4) The director may expend funds and may supply services for the purpose of carrying out an agreement under this section. [2011 c.415 §16; 2015 c.3 §32]

 

      741.525 [1963 c.349 §3; repealed by 1967 c.359 §704]

 

      741.535 [1963 c.349 §5; repealed by 1967 c.359 §704]

 

      741.540 Complaints and investigations confidential; permitted disclosures. (1) A complaint made to the Department of Consumer and Business Services with respect to any prospective or certified qualified health plan, and the record thereof, shall be confidential and may not be disclosed except as provided in ORS 741.510 and 741.520. No such complaint, or the record thereof, shall be used by the department in any action, suit or proceeding except in the investigation or prosecution of apparent violations of ORS 741.310 or other law.

      (2) Data gathered pursuant to an investigation of a complaint by the department shall be confidential, may not be disclosed except as provided in ORS 741.510 and 741.520 and may not be used in any action, suit or proceeding except in the investigation or prosecution of apparent violations of ORS 741.310 or other law.

      (3) Notwithstanding subsections (1) and (2) of this section, the department shall establish a method for making available to the public an annual statistical report containing the number, percentage, type and disposition of complaints received by the department against each health plan that is certified or that has been certified as a qualified health plan by the department. [2011 c.415 §23; 2015 c.3 §33]

 

      741.545 [1963 c.349 §4; repealed by 1967 c.359 §704]

 

      741.555 [1963 c.349 §6; repealed by 1967 c.359 §704]

 

      741.565 [1963 c.349 §7; repealed by 1967 c.359 §704]

 

MISCELLANEOUS

 

(Grace Period)

 

      741.800 Insurer to notify health care provider of qualified health plan coverage. Upon receipt of any inquiry from a health care provider regarding the eligibility, coverage or benefits of an insured under an enrollee’s plan, an insurer shall notify the health care provider, in the manner prescribed by the insurer, that the coverage is provided through a qualified health plan. [2015 c.580 §3]

 

      741.801 Insurer to notify health care provider that enrollee is in grace period; effect of failure to provide notice. (1) As used in this section and ORS 741.800:

      (a) “Enrollee” means a person who is:

      (A) Enrolled in a qualified health plan purchased through the health insurance exchange;

      (B) Responsible for paying the premium on the qualified health plan and has paid at least one premium; and

      (C) Receiving an advance payment of the premium tax credit under section 36B of the Internal Revenue Code.

      (b) “Grace period” means the period of three consecutive months during which an enrollee’s coverage continues under a qualified health plan without the payment of premiums.

      (c) “Health insurance exchange” has the meaning given that term in ORS 741.300.

      (d) “Qualified health plan” means a plan that is certified as a qualified health plan in accordance with ORS 741.310.

      (2) If an enrollee fails to pay a premium for a qualified health plan, the insurer shall notify any health care provider that the enrollee is in a grace period if the provider requests information from the insurer regarding the eligibility, coverage or benefits of the insureds under the enrollee’s plan.

      (3) If an insurer terminates the coverage of an enrollee based on the nonpayment of premiums during a grace period, the insurer shall pay a claim for reimbursement by a health care provider of a service performed during the grace period if:

      (a) The insurer fails to notify the health care provider as required by subsection (2) of this section;

      (b) The service is covered by the enrollee’s plan; and

      (c) The health care provider requests the information described in subsection (2) of this section not more than seven business days before providing the service and the insurer provides the information to the health care provider no later than two business days after the date of the provider’s request.

      (4) The requirements of this section may not be waived by agreement, and any provision of a contract entered into on or after January 1, 2016, that purports to waive the requirements of this section or that conflicts with the requirements of this section is null and void. [2015 c.580 §2]

 

      741.802 Department to produce written informational materials. The Department of Consumer and Business Services shall produce written materials containing information for consumers about the requirements for paying the premiums for qualified health plans. The department shall distribute the materials to health care providers upon request. [2015 c.580 §4]

 

      Note: 741.802 was enacted into law by the Legislative Assembly but was not added to or made a part of the Insurance Code or any chapter or series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.

 

(Penalties)

 

      741.900 Civil penalties. (1) The Director of the Department of Consumer and Business Services, in accordance with ORS 183.745, may impose a civil penalty for a violation of ORS 741.390 of no more than $10,000.

      (2) All penalties recovered under this section shall be deposited in the Health Insurance Exchange Fund. [2011 c.415 §25; 2015 c.3 §34]

 

      741.990 [Repealed by 1967 c.359 §704]

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