2011 ORS § 743.730¹
Definitions for ORS 743.730 to 743.773

For purposes of ORS 743.730 (Definitions for ORS 743.730 to 743.773) to 743.773 (Rules for ORS 743.766 to 743.769):

(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 (Requirement to offer basic health benefit plans to small employers), 743.760 (Approval of portability plans) or 743.761 (Satisfaction of requirements of ORS 743.760 by carrier offering individual health benefit plans), based upon the persons 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 (Definitions for ORS 732.517 to 732.592).

(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 condition exclusion;

(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 enrollees or late enrollees 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 approved by the Department of Consumer and Business Services under ORS 743.736 (Requirement to offer basic health benefit plans to small employers).

(5) Bona fide association means an association that meets the requirements of 42 U.S.C. 300gg-91 as amended and in effect on March 23, 2010.

(6) Carrier, except as provided in ORS 743.760 (Approval of portability plans), means any person who provides health benefit plans in this state, including:

(a) A licensed insurance company;

(b) A health care service contractor;

(c) A health maintenance organization;

(d) An association or group of employers that provides benefits by means of a multiple employer welfare arrangement and that:

(A) Is subject to ORS 750.301 (Definitions for ORS 750.301 to 750.341) to 750.341 (Requirement for multiple employer welfare arrangement to become traditional insurer); or

(B) Is fully insured and otherwise exempt under ORS 750.303 (Conditions for use of multiple employer welfare arrangement) (4) but elects to be governed by ORS 743.733 (Issuance of group health benefit plan to affiliated group of employers) to 743.737 (Requirements for small employer health benefit plans); or

(e) Any other person or corporation responsible for the payment of benefits or provision of services.

(7) Creditable coverage means prior health care coverage as defined in 42 U.S.C. 300gg as amended and in effect on February 17, 2009, and includes coverage remaining in force at the time the enrollee obtains new coverage.

(8) Dependent means the spouse or child of an eligible employee, subject to applicable terms of the health benefit plan covering the employee.

(9) Eligible employee means an employee who works on a regularly scheduled basis, with a normal work week of 17.5 [bad link] or more hours. The employer may determine hours worked for eligibility between 17.5 [bad link] 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 employer for fewer than 90 days are not eligible employees unless the employer so allows.

(10) Employee means any individual employed by an employer.

(11) 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.

(12) Exclusion period means a period during which specified treatments or services are excluded from coverage.

(13) Financially impaired means a carrier that is not insolvent and is:

(a) Considered by the director 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.

(14)(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 carriers:

(A) Group health benefit plans;

(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.

(15) Grandfathered health plan has the meaning prescribed by the United States Secretaries of Labor, Health and Human Services and the Treasury pursuant to 42 U.S.C. 18011(e).

(16) 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.

(17)(a) Health benefit plan means any:

(A) Hospital expense, medical expense or hospital or medical expense policy or certificate;

(B) Health care service contractor or health maintenance organization subscriber contract; or

(C) 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, to the extent that the plan is subject to state regulation.

(b) Health benefit plan does not include:

(A) Coverage for accident only, specific disease or condition only, credit or disability income;

(B) Coverage of Medicare services pursuant to contracts with the federal government;

(C) Medicare supplement insurance policies;

(D) Coverage of TRICARE services pursuant to contracts with the federal government;

(E) 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;

(F) Separately offered long term care insurance, including, but not limited to, coverage of nursing home care, home health care and community-based care;

(G) Independent, noncoordinated, hospital-only indemnity insurance or other fixed indemnity insurance;

(H) Short term health insurance policies that are in effect for periods of 12 months or less, including the term of a renewal of the policy;

(I) Dental only coverage;

(J) Vision only coverage;

(K) Stop-loss coverage that meets the requirements of ORS 742.065 (Insurance against risk of loss assumed under less than fully insured employee health benefit plan);

(L) Coverage issued as a supplement to liability insurance;

(M) Insurance arising out of a workers compensation or similar law;

(N) 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; or

(O) Any employee welfare benefit plan that is exempt from state regulation because of the federal Employee Retirement Income Security Act of 1974, as amended.

(c) For purposes of this subsection, renewal of a short term health insurance policy includes the issuance of a new short term health insurance policy by an insurer to a policyholder within 60 days after the expiration of a policy previously issued by the insurer to the policyholder.

(18) 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 approved by the director under ORS 743.745 (Requirements for basic health benefit plans).

(19) 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.

(20) Initial enrollment period means a period of at least 30 days following commencement of the first eligibility period for an individual.

(21) 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 February 17, 2009;

(b) The individual applies for coverage during an open enrollment period;

(c) A court issues an order that coverage be provided for a spouse or minor child under an employees employer sponsored 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 that offers multiple health benefit plans and the individual elects a different health benefit plan during an open enrollment period; or

(e) The individuals coverage under Medicaid, Medicare, TRICARE, 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 after applying for coverage in a group health benefit plan.

(22) 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 (Definitions for ORS 750.301 to 750.341) to 750.341 (Requirement for multiple employer welfare arrangement to become traditional insurer).

(23) Oregon Medical Insurance Pool means the pool created under ORS 735.610 (Oregon Medical Insurance Pool Board).

(24) Preexisting condition exclusion 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 (Definitions for ORS 743.730 to 743.773) to 743.773 (Rules for ORS 743.766 to 743.769):

(a) Pregnancy does not constitute a preexisting condition except as provided in ORS 743.766 (Use of health statements in individual health benefit plans);

(b) Genetic information does not constitute a preexisting condition in the absence of a diagnosis of the condition related to such information; and

(c) Except for coverage under an individual grandfathered health plan, a preexisting condition exclusion may not exclude coverage for services, charges or expenses incurred by an individual who is under 19 years of age.

(25) 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.

(26) Rating period means the 12-month calendar period for which premium rates established by a carrier are in effect, as determined by the carrier.

(27) Representative does not include an insurance producer or an employee or authorized representative of an insurance producer or carrier.

(28)(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 offered by the employer.

(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. [1991 c.916 §3; 1993 c.18 §157; 1993 c.615 §25; 1993 c.649 §8; 1993 c.744 §31; 1995 c.603 §§1,36; 1997 c.716 §§1,2; 1999 c.547 §8; 1999 c.987 §6; 2001 c.943 §6; 2003 c.364 §112; 2005 c.744 §38; 2007 c.389 §1; 2009 c.595 §1135; 2011 c.500 §7]

Note: The amendments to 743.730 (Definitions for ORS 743.730 to 743.773) by section 49, chapter 500, Oregon Laws 2011, become operative January 2, 2014. See section 6, chapter 322, Oregon Laws 2011, as amended by section 50, chapter 500, Oregon Laws 2011. The text that is operative on and after January 2, 2014, is set forth for the users convenience.

743.730 (Definitions for ORS 743.730 to 743.773). For purposes of ORS 743.730 (Definitions for ORS 743.730 to 743.773) to 743.773 (Rules for ORS 743.766 to 743.769):

(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 (Requirement to offer basic health benefit plans to small employers), 743.760 (Approval of portability plans) or 743.761 (Satisfaction of requirements of ORS 743.760 by carrier offering individual health benefit plans), based upon the persons 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 (Definitions for ORS 732.517 to 732.592).

(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 condition exclusion;

(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 enrollees or late enrollees 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 that provides bronze plan coverage and that is approved by the Department of Consumer and Business Services under ORS 743.736 (Requirement to offer basic health benefit plans to small employers).

(5) Bona fide association means an association that meets the requirements of 42 U.S.C. 300gg-91 as amended and in effect on 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 ORS 743.822 (Requirement to offer bronze and silver plans) (2).

(7) Carrier, except as provided in ORS 743.760 (Approval of portability plans), means any person who provides health benefit plans in this state, including:

(a) A licensed insurance company;

(b) A health care service contractor;

(c) A health maintenance organization;

(d) An association or group of employers that provides benefits by means of a multiple employer welfare arrangement and that:

(A) Is subject to ORS 750.301 (Definitions for ORS 750.301 to 750.341) to 750.341 (Requirement for multiple employer welfare arrangement to become traditional insurer); or

(B) Is fully insured and otherwise exempt under ORS 750.303 (Conditions for use of multiple employer welfare arrangement) (4) but elects to be governed by ORS 743.733 (Issuance of group health benefit plan to affiliated group of employers) to 743.737 (Requirements for small employer health benefit plans); or

(e) 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.

(9) Creditable coverage means prior health care coverage as defined in 42 U.S.C. 300gg as amended and in effect on February 17, 2009, and includes coverage remaining in force at the time the enrollee obtains new coverage.

(10) Dependent means the spouse or child of an eligible employee, subject to applicable terms of the health benefit plan covering the employee.

(11) Eligible employee means an employee who works on a regularly scheduled basis, with a normal work week of 17.5 [bad link] or more hours. The employer may determine hours worked for eligibility between 17.5 [bad link] 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 employer for fewer than 90 days are not eligible employees unless the employer so allows.

(12) Employee means any individual employed by an employer.

(13) 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.

(14) Exchange means the Oregon Health Insurance Exchange established pursuant to section 17, chapter 595, Oregon Laws 2009.

(15) Exclusion period means a period during which specified treatments or services are excluded from coverage.

(16) Financial impairment means that a carrier is not insolvent and is:

(a) Considered by the director 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) 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 carriers:

(A) 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) Grandfathered health plan has the meaning prescribed by the United States Secretaries of Labor, Health and Human Services and the Treasury pursuant to 42 U.S.C. 18011(e).

(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.

(20)(a) Health benefit plan means any:

(A) Hospital expense, medical expense or hospital or medical expense policy or certificate;

(B) Health care service contractor or health maintenance organization subscriber contract; or

(C) 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, to the extent that the plan is subject to state regulation.

(b) Health benefit plan does not include:

(A) Coverage for accident only, specific disease or condition only, credit or disability income;

(B) Coverage of Medicare services pursuant to contracts with the federal government;

(C) Medicare supplement insurance policies;

(D) Coverage of TRICARE services pursuant to contracts with the federal government;

(E) 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;

(F) Separately offered long term care insurance, including, but not limited to, coverage of nursing home care, home health care and community-based care;

(G) Independent, noncoordinated, hospital-only indemnity insurance or other fixed indemnity insurance;

(H) Short term health insurance policies that are in effect for periods of 12 months or less, including the term of a renewal of the policy;

(I) Dental only coverage;

(J) Vision only coverage;

(K) Stop-loss coverage that meets the requirements of ORS 742.065 (Insurance against risk of loss assumed under less than fully insured employee health benefit plan);

(L) Coverage issued as a supplement to liability insurance;

(M) Insurance arising out of a workers compensation or similar law;

(N) 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; or

(O) Any employee welfare benefit plan that is exempt from state regulation because of the federal Employee Retirement Income Security Act of 1974, as amended.

(c) For purposes of this subsection, renewal of a short term health insurance policy includes the issuance of a new short term health insurance policy by an insurer to a policyholder within 60 days after the expiration of a policy previously issued by the insurer to the policyholder.

(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 approved by the director under ORS 743.745 (Requirements for basic health benefit plans).

(22) 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) Initial enrollment period means a period of at least 30 days following commencement of the first eligibility period for an individual.

(24) 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 February 17, 2009;

(b) The individual applies for coverage during an open enrollment period;

(c) A court issues an order that coverage be provided for a spouse or minor child under an employees employer sponsored 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 that offers multiple health benefit plans and the individual elects a different health benefit plan during an open enrollment period; or

(e) The individuals coverage under Medicaid, Medicare, TRICARE, 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 after applying for coverage in a group health benefit plan.

(25) Minimal essential coverage has the meaning given that term in section 5000A(f) of the Internal Revenue Code.

(26) 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 (Definitions for ORS 750.301 to 750.341) to 750.341 (Requirement for multiple employer welfare arrangement to become traditional insurer).

(27) Oregon Medical Insurance Pool means the pool created under ORS 735.610 (Oregon Medical Insurance Pool Board).

(28) Preexisting condition exclusion 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 (Definitions for ORS 743.730 to 743.773) to 743.773 (Rules for ORS 743.766 to 743.769):

(a) Pregnancy does not constitute a preexisting condition except as provided in ORS 743.766 (Use of health statements in individual health benefit plans);

(b) Genetic information does not constitute a preexisting condition in the absence of a diagnosis of the condition related to such information; and

(c) Except for coverage under an individual grandfathered health plan, a preexisting condition exclusion may not exclude coverage for services, charges or expenses incurred by an individual who is under 19 years of age.

(29) 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.

(30) Rating period means the 12-month calendar period for which premium rates established by a carrier are in effect, as determined by the carrier.

(31) Representative does not include an insurance producer or an employee or authorized representative of an insurance producer or 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 ORS 743.822 (Requirement to offer bronze and silver plans) (2).

(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 offered by the employer.

(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.

Note: Additions by chapter 322, Oregon Laws 2011, to the series 743.730 (Definitions for ORS 743.730 to 743.773) to 743.773 (Rules for ORS 743.766 to 743.769), which become operative January 2, 2014, expand the series to 743.730 (Definitions for ORS 743.730 to 743.773) to 743.773 (Rules for ORS 743.766 to 743.769), 743.822 (Requirement to offer bronze and silver plans) and 743.826 (Requirements for catastrophic plans). See sections 1, 2 [743.822 (Requirement to offer bronze and silver plans) (2)], 3 [743.822 (Requirement to offer bronze and silver plans) (1)], 4 [743.826 (Requirements for catastrophic plans)] and 6, chapter 322, Oregon Laws 2011. See Preface to Oregon Revised Statutes for further explanation.