ORS 743B.013
Requirements for small employer health benefit plans


(1)

A health benefit plan issued to a small employer:

(a)

Other than a grandfathered health plan, must cover essential health benefits consistent with 42 U.S.C. 300gg-11.

(b)

May require an affiliation period that does not exceed two months for an enrollee or 90 days for a late enrollee.

(c)

May not apply a preexisting condition exclusion to any enrollee.

(2)

Late enrollees in a small employer health benefit plan may be subjected to a group eligibility waiting period that does not exceed 90 days.

(3)

Each small employer health benefit plan is renewable with respect to all eligible enrollees at the option of the policyholder, small employer or contract holder unless:

(a)

The policyholder, small employer or contract holder fails to pay the required premiums.

(b)

The policyholder, small employer or contract holder or, with respect to coverage of individual enrollees, an enrollee or a representative of an enrollee engages in fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan.

(c)

The number of enrollees covered under the plan is less than the number or percentage of enrollees required by participation requirements under the plan.

(d)

The small employer fails to comply with the contribution requirements under the health benefit plan.

(e)

The carrier discontinues both offering and renewing all of the carrier’s small employer health benefit plans in this state or in a specified service area within this state. In order to discontinue plans under this paragraph, the carrier:

(A)

Must give notice of the decision to the Department of Consumer and Business Services and to all policyholders covered by the plans;

(B)

May not cancel coverage under the plans for 180 days after the date of the notice required under subparagraph (A) of this paragraph if coverage is discontinued in the entire state or in a specified service area, except that:
(i)
The carrier shall cancel coverage in accordance with subparagraph (C) of this paragraph if the cancellation is for a specified service area in the circumstances described in subparagraph (C) of this paragraph; and
(ii)
The Director of the Department of Consumer and Business Services may specify a cancellation date other than the cancellation date specified in this subparagraph if the carrier is subject to a delinquency proceeding, as defined in ORS 734.014 (Definitions); and

(C)

May not cancel coverage under the plans for 90 days after the date of the notice required under subparagraph (A) of this paragraph if coverage is discontinued in a specified service area because of an inability to reach an agreement with the health care providers or organization of health care providers to provide services under the plans within the service area.

(f)

The carrier discontinues both offering and renewing a small employer health benefit plan in a specified service area within this state because of an inability to reach an agreement with the health care providers or organization of health care providers to provide services under the plan within the service area. In order to discontinue a plan under this paragraph, the carrier:

(A)

Must give notice to the department and to all policyholders covered by the plan;

(B)

May not cancel coverage under the plan for 90 days after the date of the notice required under subparagraph (A) of this paragraph; and

(C)

Must offer in writing to each small employer covered by the plan, all other small employer health benefit plans that the carrier offers to small employers in the specified service area. The carrier shall issue any such plans pursuant to the provisions of ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans). The carrier shall offer the plans at least 90 days prior to discontinuation.

(g)

The carrier discontinues both offering and renewing a health benefit plan, other than a grandfathered health plan, for all small employers in this state or in a specified service area within this state, other than a plan discontinued under paragraph (f) of this subsection.

(h)

The carrier discontinues both offering and renewing a grandfathered health plan for all small employers in this state or in a specified service area within this state, other than a plan discontinued under paragraph (f) of this subsection.

(i)

With respect to plans that are being discontinued under paragraph (g) or (h) of this subsection, the carrier must:

(A)

Offer in writing to each small employer covered by the plan, all other health benefit plans that the carrier offers to small employers in the specified service area.

(B)

Issue any such plans pursuant to the provisions of ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans).

(C)

Offer the plans at least 90 days prior to discontinuation.

(D)

Act uniformly without regard to the claims experience of the affected policyholders or the health status of any current or prospective enrollee.

(j)

The Director of the Department of Consumer and Business Services orders the carrier to discontinue coverage in accordance with procedures specified or approved by the director upon finding that the continuation of the coverage would:

(A)

Not be in the best interests of the enrollees; or

(B)

Impair the carrier’s ability to meet contractual obligations.

(k)

In the case of a small employer health benefit plan that delivers covered services through a specified network of health care providers, there is no longer any enrollee who lives, resides or works in the service area of the provider network.

(L)

In the case of a health benefit plan that is offered in the small employer market only to one or more bona fide associations, the membership of an employer in the association ceases and the termination of coverage is not related to the health status of any enrollee.

(4)

A carrier may modify a small employer health benefit plan at the time of coverage renewal. The modification is not a discontinuation of the plan under subsection (3)(e), (g) and (h) of this section.

(5)

Notwithstanding any provision of subsection (3) of this section to the contrary, a carrier may not rescind the coverage of an enrollee in a small employer health benefit plan unless:

(a)

The enrollee or a person seeking coverage on behalf of the enrollee:

(A)

Performs an act, practice or omission that constitutes fraud; or

(B)

Makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan;

(b)

The carrier provides at least 30 days’ advance written notice, in the form and manner prescribed by the department, to the enrollee; and

(c)

The carrier provides notice of the rescission to the department in the form, manner and time frame prescribed by the department by rule.

(6)

Notwithstanding any provision of subsection (3) of this section to the contrary, a carrier may not rescind a small employer health benefit plan unless:

(a)

The small employer or a representative of the small employer:

(A)

Performs an act, practice or omission that constitutes fraud; or

(B)

Makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan;

(b)

The carrier provides at least 30 days’ advance written notice, in the form and manner prescribed by the department, to each plan enrollee who would be affected by the rescission of coverage; and

(c)

The carrier provides notice of the rescission to the department in the form, manner and time frame prescribed by the department by rule.

(7)

Intentionally left blank —Ed.

(a)

A carrier may continue to enforce reasonable employer participation and contribution requirements on small employers. However, participation and contribution requirements shall be applied uniformly among all small employer groups with the same number of eligible employees applying for coverage or receiving coverage from the carrier. In determining minimum participation requirements, a carrier shall count only those employees who are not covered by an existing group health benefit plan, 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.

(b)

A carrier may not deny a small employer’s application for coverage under a health benefit plan based on participation or contribution requirements but may require small employers that do not meet participation or contribution requirements to enroll during the open enrollment period beginning November 15 and ending December 15.

(8)

Premium rates for small employer health benefit plans, except grandfathered health plans, are subject to the following provisions:

(a)

Each carrier must file with the department the initial geographic average rate and any changes in the geographic average rate with respect to each health benefit plan issued by the carrier to small employers.

(b)

Intentionally left blank —Ed.

(A)

The variations in premium rates charged during a rating period for health benefit plans issued to small employers must be based solely on the factors specified in subparagraph (B) of this paragraph. A carrier may elect which of the factors specified in subparagraph (B) of this paragraph apply to premium rates for health benefit plans for small employers. All other factors must be applied in the same actuarially sound way to all small employer health benefit plans.

(B)

The variations in premium rates described in subparagraph (A) of this paragraph may be based only on one or more of the following factors as prescribed by the department by rule:
(i)
The ages of enrolled employees and their dependents, except that the rate for adults may not vary by more than three to one;
(ii)
The level at which enrolled employees and dependents of enrolled employees engage in tobacco use, except that the rate may not vary by more than 1.5 to one; and
(iii)
Adjustments to reflect differences in family composition.

(C)

A carrier shall apply the carrier’s schedule of premium rate variations as approved by the department and in accordance with this paragraph. Except as otherwise provided in this section, the premium rate established by a carrier for a small employer health benefit plan applies uniformly to all employees of the small employer enrolled in that plan.

(c)

Except as provided in paragraph (b) of this subsection, the variation in premium rates between different health benefit plans offered by a carrier to small employers must be based solely on objective differences in plan design or coverage, age, tobacco use and family composition and must not include differences based on the risk characteristics of groups assumed to select a particular health benefit plan.

(d)

A carrier may not increase the rates of a health benefit plan issued to a small employer more than once in a 12-month period. Annual rate increases are effective on the plan anniversary date of the health benefit plan issued to a small employer. The percentage increase in the premium rate charged to a small employer for a new rating period may not exceed the sum of the following:

(A)

The percentage change in the geographic average rate measured from the first day of the prior rating period to the first day of the new period; and

(B)

Any adjustment attributable to changes in age and differences in family composition.

(9)

Premium rates for grandfathered health plans are subject to requirements prescribed by the department by rule.

(10)

In connection with the offering for sale of any health benefit plan to a small employer, each carrier shall make a reasonable disclosure as part of the carrier’s solicitation and sales materials of:

(a)

The full array of health benefit plans that are offered to small employers by the carrier;

(b)

The authority of the carrier to adjust rates and premiums, and the extent to which the carrier considers age, tobacco use, family composition and geographic factors in establishing and adjusting rates and premiums; and

(c)

The benefits and premiums for all health insurance coverage for which the employer is qualified.

(11)

Intentionally left blank —Ed.

(a)

Each carrier shall maintain at the carrier’s principal place of business a complete and detailed description of the carrier’s rating practices and renewal underwriting practices relating to the carrier’s small employer health benefit plans, including information and documentation that demonstrate that the carrier’s rating methods and practices are based upon commonly accepted actuarial practices and are in accordance with sound actuarial principles.

(b)

A carrier offering a small employer health benefit plan shall file with the department at least once every 12 months an actuarial certification that the carrier is in compliance with ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans) and that the rating methods of the carrier are actuarially sound. Each certification must be in a uniform form and manner and must contain such information as specified by the department. The carrier shall retain a copy of each certification at the carrier’s principal place of business. A carrier is not required to file the actuarial certification under this paragraph if the department has approved the carrier’s rate filing within the preceding 12-month period.

(c)

A carrier shall make the information and documentation described in paragraph (a) of this subsection available to the department upon request. Except as provided in ORS 743.018 (Filing of rates for life and health insurance) and except in cases of violations of ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans), the information is proprietary and trade secret information and is not subject to disclosure to persons outside the department except as agreed to by the carrier or as ordered by a court of competent jurisdiction.

(12)

A carrier may not provide any financial or other incentive to any insurance producer that would encourage the insurance producer to sell health benefit plans of the carrier to small employer groups based on a small employer group’s anticipated claims experience.

(13)

For purposes of this section, the date a small employer health benefit plan is continued is the anniversary date of the first issuance of the health benefit plan.

(14)

A carrier shall include a provision that offers coverage to all eligible employees of a small employer and to all dependents of the eligible employees to the extent the employer chooses to offer coverage to dependents.

(15)

All small employer health benefit plans must contain special enrollment periods during which eligible employees and dependents may enroll for coverage, as provided by federal law and rules adopted by the department.

(16)

A small employer health benefit plan may not impose annual or lifetime limits on the dollar amount of essential health benefits. [Formerly 743.737; 2017 c.479 §16a; 2017 c.701 §23]

Source: Section 743B.013 — Requirements for small employer health benefit plans, https://www.­oregonlegislature.­gov/bills_laws/ors/ors743B.­html.

743B.001
Definitions
743B.003
Purposes
743B.005
Definitions
743B.010
Issuance of group health benefit plan to affiliated group of employers
743B.011
Group health benefit plans subject to provisions of specified laws
743B.012
Requirement to offer all health benefit plans to small employers
743B.013
Requirements for small employer health benefit plans
743B.020
Eligible employees and small employers
743B.100
Department’s authority to regulate market
743B.102
Certifications and disclosure of coverage
743B.103
Use of health-related information
743B.104
Coverage in group health benefit plans
743B.105
Requirements for group health benefit plans other than small employer plans
743B.109
Short term health insurance policies
743B.110
Implementation of federal laws
743B.125
Individual health benefit plans
743B.126
Carrier marketing of individual health benefit plans
743B.127
Rules for ORS 743.022, 743B.125 and 743B.126
743B.128
Exceptions to requirement to actively market all plans
743B.129
Shortening period of exclusion following discontinued offering
743B.130
Requirement to offer bronze and silver plans
743B.195
Enforcement of Newborns’ and Mothers’ Health Protection Act of 1996
743B.197
Health Care Consumer Protection Advisory Committee
743B.200
Requirements for insurers offering managed health insurance
743B.202
Requirements for insurers offering managed health or preferred provider organization insurance
743B.204
Required managed health insurance contract provision
743B.220
Requirements for insurers that require designation of participating primary care physician
743B.222
Designation of women’s health care provider as primary care provider
743B.225
Continuity of care
743B.227
Referrals to specialists
743B.250
Required notices to applicants and enrollees
743B.252
External review
743B.253
Director to contract with independent review organizations to provide external review
743B.254
Required statements regarding external reviews
743B.255
Enrollee application for external review
743B.256
Duties of independent review organizations
743B.257
Civil penalty for failure to comply by insurer that agreed to be bound by decision
743B.258
Private right of action
743B.260
Claims and appeals of adverse benefit determinations under disability income insurance policies
743B.280
Definitions for ORS 743B.280 to 743B.285
743B.281
Estimate of costs for in-network procedure or service
743B.282
Estimate of costs for out-of-network procedure or service
743B.283
Submission of methodology used to determine insurer’s allowable charges
743B.284
Alternative mechanism for disclosure of costs and charges
743B.285
Rules
743B.287
Balance billing prohibited for health care facility services
743B.290
Hospital payment of copayment or deductible for insured patient
743B.300
Disclosure of differences in replacement health insurance policies
743B.310
Rescinding coverage
743B.320
Minimum grace period
743B.321
Applicability of ORS 743B.320
743B.323
Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium
743B.324
Rules for certain notice requirements
743B.330
Notice to policyholder required for cancellation or nonrenewal of health benefit plan
743B.340
When group health insurance policies to continue in effect upon payment of premium by insured individual
743B.341
Continuation of benefits after termination of group health insurance policy
743B.342
Continuation of benefits after injury or illness covered by workers’ compensation
743B.343
Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older
743B.344
Procedure for obtaining continuation of coverage under ORS 743B.343
743B.345
Premium for continuation of coverage under ORS 743B.344
743B.347
Continuation of coverage under group policy upon termination of membership in group health insurance policy
743B.400
Decisions regarding health care facility length of stay, level of care and follow-up care
743B.403
Insurer prohibited practices
743B.405
Medical services contract provisions
743B.406
Vision care providers
743B.407
Naturopathic physicians
743B.420
Prior authorization requirements
743B.422
Utilization review requirements for medical services contracts to which insurer not party
743B.423
Utilization review requirements for insurers offering health benefit plan
743B.424
Applicability
743B.425
Prior authorization prohibited for first 60 days of treatment for opioid or opiate withdrawal and for post-exposure prophylactic antiretroviral drugs
743B.427
Nonquantitative treatment limitations on coverage of behavioral health conditions
743B.450
Prompt payment of claims
743B.451
Refund of paid claims
743B.452
Interest on unpaid claims
743B.453
Underpayment of claims
743B.454
Claims submitted during credentialing period
743B.458
Performance-based incentive payments for primary care
743B.460
Conditions for restricting payments to only in-network providers
743B.462
Direct payments to providers
743B.470
Medicaid not considered in coverage eligibility determination
743B.475
Guidelines for coordination of benefits
743B.500
Selling and leasing of provider panels by contracting entity
743B.501
Registration of contracting entity
743B.502
Third party contracts for leasing of provider panels
743B.503
Additional requirements for third party contracts
743B.505
Provider networks
743B.550
Disclosure of information
743B.555
Confidential communications
743B.601
Synchronization of prescription drug refills
743B.602
Step therapy
743B.800
Risk adjustment procedures
743B.810
Enrollees covered by workers’ compensation
Green check means up to date. Up to date