Eligibility for pool coverage
- • rules
(1) Except as provided in subsection (3) of this section, a person who is a resident of this state, as defined by the Oregon Medical Insurance Pool Board, is eligible for medical pool coverage if:
(a) An insurer, or an insurance company with a certificate of authority in any other state, has made within a time frame established by the board an adverse underwriting decision, as defined in ORS 746.600 (Definitions for ORS 746.600 to 746.690) (1)(a)(A), (B) or (D), on individual medical insurance for health reasons while the person was a resident;
(b) The person has a history of any medical or health conditions on the list adopted by the board under subsection (2) of this section;
(c) The person is a spouse or dependent of a person described in paragraph (a) or (b) of this subsection; or
(d) The person is eligible for the credit for health insurance costs under section 35 of the federal Internal Revenue Code, as amended and in effect on December 31, 2004.
(2) The board may adopt a list of medical or health conditions for which a person is eligible for pool coverage without applying for individual medical insurance pursuant to this section.
(3) A person is not eligible for coverage under ORS 735.600 (Legislative intent) to 735.650 (Application of provisions of Insurance Code) if:
(a) Except as provided in ORS 735.625 (Coverage) (3)(c), the person is eligible to receive health services as defined in ORS 414.705 (Definitions for ORS 414.705 to 414.750) that meet or exceed those adopted by the board or is eligible for Medicare;
(b) The person has terminated coverage in the pool within the last 12 months and the termination was for:
(A) A reason other than becoming eligible to receive health services as defined in ORS 414.705 (Definitions for ORS 414.705 to 414.750); or
(B) A reason that does not meet exception criteria established by the board;
(c) The person has exceeded the maximum lifetime benefit established by the board;
(d) The person is an inmate of or a patient in a public institution named in ORS 179.321 (Responsibility to supervise state institutions);
(e) The person has, on the date of issue of coverage by the board, coverage under health insurance or a self-insurance arrangement that is substantially equivalent to coverage under ORS 735.625 (Coverage); or
(f) The person has the premiums paid or reimbursed by a public entity or a health care provider for the sole purpose of reducing the financial loss or obligation of the payer.
(4) A person applying for coverage shall establish initial eligibility by providing evidence that the board requires.
(5)(a) Notwithstanding ORS 735.625 (Coverage) (4)(c) and subsection (3)(a) of this section, if a person becomes eligible for Medicare after being enrolled in the pool for a period of time as determined by the board by rule, that person may continue coverage within the pool as secondary coverage to Medicare.
(b) The board may adopt rules concerning the terms and conditions for the coverage provided under paragraph (a) of this subsection.
(6) The board may adopt rules to establish additional eligibility requirements for a person described in subsection (1)(d) of this section. [1987 c.838 §5; 1989 c.838 §11; 1993 c.130 §1; 1993 c.212 §1; 1999 c.754 §1; 2005 c.305 §§1,3; 2005 c.634 §1; 2005 c.635 §§2,3]
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent. Currency Information