Health benefit coverage for guaranteed association
(1) As used in this section, “guaranteed association” means an association that:
(a) The Director of the Department of Consumer and Business Services has determined under ORS 743.524 (Eligibility of association to be group health policyholder) meets the requirements described in ORS 731.098 (“Group health insurance”) (2); and
(b) Is a statewide nonprofit organization representing the interests of individuals licensed under ORS chapter 696.
(2) A carrier may offer a health benefit plan to a guaranteed association if the plan provides health benefits covering 500 or more members or dependents of members of the association.
(3) When a carrier offers coverage to a guaranteed association under subsection (2) of this section, the carrier shall offer coverage to all members of the association and all dependents of the members of the association without regard to the actual or expected health status of any member or any dependent of a member of the association.
(4) A carrier offering a health benefit plan under subsection (2) of this section shall establish premium rates as follows:
(a) For the initial 12-month period of coverage, the carrier shall submit to the director a certified statement that the premium rates charged to the guaranteed association are actuarially sound. The statement must be signed by an actuary certifying the accuracy of the rating methodology as established by the American Academy of Actuaries.
(b) For any subsequent 12-month period of coverage, according to a rating methodology as established by the American Academy of Actuaries.
(5) A member of a guaranteed association may apply for coverage offered by a carrier under subsection (2) of this section only:
(a) If the member has been an active member of the association for no less than 30 days;
(b) During an annual open enrollment period offered by the association; and
(c) After meeting any additional eligibility requirements agreed upon by the association and the carrier.
(6) Notwithstanding subsection (5) of this section, if a member or a dependent of a member of a guaranteed association terminates coverage under the health benefit plan, the member or dependent shall be excluded from coverage for 12 months from the date of termination of coverage. The member may enroll for coverage of the member or the dependent during an annual open enrollment period following the expiration of the exclusion period. [Formerly 743.757]
Note: Definitions for 743.535 (Health benefit coverage for guaranteed association) may be found in 743B.005 (Definitions).
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