Requirement to offer all health benefit plans to small employers
- • offering of plan by carriers
- • exceptions
(1) As a condition of transacting business in the small employer health insurance market in this state, a carrier shall offer small employers all of the carrier’s health benefit plans, approved by the Department of Consumer and Business Services for use in the small employer market, for which the small employer is eligible.
(2) A carrier shall issue to a small employer any health benefit plan that is offered by the carrier if the small employer applies for the plan and agrees to make the required premium payments and to satisfy the other provisions of the health benefit plan.
(3) A multiple employer welfare arrangement, professional or trade association or other similar arrangement established or maintained to provide benefits to a particular trade, business, profession or industry or their subsidiaries may not issue coverage to a group or individual that is not in the same trade, business, profession or industry as that covered by the arrangement. The arrangement shall accept all groups and individuals in the same trade, business, profession or industry or their subsidiaries that apply for coverage under the arrangement and that meet the requirements for membership in the arrangement. For purposes of this subsection, the requirements for membership in an arrangement may not include any requirements that relate to the actual or expected health status of the prospective enrollee.
(4) A carrier shall, pursuant to subsection (2) of this section, accept applications from and offer coverage to a small employer group covered under an existing health benefit plan regardless of whether a prospective enrollee is excluded from coverage under the existing plan because of late enrollment. When a carrier accepts an application for a small employer group, the carrier may continue to exclude the prospective enrollee excluded from coverage by the replaced plan until the prospective enrollee would have become eligible for coverage under that replaced plan.
(5) A carrier is not required to accept applications from and offer coverage pursuant to subsection (2) of this section if the department finds that acceptance of an application or applications would endanger the carrier’s ability to fulfill its contractual obligations or result in financial impairment of the carrier.
(6) A carrier shall actively market all health benefit plans that are offered by the carrier to small employers in the geographical areas in which the carrier makes coverage available or provides benefits.
(7)(a) Subsection (2) of this section does not require a carrier to offer coverage to or accept applications from:
(A) A small employer if the small employer is not physically located in the carrier’s approved service area;
(B) An employee of a small employer if the employee does not work or reside within the carrier’s approved service areas; or
(C) Small employers located within an area where the carrier reasonably anticipates, and demonstrates to the department, that it will not have the capacity in its network of providers to deliver services adequately to the enrollees of those small employer groups because of its obligations to existing small employer group contract holders and enrollees.
(b) A carrier that does not offer coverage pursuant to paragraph (a)(C) of this subsection may not offer coverage in the applicable service area to new employer groups other than small employers until the carrier resumes enrolling groups of new small employers in the applicable area.
(8) For purposes 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), except as provided in this subsection, carriers that are affiliated carriers or that are eligible to file a consolidated tax return pursuant to ORS 317.715 (Tax return of corporation in affiliated group making consolidated federal return) shall be treated as one carrier and any restrictions or limitations imposed by ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans) apply as if all health benefit plans delivered or issued for delivery to small employers in this state by the affiliated carriers were issued by one carrier. However, any insurance company or health maintenance organization that is an affiliate of a health care service contractor located in this state, or any health maintenance organization located in this state that is an affiliate of an insurance company or health care service contractor, may treat the health maintenance organization as a separate carrier and each health maintenance organization that operates only one health maintenance organization in a service area in this state may be considered a separate carrier.
(9) A carrier that elects to discontinue offering all of its health benefit plans to small employers under ORS 743B.013 (Requirements for small employer health benefit plans) (3)(e) or elects to discontinue renewing all such plans is prohibited from offering health benefit plans to small employers in this state for a period of five years from:
(a) The date of notice to the department pursuant to ORS 743B.013 (Requirements for small employer health benefit plans) (3)(e); or
(b) If notice is not provided under paragraph (a) of this subsection, the date on which the department provides notice to the carrier that the department has determined that the carrier has effectively discontinued offering health benefit plans to small employers in this state.
(10) The department may, in accordance with ORS 743B.129 (Shortening period of exclusion following discontinued offering), shorten the period of prohibition described in subsection (9) of this section if necessary to ensure, in all geographic areas of this state, that:
(a) A competitive health insurance market exists;
(b) Small employers have a reasonable number of health insurance options available to them; and
(c) Consumers who purchase insurance are protected. [Formerly 743.736; 2017 c.206 §4]
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.