Continuation of coverage under group policy upon termination of membership in group health insurance policy
- • applicability of waiting period to rehired employee
(1) As used in this section:
(a) “Covered person” means an individual who was a certificate holder under a group health insurance policy:
(A) On the day before a qualifying event; and
(B) During the three-month period ending on the date of the qualifying event.
(b) “Qualified beneficiary” means:
(A) A spouse or dependent child of a covered person who, on the day before a qualifying event, was insured under the covered person’s group health insurance policy; or
(B) A child born to or adopted by a covered person during the period of the continuation of coverage under this section who would have been insured under the covered person’s policy if the child had been born or adopted on the day before the qualifying event.
(c) “Qualifying event” means the loss of membership in a group health insurance policy caused by:
(A) Voluntary or involuntary termination of the employment of a covered person;
(B) A reduction in hours worked by a covered person;
(C) A covered person becoming eligible for Medicare;
(D) A qualified beneficiary losing dependent child status under a covered person’s group health insurance policy;
(E) Termination of membership in the group covered by the group health insurance policy; or
(F) The death of a covered person.
(2)(a) A grandfathered health plan, as defined in ORS 743B.005 (Definitions), providing coverage under a group health insurance policy for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, must contain a provision that a covered person and any qualified beneficiary may continue coverage under the policy as provided in this section.
(b) A group health insurance policy that provides coverage for one or more of the essential health benefits, other than a grandfathered health plan, must contain a provision that a covered person and any qualified beneficiary may continue coverage under the policy as provided in this section.
(3) Continuation of coverage is not available to a covered person or qualified beneficiary who is eligible for:
(a) Medicare; or
(b) The same coverage under any other program that was not covering the covered person or qualified beneficiary on the day before a qualifying event.
(4) The continued coverage must be offered in the same manner as it is provided to other certificate holders under the group health insurance policy.
(5) A covered person or qualified beneficiary must submit a written request for continuation of coverage to the insurer within the time prescribed by the insurer, except that an insurer may not require a request to be submitted less than 10 days after the later of:
(a) The date of a qualifying event; or
(b) The date the insurer provides the notice required by subsection (10) of this section.
(6) A covered person or qualified beneficiary who requests continuation of coverage shall pay the premium on a monthly basis and in advance to the insurer or to the employer or policyholder, whichever the group policy provides. The required premium payment may not exceed the group premium rate for the insurance being continued under the group policy as of the date the premium payment is due.
(7) Continuation of coverage as provided under this section ends on the earliest of the following dates:
(a) Nine months after the date of the qualifying event that was the basis for the continuation of coverage.
(b) The end of the period for which the last timely premium payment for the coverage is received by the insurer.
(c) The premium payment due date coinciding with or next following the date that continuation of coverage ceases to be available in accordance with subsection (3) of this section.
(d) The date that the policy is terminated. However, if the policyholder replaces the terminated policy with similar coverage under another group health insurance policy:
(A) The covered person and qualified beneficiaries may obtain coverage under the replacement policy for the balance of the period that the covered person or qualified beneficiary would have remained covered under the terminated policy in accordance with this section; and
(B) The terminated policy must continue to provide benefits to the covered person and qualified beneficiaries to the extent of that policy’s accrued liabilities and extensions of benefits as if the replacement had not occurred.
(8) A qualified beneficiary who is not eligible for continuation of coverage under ORS 743B.343 (Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older) may continue coverage under this section upon the dissolution of marriage with or the death of the covered person in the same manner that a covered person may exercise the right to continue coverage under this section.
(9) A covered person rehired by an employer no later than nine months after the layoff of the covered person by the employer may not be subjected to a waiting period for coverage under the employer’s group health insurance policy if the covered person was eligible for coverage at the time of the layoff, regardless of whether the covered person continued coverage during the layoff.
(10) If an insurer terminates the group health insurance coverage of a covered person or qualified beneficiary without providing replacement coverage that meets the criteria in subsection (7)(d) of this section, the insurer shall provide written notice to the covered person and any qualified beneficiary no later than 10 days after the insurer is notified of the qualifying event under subsection (5) of this section. The notice shall include information prescribed by the Director of the Department of Consumer and Business Services.
(11) This section applies only to employers who are not required to make available continuation of health insurance benefits under Titles X and XXII of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, P.L. 99-272, April 7, 1986. [Formerly 743.610]
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.