Or. Admin. R. ch. 836, div. 53 – Health Benefit Plans | Midpage

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Oregon Administrative Rules

53

Or. Admin. R. ch. 836, div. 53

Health Benefit Plans

Department of Consumer and Business Services

0000Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53 0001Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements 0002Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements 0003Prohibition of Exclusion Period for Pregnancy 0004Compliance with Federal and State Law 0005Prescription Drug Identification Cards 0006Issuance of Group Health Benefit Coverage to Employer Association 0007Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements 0008Essential Health Benefits for Plan Years 2014, 2015 and 2016 0009Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016 0011Standard Bronze Plan Health Savings Account Eligible Requirement 0012Essential Health Benefits for Plan Years Beginning on and after January 1, 2017 0013Oregon Standard Bronze and Silver Health Benefit Plans 0014Standards and Process for Shortened Period of Market Prohibition 0015Definition of Small Employer 0017Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022 0019Purpose; Statutory Authority; Enforcement 0021Plans Offered to Oregon Small Employers 0027Copayments for Certain Primary Care Visits 0028Primary Care Provider Assignment Methodology 0030Marketing of a Health Benefit Plan to Small Employers 0050Trade Practices Relating to Small Employer Health Benefit Plans 0063Rating for Nongrandfathered Small Group Plans 0065Rating for Grandfathered Small Group Plans 0066Rating for Transitional Health Benefit Plans Offered to Small Employers 0070Multiple Employer Welfare Arrangements 0100Work Related Injuries or Disease 0105Coordination of Payment for Interim Medical Services 0211Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan 0221Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans 0230Underwriting 0300Purpose; Statutory Authority; Applicability of Network Adequacy Requirements 0310Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0355 0325Network Adequacy Reporting Requirements 0335Nationally Recognized Standard for Annual Network Adequacy Evaluation 0345Quantitative Network Adequacy Access Standards 0350Provider Directory Requirements for Network Adequacy 0355Behavioral Health Network Composition and Reporting 0410Purpose; Statutory Authority; Enforcement 0415Cancellation of an Individual Health Benefit Plan Coverage 0418Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic 0431Underwriting, Enrollment and Benefit Design 0435Health Benefit Plan Coverage of Well-woman Preventive Care Services 0441Gender Affirming Treatment 0444Purpose and Statutory Authority 0447Definitions 0451Balance Billing Prohibition and Consumer Cost-Sharing for Ground Ambulance Services 0454Payments to Ground Ambulance Services Organizations 0457Ground Ambulance Service Organization Rate Reporting to the Department 0461Self-Funded Group Health Plan, Public Employees' Benefit Board and Oregon Educators Benefit Board, Election to Participate 0465Rating for Individual Health Benefit Plans 0472Statutory Authority and Implementation 0473Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans 0474Process For Rate Filing for Individual and Small Employer Health Benefit Plans 0475Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan 0480Consumer Friendly Summary Document for Rate Filings 0510Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage 0600Purpose; Statutory Authority; Applicability 0605Definitions for OAR 836-053-0600 to 836-053-0615 0610Carrier Response to Request for Confidentiality 0615Carrier Reporting Requirements 0825Rescission of a Group Health Benefit Plan 0830Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy 0835Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy 0851Purpose; Authority; Applicability; and Enforcement 0857Definitions 0863Notifications 0900Purpose; Statutory Authority 0910Rate Filing 1000Statutory Authority and Implementation 1010Insurer Policies 1020Drug Formularies 1030Written Information to Enrollees 1033Cultural and Linguistic Appropriateness 1035Summary of Benefits and Explanation of Coverage 1060Definitions 1070Reporting of Grievances and Prior Authorization; Format and Contents 1080Tracking Grievances and Prior Authorization Requests 1090Assistance in Filing Grievances 1100Internal Appeals Process 1110Notice of Complaint Filing with Director 1130Annual Summary, Utilization Review 1140Appeal and Utilization Review Determinations 1170Annual Summary, Quality Assessment Activities 1180Format and Instructions for Report Required by ORS 743.818 1190Annual Summary, Uniform Indicators of Network Adequacy 1200Prior Authorization Requirements for Health Benefit Plans 1203Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans 1205Uniform Prescription Drug Prior Authorization Request Form 1300Purpose and Scope; Application 1305Definitions; Authority to Act for Enrollee 1310Contracting Requirements 1315Performance Criteria 1317Professional Qualifications 1320Conflict of Interest 1325Procedures for Conducting External Reviews 1330Criteria and Considerations for External Review Determinations 1335Procedures for Complaint Investigation 1337Preliminary Review by Insurer 1340Timelines and Notice for Dispute That is Not Expedited 1342Timelines and Notice for Expedited Decision-Making 1345Quality Assurance Mechanisms 1350Ongoing Requirements for Independent Review Organizations 1355Synopses 1360External Review Reporting 1365Fees for External Reviews 1400Format and Instructions for Report Required by ORS 743.748 1403Definitions of Coordinated Care and Case Management for Behavioral Health Care Services 1404Definitions; Noncontracting Providers; Co-Morbidity Disorders 1405General Requirements for Coverage of Behavioral Health Conditions 1407Prohibited Exclusions 1408Required Disclosures 1409Definitions 1410Procedures 1415Instructions 1420Purpose and statutory authority 1425Definitions for behavioral health benefits reporting 1430Form and Manner for Behavioral Health Benefits Reporting 1500Purpose; Statutory Authority; Applicability 1505Definitions for OAR 836-053-1500 to 836-053-1510 1510Prominent Carrier Reporting Requirements 1520Purpose; Statutory Authority; Applicability 1525Definitions 1530Reporting Requirements 1630Drug Price Transparency Insurer Reporting