Or. Admin. R. 836-053-0230

Current through Register Vol. 63, No. 8, August 1, 2024

Section 836-053-0230 - Underwriting

(1) Every group health benefit plan issued by a carrier must specify all of the participation, contribution and eligibility requirements that have been agreed upon by the carrier and the covered group, and the carrier must apply those requirements uniformly within each category of eligible members.

(2) A carrier offering a group health benefit plan shall not use health statements, except as provided in ORS 743B.103. A health statement for a group health benefit plan also must comply with the requirements of OAR 836-053-0510. After enrollment, health statements or other information may be used by a carrier for the purpose of providing services or arranging for the provision of services under a group health benefit plan.

(3) A carrier offering a group health benefit plan shall not use health statements or other information revealing individual health status to determine the acceptance or rejection of a group that has applied for coverage. Impermissible other information includes claim records that identify individual claimants.

(4) If a carrier accepts a group for coverage, the carrier shall not:

(a) Decline to offer coverage to any eligible member;

(b) Impose any terms or conditions on the coverage of an eligible member that are based on the actual or expected health status of the member, except as provided in ORS 743B.105; or

(c) Delay enrollment for an otherwise eligible employee or dependent who is disabled when enrollment would normally occur.

(5) A late enrollee, as defined in ORS 743B.005, must be accepted for coverage in a group health benefit plan, but may be subject to the coverage limitations specified in ORS 743B.105.

(6) An enrollee who qualifies under a special enrollment period, as specified in ORS 743B.105, must be accepted for coverage in a group health benefit plan and shall not be considered a late enrollee.

(7) A modification to an existing group health benefit plan that is required by ORS 743B.103 to 743B.105 or by OAR 836-053-0210 to 836-053-0250 shall be implemented for each policyholder on the next renewal date. For the purposes of this subsection, the next renewal date means the first renewal date of the policy issued to the policyholder that occurs on or after the operative date of the governing statutory provision (i.e., October 1, 1996, for SB 152 (1995); August 1, 1997, for SB 98 (1997)).

(8) A group health benefit plan shall be renewable at the option of the policyholder and shall not be discontinued by the carrier during or at the termination of the contract period except in the circumstances specified in ORS 743B.105 and consistent with the requirements of HIPAA (42 U.S.C. 300gg-12).

Or. Admin. R. 836-053-0230

ID 12-1996, f. & cert. ef. 9-23-96; ID 5-1998, f. & cert. ef. 3-9-98; ID 4-2016, f. & cert. ef. 4/8/2016

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 743.522 & 743B.103 to 743B.105