Or. Admin. R. 836-053-1000
Current through Register Vol. 63, No. 8, August 1, 2024
Section 836-053-1000 - Statutory Authority and Implementation(1) OAR 836-053-1000 to 836-053-1200 are adopted under the authority of ORS 731.244, 743.814, and 743.819, for the purpose of implementing ORS 743.804, 743.807, 743.814, 743.817, 743.819, 743.821, 743.829, 743.837 and 743A.012. The filing and reporting requirements in this rule and in OAR 836-053-1070, 836-053-1130, 836-053-1170, and 836-053-1190 apply to all domestic insurers transacting health benefit plans, including health care service contractors, to all foreign carriers transacting health benefit plans who transacted $2 million or more in annual health benefit plan premium in Oregon, and to other carriers transacting health benefit plans as determined by the Director of the Department of Consumer and Business Services.(2) When an insurer maintains more than one type of health benefit plan, the insurer shall comply with OAR 836-053-1000 to 836-053-1200 on a plan-by-plan basis.(3) Not later than June 30 of each year, each insurer shall file with the director for the immediately preceding calendar year the following information as required of the insurer: (a) An annual summary of the insurer's aggregate data relating to grievances, appeals and applications for external review, required by ORS 743.804of all insurers;(b) An annual summary relating to the insurer's utilization review policies, required by ORS 743.807(1) of each insurer that provides utilization review or has utilization review provided on its behalf;(c) An annual summary relating to the insurer's quality assessment activities required by ORS 743.814(2) of each insurer that offers managed health insurance;(d) The results of all publicly available federal Health Care Financing Administration reports and accreditation surveys by national accreditation organizations required by ORS 743.814(3)(a) of each insurer that offers managed health insurance;(e) The insurer's health promotion and disease prevention activities, if any, including a summary of screening and preventive health care activities covered by the insurer, required by ORS 743.814(3)(b) of each insurer that offers managed health insurance. The insurer may submit the summary required in this subsection in the format of the insurer's choosing, including a summary prepared for another purpose. The summary required in this subsection shall include the following activities, to the extent the insurer engages in them, and may include any additional information that the insurer deems significant in describing its health promotion and disease prevention activities: (A) Tobacco use and cessation;(B) Cancer screening, including mammography;(C) Diabetes education and home monitoring;(E) Childbirth education and parenting support;(G) Cardiovascular health; and(H) Injury prevention; and(f) An annual summary relating to the scope of the insurer's network and to the accessibility of services, required by ORS 743.817(1) of each insurer that offers managed health insurance.(4) In order to minimize duplicative reporting requirements, an insurer may submit a copy of a report prepared for a national accreditation organization to meet the reporting requirements of section (3)(e) of this rule relating to the insurer's health promotion and disease prevention activities, OAR 836-053-1130(1) relating to the insurer's utilization review policies, OAR 836-053-1170(1) relating to the insurer's quality assessment activities and OAR 836-053-1190(1) relating to the insurer's provider network and the accessibility of services. To the extent that a report prepared for a national accreditation organization does not include information required by the department, the insurer must submit an addendum to the report that provides this information.(5) If information required to be filed annually with the department pursuant to this rule has not changed since an insurer's previous annual filing, an insurer may satisfy the reporting requirements of this rule by indicating that the information has not changed, or if some but not all information has changed, by submitting an addendum to the previous annual filing indicating only the information that has changed since the previous filing. However, every third year the insurer must file all required information, including information that may not have changed since the previous filing. For example, if an insurer made an annual filing in 1998, it is sufficient to indicate in 1999 and 2000 that certain information has not changed since the previous annual filing or to submit an addendum indicating the information that has changed, but the filing in 2001 must contain all information required by the department pursuant to this rule.(6) All filings required in section (3) of this rule must be made electronically.(7) For purposes of OAR 836-053-1000 to 836-053-1200, "insurer" also includes a health care service contractor as defined in ORS 750.005 and a multiple employer welfare arrangement as defined in ORS 750.301.(8) OAR 836-053-1000 to 836-053-1200 apply to a self-insured public entity to the extent provided in ORS 731.036.(9) An insurer shall administer the plan in compliance with ORS 743.804, 743.807, 743.814, 743.817, 743.821, 743.829, 743.837 and 743A.012 and OAR 836-053-1000 to 836-053-1200. (10) An insurer shall comply with the federal Newborns' and Mothers' Health Protection Act of 1996, as referred to in ORS 743.823 with respect to group health insurance plans and individual health insurance plans.Or. Admin. R. 836-053-1000
ID 1-1998, f. & cert. ef. 1-15-98; ID 5-2000, f. & cert. ef. 5-11-00; ID 15-2010, f. & cert. 8-19-10; ID 23-2011, f. & cert. ef. 12-19-11Stat. Auth.: ORS 731.244, 743.814 & 743.819
Stats. Implemented: ORS 743.804, 743.807, 743.814, 743.817, 743.819, 743.821, 743.829, 743.837 & 743A.012