Or. Admin. R. 836-080-0670

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

Section 836-080-0670 - Authorization Exemptions

(1) A licensee or insurance-support organization may disclose personal or privileged information about an individual collected or received in connection with a health insurance transaction without obtaining the written authorization required by OAR 836-080-0665 if the disclosure meets one or more of the following conditions, in which a disclosure:

(a) Is reasonably necessary to enable a person other than the licensee or insurance support organization to:

(A) Perform a business, professional or insurance function for the disclosing licensee or insurance-support organization and the person agrees not to disclose the information further without the individual's written authorization unless the further disclosure:

(i) Would otherwise be permitted by this rule if made by a licensee or insurance-support organization; or

(ii) Is reasonably necessary for the person to perform its function for the disclosing licensee or insurance-support organization.

(B) Provide information to the disclosing licensee or insurance-support organization for the purpose of:

(i) Determining an individual's eligibility for a health insurance benefit or payment; or

(ii) Detecting or preventing criminal activity, fraud, material misrepresentation or material nondisclosure in connection with a health insurance transaction.

(b) Is to a licensee, insurance-support organization or self-insurer, if the information disclosed is limited to that which is reasonably necessary:

(A) To detect or prevent criminal activity, fraud, material misrepresentation or material nondisclosure in connection with an insurance transaction; or

(B) For either the disclosing or receiving licensee or insurance-support organization to perform its function in connection with an insurance transaction involving the individual.

(c) Is to a medical care institution or medical professional and discloses only such information as is reasonably necessary to accomplish one or more of the following purposes:

(A) Verifying insurance coverage or benefits.

(B) Informing an individual of a medical problem of the individual, of which the individual may not be aware.

(C) Conducting an operations or services audit.

(d) Is required or authorized for compliance with federal, state or local laws, rules or other applicable legal requirements.

(e) Is required for compliance with a properly authorized civil, criminal or regulatory investigation or a subpoena or summons by a federal, state or local authority.

(f) Is required for response to judicial process or a government regulatory authority having jurisdiction over a licensee for examination, compliance or other purposes as authorized by law.

(g) Is required for protection of the confidentiality or security of a licensee's records pertaining to the individual, service, product or transaction.

(h) Is required for institutional risk control or for resolving disputes or inquiries relating to the individual.

(i) Is to a person holding a legal or beneficial interest relating to the individual.

(j) Is to a person acting in a fiduciary or representative capacity on behalf of the individual.

(k) Is to provide information to an insurance rate advisory organization, a guaranty fund or agency, an agency that is rating a licensee, a person that is assessing the licensee's compliance with industry standards, or the licensee's attorneys, accountants and auditors.

(l) Is allowed or required under other provisions of law and in accordance with the federal Right to Financial Privacy Act of 1978 (12 U.S.C. 3401 et seq.) to law enforcement agencies, but only to the extent that disclosure is specifically allowed or required, including the Federal Reserve Board, Office of the Comptroller of the Currency, Federal Deposit Insurance Corporation, Office of Thrift Supervision, National Credit Union Administration, the Securities and Exchange Commission, the Secretary of the Treasury, with respect to 31 U.S.C. (Chapter 53, Subchapter II (Records and Reports on Monetary Instruments and transactions) and 12 U.S.C. Chapter 21 (Financial record-keeping), a state insurance authority, and the federal Trade Commission), a self-regulatory organization or for an investigation on a matter related to public safety, or is otherwise specifically permitted or required by law.

(m) Meets any of the following conditions:

(A) It is necessary to effect, administer or enforce a transaction that an individual requests or authorizes, in that the disclosure is required or is a usual, appropriate or acceptable method of handling the transaction. The condition in this subparagraph has the meaning given in section 509 of the federal Gramm-Leach-Bliley Act (P.L. 106-102).

(B) It is in connection with treatment, payment or health care operations.

(C) It is in connection with servicing or processing an insurance product or service that an individual requests or authorizes.

(D) It is in connection with maintaining or servicing an individual's account with the licensee, a proposed or actual securitization, secondary market sale or similar transaction related a transaction of the individual.

(n) Is made for the purpose of conducting actuarial or research studies, if:

(A) No individual may be identified in any resulting actuarial or research report;

(B) Materials allowing the individual to be identified are returned or destroyed as soon as they are no longer needed; and

(C) The actuarial or research organization agrees not to disclose the information unless the disclosure would otherwise be permitted by this section if made by a licensee or insurance-support organization.

(o) Is to a party or a representative of a party to a proposed or consummated sale, transfer, merger or consolidation of all or part of the business of the licensee or insurance-support organization.

(p) Is to an affiliate whose only use of the information will be in connection with an audit of the licensee.

(q) Is to a consumer reporting agency in accordance with the federal Fair Credit Reporting Act (15 U.S.C. 1681 et seq.) or from a consumer report prepared by a consumer reporting agency.

(r) Is to a group policyholder for the purpose of reporting claims experience or conducting an audit of the licensee's operations or services, and the information disclosed is reasonably necessary for the group policyholder to conduct the review or audit.

(s) Is to a licensee for purposes related to replacement of a group benefit plan, a group health plan or a group welfare plan.

(t) Is to a professional peer review organization for the purpose of reviewing the service or conduct of a medical care institution or medical professional.

(u) Is to a governmental authority for the purpose of determining the individual's eligibility for health benefits for which the governmental authority may be liable.

(v) Is to a policyholder or certificate holder, or an agent or other representative thereof, for the purpose of providing information regarding the status of a health insurance transaction.

(2) A licensee may disclose personal or privileged information to an affiliate in connection with the marketing of a financial product or service if the affiliate agrees not to disclose the information for any other purpose or to an unaffiliated persons except as authorized in section (1) of this rule. If a disclosure under this section is made for marketing a product or service other than the product or service of the disclosing licensee, individually identifiable health information may not be disclosed without the authorization required by OAR 836-080-0665.

(3) A licensee may disclose personal or privileged information to a nonaffiliated third party whose only use of the information will be pursuant to a joint marketing agreement for marketing of a product or service. As used in this subsection, "joint marketing agreement" means a formal written contract pursuant to which an insurer jointly offers, endorses or sponsors a financial product or service with a financial institution. Information that may be disclosed under this subsection does not include individually identifiable health information, privileged information or personal information relating to an individual's character, personal habits, mode of living or general reputation, or any classification derived from such information, except as authorized in section (1) of this rule.

(4) A licensee or insurance support organization shall not disclose an access number or access code for an individual's policy or transaction account, whether directly or through an affiliate, to any nonaffiliate for use in telemarketing, direct mail marketing or other marketing through electronic mail to an individual, other than to a consumer reporting agency. This section does not apply if a licensee or insurance support organization discloses an access number or access code:

(a) To its service provider solely in order to perform marketing for its own products or services, as long as the service provider is not authorized to directly initiate charges to the account;

(b) To an insurance producer solely in order to perform marketing for its own products or services; or

(c) To a participant in an affinity or similar program where the participants in the program are identified to the individual when the individual enters into the program. An access number or access code does not include a number or code in an encrypted form, as long as the licensee or insurance support organization does not provide the recipient with a means to decode the number or code. For purposes of this subsection, a policy or transaction account is an account other than a deposit account or a credit card account. A policy or transaction account does not include an account to which third parties cannot initiate charges.

(5) Personal or privileged information may be acquired by a group practice prepayment health care service contractor from providers that contract with the health care service contractor and may be transferred among providers that contract with the health care service contractor for the purpose of administering plans offered by the health care service contractor. The information may not be disclosed otherwise by the health care service contractor except in accordance with OAR 836-080-0670 or 836-080-0675.

(6) This rule does not authorize the disclosure of personal or privileged information that is also individually identifiable health information when disclosure of the individually identifiable health information is prohibited or is otherwise regulated under the federal Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191).

Or. Admin. R. 836-080-0670

ID 4-2005, f. & cert. ef. 4-1-05

Stat. Auth.: ORS 731.244 & 746.608

Stats. Implemented: ORS 746.600 & 746.607