Or. Admin. Code § 836-053-0830

Current through Register Vol. 63, No. 11, November 1, 2024

Section 836-053-0830 - Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy

(1) The notice required by ORS 743B.310(2) to the individual whose coverage is rescinded must be in writing and include all of the following:

(a) Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact underlying the rescission.

(b) An explanation as to why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact.

(c) A statement informing the individual of any right the individual has to file a grievance or to request a review of the decision to rescind coverage.

(d) A description of the health carrier's grievance procedures, including any time limits applicable to those procedures if such procedures are available to the individual.

(e) A statement explaining that complaints relating to the notice of rescission required by ORS 743B.310(2) may be made with the Department of Consumer and Business Services by writing to the departement at PO Box 14480, Salem, OR 97309-0405; by calling 503-947-7984 or toll-free 888-877-4894; online at dfr.oregon.gov; or by electronic mail to DFR.InsuranceHelp@dcbs.oregon.gov. The statement shall also explain at such complaints to the Department of Consumer and Business Services do not constitute grievances under the health benefit plan or health insurance policy and may not preserve an enrollee's rights under the plan or policy.

(f) The toll-free customer service number of the insurer.

(g) The effective date of the rescission and the date back to which the coverage will be rescinded.

(2) Subject to ORS 743.777, a health carrier may provide the notice required under ORS 743B.310(2) for individual health insurance either by first class mail or electronically.

(3)

(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. The notice required by ORS 743B.310(4) must include information related to rescission of individual health benefit plans and individual health insurance policies including but not limited to the total number of:

(A) Fully rescinded individual health benefit plans and individual health insurance policies;

(B) Partially rescinded individual health benefit plans and health insurance policies;

(C) Individual health benefit plans and individual health insurance policies in force on December 31 of the report year; and

(D) Enrollees affected by full or partial rescission of an individual health benefit plan or individual health insurance policy.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0825 and OAR 836-053-0835.

(4) A health carrier may not rescind coverage for fraud if an individual fails to accurately comply with the requirement to provide reasonable assurance that pediatric dental coverage is separately provided.

Or. Admin. Code § 836-053-0830

ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 4-2016, f. & cert. ef. 4/8/2016; ID 34-2023, minor correction filed 07/20/2023, effective 7/20/2023

Statutory/Other Authority: ORS 731.244 & ORS 743B.310

Statutes/Other Implemented: ORS 743B.310 & ORS 743B.003