OAR 836-053-0013
Oregon Standard Bronze and Silver Health Benefit Plans

(1) This rule applies to plan years beginning on and after January 1, 2017.
(2) As used in this rule, “coverage” includes medically necessary benefits, services, prescription drugs and medical devices. “Coverage” does not include coinsurance, copayments, deductibles, other cost sharing, provider networks, out-of-network coverage, or administrative functions related to the provision of coverage, such as eligibility and medical necessity determinations.
(3) For purposes of coverage required under this rule:
(a) “Inpatient” includes but is not limited to:
(A) Inpatient surgery;
(B) Intensive care unit, neonatal intensive care unit, maternity and skilled nursing facility services; and
(C) Mental health and substance abuse treatment.
(b) “Outpatient” includes but is not limited to services received from ambulatory surgery centers and physician and anesthesia services and benefits when applicable.
(c) A reference to a specific version of a code or manual, including but not limited to references to ICD-10, CPT, Diagnostic and Statistical Manual of Mental Disorders, (DSM-5), Fifth Edition; place of service and diagnosis includes a reference to a code with equivalent coverage under the most recent version of the code or manual.
(4) When offering a plan required under ORS 743B.130 (Requirement to offer bronze and silver plans), an insurer must:
(a) Use the following naming convention: “[Name of Insurer] Standard [Bronze/HSA/Silver] Plan.” The name of insurer may be shortened to an easily identifiable acronym that is commonly used by the insurer in consumer facing publications.
(b) Include a service area or network identifier in the plan name if the plan is not offered on a statewide basis with a statewide network.
(5) Coverage required under ORS 743B.130 (Requirement to offer bronze and silver plans) must be provided in accordance with the requirements of sections (6) to (11) of this rule.
(6) Coverage must be provided in a manner consistent with the requirements of:
(a) 45 CFR 156, except that actuarial substitution of coverage within an essential health benefits category is prohibited;
(b) OAR 836-053-1404 (Definitions; Noncontracting Providers; Co-Morbidity Disorders), 836-053-1405 (General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency), 836-053-1407 (Prohibited Exclusions) and 836-053-1408 (Required Disclosures);
(c) The federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, 29 U.S.C. 1185a and implementing regulations at 45 CFR 146.136 and 147.160; and
(d) For plan years beginning on or after January 1, 2019, Chapter 721, Oregon Laws 2017 (Enrolled House Bill 3391).
(7) Coverage must provide essential health benefits as defined in OAR 836-053-0012 (Essential Health Benefits for Plan Years Beginning on and after January 1, 2017).
(8) Except when a specific benefit exclusion applies, or a claim fails to satisfy the insurer’s definition of medical necessity or fails to meet other issuer requirements the following coverage must be provided:
(a) Ambulatory services;
(b) Emergency services;
(c) Hospitalization services;
(d) Maternity and newborn services;
(e) Rehabilitation and habilitation services including:
(A) Professional physical therapy services;
(B) Professional occupational therapy;
(C) Physical therapy performed by an occupational therapist; and
(D) Professional speech therapy;
(f) Laboratory services;
(g) All grade A and B United States Preventive Services Task Force preventive services, Bright Futures recommended medical screenings for children, Institute of Medicine recommended women’s guidelines, and Advisory Committee on Immunization Practices recommended immunizations for children coverage must be provided without cost share; and
(h)(A) Prescription drug coverage at the greater of:
(i) At least one drug in every United States Pharmacopeia (USP) category and class as the prescription drug coverage of the plan described in OAR 836-053-0012 (Essential Health Benefits for Plan Years Beginning on and after January 1, 2017)(2); or
(ii) The same number of prescription drugs in each category and class as the prescription drug coverage of the plan described in OAR 836-053-0012 (Essential Health Benefits for Plan Years Beginning on and after January 1, 2017)(2).
(B) Insurers must submit the formulary drug list for review and approval. The formulary drug list must comply with filing requirements posted on the Department of Consumer and Business Services website.
(C) For plan years beginning on or after January 1, 2017 insurers must use a pharmacy and therapeutics committee that complies with the standards set forth in 45 CFR 156.122.
(9) Copays and coinsurance for coverage required under ORS 743B.130 (Requirement to offer bronze and silver plans) must comply with the following:
(a) Non-specialist copays apply to physical therapy, speech therapy, occupational therapy and vision services when these services are provided in connection with an office visit.
(b) Subject to the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, 29 U.S.C. 1185a, specialist copays apply to specialty providers including mental health and substance abuse providers, if and when such providers act in a specialist capacity as determined under the terms of the health benefit plan.
(c) Coinsurance for emergency room coverage must be waived if a patient is admitted, at which time the inpatient coinsurance applies.
(10) Deductibles for coverage required under ORS 743B.130 (Requirement to offer bronze and silver plans) must comply with the following:
(a) For a bronze plan, in accordance with the coinsurance, copayment and deductible amounts and coverage requirements for a bronze plan set forth in the cost-sharing matrix as adopted in Exhibit 1 to this rule.
(b) For a silver plan, in accordance with the coinsurance, copayment and deductible amounts and coverage requirements for a silver plan set forth in the cost-sharing matrix as adopted in Exhibit 2 to this rule.
(c) The individual deductible applies to all enrollees, and the family deductible applies when multiple family members incur claims.
(11) Dollar limits for coverage required under ORS 743B.130 (Requirement to offer bronze and silver plans) must comply with the following:
(a) Annual dollar limits must be converted to a non-dollar actuarial equivalent.
(b) Lifetime dollar limits must be converted to a non-dollar actuarial equivalent.
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 836-053-0013 — Oregon Standard Bronze and Silver Health Benefit Plans, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-053-0013.

836‑053‑0000
Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53 836‑053‑0001
Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements 836‑053‑0002
Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements 836‑053‑0003
Prohibition of Exclusion Period for Pregnancy 836‑053‑0004
Compliance with Federal and State Law 836‑053‑0005
Prescription Drug Identification Cards 836‑053‑0007
Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements 836‑053‑0008
Essential Health Benefits for Plan Years 2014, 2015 and 2016 836‑053‑0009
Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016 836‑053‑0011
Standard Bronze Plan Health Savings Account Eligible Requirement 836‑053‑0012
Essential Health Benefits for Plan Years Beginning on and after January 1, 2017 836‑053‑0013
Oregon Standard Bronze and Silver Health Benefit Plans 836‑053‑0014
Standards and Process for Shortened Period of Market Prohibition 836‑053‑0015
Definition of Small Employer 836‑053‑0017
Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022 836‑053‑0019
Purpose 836‑053‑0021
Plans Offered to Oregon Small Employers 836‑053‑0030
Marketing of a Health Benefit Plan to Small Employers 836‑053‑0050
Trade Practices Relating to Small Employer Health Benefit Plans 836‑053‑0063
Rating for Nongrandfathered Small Group Plans 836‑053‑0065
Rating for Grandfathered Small Group Plans 836‑053‑0066
Rating for Transitional Health Benefit Plans Offered to Small Employers 836‑053‑0070
Multiple Employer Welfare Arrangements 836‑053‑0100
Work Related Injuries or Disease 836‑053‑0105
Coordination of Payment for Interim Medical Services 836‑053‑0211
Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan 836‑053‑0221
Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans 836‑053‑0230
Underwriting 836‑053‑0300
Purpose 836‑053‑0310
Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0350 836‑053‑0320
Annual Report Requirements for Network Adequacy 836‑053‑0330
Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements 836‑053‑0340
Factor-Based Evidence of Compliance with Network Adequacy Requirements 836‑053‑0350
Provider Directory Requirements for Network Adequacy 836‑053‑0410
Purpose 836‑053‑0415
Cancellation of an Individual Health Benefit Plan Coverage 836‑053‑0418
Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic 836‑053‑0431
Underwriting, Enrollment and Benefit Design 836‑053‑0435
Health Benefit Plan Coverage of Well-woman Preventive Care Services 836‑053‑0465
Rating for Individual Health Benefit Plans 836‑053‑0472
Statutory Authority and Implementation 836‑053‑0473
Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans 836‑053‑0474
Process For Rate Filing for Individual and Small Employer Health Benefit Plans 836‑053‑0475
Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan 836‑053‑0510
Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage 836‑053‑0600
Purpose 836‑053‑0605
Definitions for OAR 836-053-0600 to 836-053-0615 836‑053‑0610
Carrier Response to Request for Confidentiality 836‑053‑0615
Carrier Reporting Requirements 836‑053‑0825
Rescission of a Group Health Benefit Plan 836‑053‑0830
Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy 836‑053‑0835
Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy 836‑053‑0851
Purpose 836‑053‑0857
Definitions 836‑053‑0863
Notifications 836‑053‑0900
Purpose 836‑053‑0910
Rate Filing 836‑053‑1000
Statutory Authority and Implementation 836‑053‑1010
Insurer Policies 836‑053‑1020
Drug Formularies 836‑053‑1030
Written Information to Enrollees 836‑053‑1033
Cultural and Linguistic Appropriateness 836‑053‑1035
Summary of Benefits and Explanation of Coverage 836‑053‑1060
Definitions 836‑053‑1070
Reporting of Grievances 836‑053‑1080
Tracking Grievances 836‑053‑1090
Assistance in Filing Grievances 836‑053‑1100
Internal Appeals Process 836‑053‑1110
Notice of Complaint Filing with Director 836‑053‑1130
Annual Summary, Utilization Review 836‑053‑1140
Appeal and Utilization Review Determinations 836‑053‑1170
Annual Summary, Quality Assessment Activities 836‑053‑1180
Format and Instructions for Report Required by ORS 743.818 836‑053‑1190
Annual Summary, Uniform Indicators of Network Adequacy 836‑053‑1200
Prior Authorization Requirements for Health Benefit Plans 836‑053‑1203
Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans 836‑053‑1205
Uniform Prescription Drug Prior Authorization Request Form 836‑053‑1300
Purpose and Scope 836‑053‑1305
Definitions 836‑053‑1310
Contracting Requirements 836‑053‑1315
Performance Criteria 836‑053‑1317
Professional Qualifications 836‑053‑1320
Conflict of Interest 836‑053‑1325
Procedures for Conducting External Reviews 836‑053‑1330
Criteria and Considerations for External Review Determinations 836‑053‑1335
Procedures for Complaint Investigation 836‑053‑1337
Preliminary Review by Insurer 836‑053‑1340
Timelines and Notice for Dispute That is Not Expedited 836‑053‑1342
Timelines and Notice for Expedited Decision-Making 836‑053‑1345
Quality Assurance Mechanisms 836‑053‑1350
Ongoing Requirements for Independent Review Organizations 836‑053‑1355
Synopses 836‑053‑1360
External Review Reporting 836‑053‑1365
Fees for External Reviews 836‑053‑1400
Format and Instructions for Report Required by ORS 743.748 836‑053‑1403
Definitions of Coordinated Care and Case Management for Behavioral Health Care Services 836‑053‑1404
Definitions 836‑053‑1405
General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency 836‑053‑1407
Prohibited Exclusions 836‑053‑1408
Required Disclosures 836‑053‑1409
Definitions 836‑053‑1410
Procedures 836‑053‑1415
Instructions 836‑053‑1500
Purpose 836‑053‑1505
Definitions for OAR 836-053-1500 to 836-053-1510 836‑053‑1510
Prominent Carrier Reporting Requirements 836‑053‑1520
Purpose 836‑053‑1525
Definitions 836‑053‑1530
Reporting Requirements 836‑053‑1600
Purpose 836‑053‑1605
Definitions for 836-053-1600 to 836-053-1615 836‑053‑1610
Non-anesthesia-related claims 836‑053‑1615
Anesthesia-related claims
Last Updated

Jun. 8, 2021

Rule 836-053-0013’s source at or​.us