OAR 836-053-1030
Written Information to Enrollees

(1)

Each insurer must furnish written information to policyholders that is required by ORS 743.804, including but not limited to information relating to enrollee rights and responsibilities, including the right to appeal adverse benefit determinations, services, access thereto and related charges and scheduling, and access to external review, as provided in this rule. An insurer:

(a)

Must furnish the information regarding an individual health insurance policy to each policyholder; and

(b)

Must furnish the information regarding a group health insurance policy to the group policyholder for distribution to enrollees of the group policy.

(2)

Intentionally left blank —Ed.

(a)

The written information described in section (1) of this rule must be included either in the policy or in other evidence of coverage that is delivered to the individual policyholder by the insurer, or in the case of a group health insurance policy, that is delivered by the insurer to the group policyholder for distribution to enrollees.

(b)

As used inORS 743.804(2)(g), “continued coverage under the health benefit plan” means coverage of an ongoing course of treatment previously approved by the insurer.

(c)

The information required under subsection (a) of this section must include all of the following:

(A)

A description of the external review process, including when external review is available and how to request external review. The description must include the phone number of the Oregon Insurance Division.

(B)

A disclosure that when filing a request for an external review the enrollee will be required to authorize the release of any records, including medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.

(C)

A disclosure that the enrollee is financially responsible for benefits paid to or on behalf of an enrollee pursuant to ORS 743.804(2)(g) if the insurer’s adverse benefit determination is upheld on appeal.

(D)

A disclosure that the enrollee may request and receive from the insurer the information the insurer is required to disclose under ORS 743.804(5).

(3)

The information required by ORS 743.804 must include the following in relation to referrals for specialty care, behavioral health services, hospital services and other services, in addition to other relevant information regarding referrals:

(a)

If applicable, how gate keeping or access controls apply to referrals and whether and how the controls differ for specialty care, behavioral health services and hospital services; and

(b)

Any limitation on referrals if a plan has a defined network of participating providers and if referrals for specialty care may be limited to a portion of the network, such as to those specialists who contract with an enrollee’s primary care group.

(4)

The information required by ORS 743.804 must include the information required by ORS 743A.012 (Emergency services), relating to coverage of emergency medical conditions and obtaining emergency services, including a statement of the prudent layperson standard for an emergency medical condition, as that term is defined in 743A.012 (Emergency services). An insurer may meet the requirement of providing information in 743A.012 (Emergency services) by providing adequate disclosure in the information required by 743.804(1) and this rule. An insurer may use the following statement regarding the use of the emergency telephone number 9-1-1, or other wording that appropriately discloses its use:
“If you or a member of your family needs immediate assistance for a medical emergency, call 9-1-1 or go directly to an emergency room.”

(5)

The information required by ORS 743.804(1)(b) and (4) must include information regarding the use of the insurer’s grievance process, including the assistance available to enrollees in filing written grievances in accordance with OAR 836-053-1090 (Assistance in Filing Grievances) and the utilization review appeal procedures required by ORS 743.807(2)(c). The information must be contained in a separate section and captioned in a manner that clearly indicates that the section addresses grievances and appeals.

(6)

The information required by ORS 743.804(1)(b) and (4) must include a notice that states the right of an enrollee to file a complaint with or seek assistance from the Director of the Department of Consumer and Business Services. An insurer may use the following statement or other appropriate wording for this purpose:
“You have the right to file a complaint or seek other assistance from the Oregon Insurance Division. Assistance is available:
By calling (503) 947-7984 or the toll free message line at (888) 877-4894;
By electronic mail at: cp.ins@state.or.us;
By writing to the Oregon Division of Insurance, Consumer Advocacy Unit at:
PO Box 14480; Salem, OR 97309-0405; or
Through the Internet at http://www.insurance.oregon.gov/consumer/consumer.html.”

(7)

The information required by ORS 743.804(1) for an insurance policy providing managed health care must include a description of the procedures by which enrollees, purchasers and providers may participate in the development and implementation of insurer policy and operation.

(8)

The portion of the information required by ORS 743.804 that describes how an insurer makes decisions regarding coverage and payment for treatment or services must include a notice to enrollees that they may request an additional written summary of information that the insurer may consider in its utilization review of a particular condition to the extent the insurer maintains such criteria. The notice to enrollees must include the name and telephone number of the administrative section of the insurer that handles enrollee requests for information.

(9)

If a plan has a defined network of participating providers, the information required by ORS 743.804 must include a list of all participating primary care providers, direct access providers and all specialty care providers. For the purposes of this section, a primary care provider or direct access provider is a participating provider under the terms of the plan who an enrollee may designate as the primary care provider for the enrollee or from whom an enrollee may obtain services without referral. The list of providers must include for each provider the provider’s name, professional designation, category of practice and the city in which the practice of the provider is located.

(10)

If a plan includes risk-sharing arrangements with physicians or other providers, the information required by ORS 743.804 must contain a statement to that effect, including a brief description of risk-sharing in general and must notify enrollees that additional information is available upon request. For the purpose of this requirement, a risk-sharing arrangement does not include a fee-for-service arrangement or a discounted fee-for-service arrangement. An insurer may use the following statement or other appropriate wording to describe risk-sharing:
“This plan includes “risk-sharing” arrangements with physicians who provide services to the members of this plan. Under a risk-sharing arrangement, the providers that are responsible for delivering health care services are subject to some financial risk or reward for the services they deliver. An example of a risk-sharing arrangement is a contract between an insurer and a group of heart surgeons in which the surgeons agree to provide all of the heart operations needed by plan members and the insurer agrees to pay a fixed monthly amount for those services.”

(11)

If the insurer of a plan uses a mandatory closed formulary, the information required by ORS 743.804 for that plan must prominently disclose and explain the formulary provision. The disclosure and explanation must be in boldfaced type or otherwise emphasized.

(12)

An insurer that issues a health benefit plan must include a notice with the information required by ORS 743.804 that discloses that additional information is available to enrollees upon request ]. The notice must include the name and telephone number of the insurer’s administrative section that handles enrollee requests for information. The notice must also include the contact described in section (6) of this rule and a statement that the following additional information may be available from the Department of Consumer and Business Services: (a) An annual summary of grievances and appeals;

(b)

An annual summary of utilization review policies;

(c)

An annual summary of quality assessment activities;

(d)

The results of all publicly available accreditation surveys;

(e)

An annual summary of the insurer’s health promotion and disease prevention activities;

(f)

An annual summary of scope of network and accessibility of services.

Source: Rule 836-053-1030 — Written Information to Enrollees, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-053-1030.

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 836-053-1030’s source at or​.us