Division 53
Health Benefit Plans

Rules

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