- standards for benefit and claims payments
(1)A Medicare supplement insurance policy, contract or certificate in force in the state may not contain benefits which duplicate benefits provided by Medicare.
(2)The Director of the Department of Consumer and Business Services shall adopt by rule specific standards for policy provisions of Medicare supplement policies and certificates. The standards shall be in addition to and in accordance with applicable laws of this state. A requirement of the Insurance Code relating to minimum required policy benefits, other than the minimum standards contained in ORS 743.680 (Definitions for ORS 743.680 to 743.689) to 743.689 (Director’s authority upon violation of ORS 743.680 to 743.689), may not apply to Medicare supplement policies. The standards may cover, but not be limited to:
(a)Terms of renewability;
(b)Initial and subsequent conditions of eligibility;
(c)Nonduplication of coverage;
(e)Benefit limitations, exceptions and reductions;
(g)Requirements for replacement;
(h)Recurrent conditions; and
(i)Definitions of terms.
(3)Provisions established by the director governing eligibility for Medicare supplement insurance shall not be limited to persons qualifying for Medicare by reason of age.
(4)The director may adopt by rule standards that specify prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the director, are unjust, unfair or unfairly discriminatory to any person insured or proposed for coverage under a Medicare supplement policy.
(5)Notwithstanding any other provision of law of this state, a Medicare supplement policy may not deny a claim for losses incurred more than six months from the effective date of coverage for a preexisting condition. The policy may not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician or naturopathic physician within six months before the effective date of coverage.
(6)The director shall adopt by rule standards for benefits and claims payment under Medicare supplement policies. [1989 c.255 §§3,4; 1993 c.113 §3; 2017 c.356 §97]
Section 743.683 — Policy contents; standards for benefit and claims payments; rules,