Health Benefit Plans: Individual and Group

ORS 743B.005

For purposes of ORS 743.004 (Submission of information by carriers offering health benefit plans), 743.007 (Data reporting), 743.022 (Premium rates for individual health benefit plans), 743.416 (Due date for first premium payment), 743.417 (Grace period for subsequent premium payments), 743.535 (Health benefit coverage for guaranteed association), 743B.003 (Purposes) to 743B.127 (Rules for ORS 743), 743B.109 (Short term health insurance policies), 743B.128 (Exceptions to requirement to actively market all plans), 743B.250 (Required notices to applicants and enrollees) and 743B.323 (Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium):


“Actuarial certification” means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the Director of the Department of Consumer and Business Services that a carrier is in compliance with the provisions of ORS 743B.012 (Requirement to offer all health benefit plans to small employers) based upon the person’s examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the carrier in establishing premium rates for small employer health benefit plans.


“Affiliate” of, or person “affiliated” with, a specified person means any carrier who, directly or indirectly through one or more intermediaries, controls or is controlled by or is under common control with a specified person. For purposes of this definition, “control” has the meaning given that term in ORS 732.548 (Definitions for ORS 732).


“Affiliation period” means, under the terms of a group health benefit plan issued by a health care service contractor, a period:


That is applied uniformly and without regard to any health status related factors to an enrollee or late enrollee;


That must expire before any coverage becomes effective under the plan for the enrollee or late enrollee;


During which no premium shall be charged to the enrollee or late enrollee; and


That begins on the enrollee’s or late enrollee’s first date of eligibility for coverage and runs concurrently with any eligibility waiting period under the plan.


“Bona fide association” means an association that:


Has been in active existence for at least five years;


Has been formed and maintained in good faith for purposes other than obtaining insurance;


Does not condition membership in the association on any factor relating to the health status of an individual or the individual’s dependent or employee;


Makes health insurance coverage that is offered through the association available to all members of the association regardless of the health status of the member or individuals who are eligible for coverage through the member;


Does not make health insurance coverage that is offered through the association available other than in connection with a member of the association;


Has a constitution and bylaws; and


Is not owned or controlled by a carrier, producer or affiliate of a carrier or producer.


“Carrier” means any person who provides health benefit plans in this state, including:


A licensed insurance company;


A health care service contractor;


A health maintenance organization;


An association or group of employers that provides benefits by means of a multiple employer welfare arrangement and that:


Is subject to ORS 750.301 (Definitions for ORS 750) to 750.341 (Requirement for multiple employer welfare arrangement to become traditional insurer); or


Is fully insured and otherwise exempt under ORS 750.303 (Conditions for use of multiple employer welfare arrangement) (4) but elects to be governed by ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans); or


Any other person or corporation responsible for the payment of benefits or provision of services.


“Dependent” means the spouse or child of an eligible employee, subject to applicable terms of the health benefit plan covering the employee.


“Eligible employee” means an employee who is eligible for coverage under a group health benefit plan.


“Employee” means any individual employed by an employer.


“Enrollee” means an employee, dependent of the employee or an individual otherwise eligible for a group or individual health benefit plan who has enrolled for coverage under the terms of the plan.


“Exchange” means the health insurance exchange as defined in ORS 741.300 (Definitions).


“Exclusion period” means a period during which specified treatments or services are excluded from coverage.


“Financial impairment” means that a carrier is not insolvent and is:


Considered by the director to be potentially unable to fulfill its contractual obligations; or


Placed under an order of rehabilitation or conservation by a court of competent jurisdiction.
(13)(a) “Geographic average rate” means the arithmetical average of the lowest premium and the corresponding highest premium to be charged by a carrier in a geographic area established by the director for the carrier’s:


Group health benefit plans offered to small employers; or


Individual health benefit plans.


“Geographic average rate” does not include premium differences that are due to differences in benefit design, age, tobacco use or family composition.


“Grandfathered health plan” has the meaning prescribed by rule by the United States Secretaries of Labor, Health and Human Services and the Treasury pursuant to 42 U.S.C. 18011(e) that is in effect on January 1, 2017.


“Group eligibility waiting period” means, with respect to a group health benefit plan, the period of employment or membership with the group that a prospective enrollee must complete before plan coverage begins.
(16)(a) “Health benefit plan” means any:


Hospital expense, medical expense or hospital or medical expense policy or certificate;


Subscriber contract of a health care service contractor as defined in ORS 750.005 (Definitions); or


Plan provided by a multiple employer welfare arrangement or by another benefit arrangement defined in the federal Employee Retirement Income Security Act of 1974, as amended, to the extent that the plan is subject to state regulation.


“Health benefit plan” does not include:


Coverage for accident only, specific disease or condition only, credit or disability income;


Coverage of Medicare services pursuant to contracts with the federal government;


Medicare supplement insurance policies;


Coverage of TRICARE services pursuant to contracts with the federal government;


Benefits delivered through a flexible spending arrangement established pursuant to section 125 of the Internal Revenue Code of 1986, as amended, when the benefits are provided in addition to a group health benefit plan;


Separately offered long term care insurance, including, but not limited to, coverage of nursing home care, home health care and community-based care;


Independent, noncoordinated, hospital-only indemnity insurance or other fixed indemnity insurance;


Short term health insurance policies;


Dental only coverage;


Vision only coverage;


Stop-loss coverage that meets the requirements of ORS 742.065 (Insurance against risk of loss assumed under less than fully insured employee health benefit plan);


Coverage issued as a supplement to liability insurance;


Insurance arising out of a workers’ compensation or similar law;


Automobile medical payment insurance or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance; or


Any employee welfare benefit plan that is exempt from state regulation because of the federal Employee Retirement Income Security Act of 1974, as amended.


“Individual health benefit plan” means a health benefit plan:


That is issued to an individual policyholder; or


That provides individual coverage through a trust, association or similar group, regardless of the situs of the policy or contract.


“Initial enrollment period” means a period of at least 30 days following commencement of the first eligibility period for an individual.


“Late enrollee” means an individual who enrolls in a group health benefit plan subsequent to the initial enrollment period during which the individual was eligible for coverage but declined to enroll. However, an eligible individual shall not be considered a late enrollee if:


The individual qualifies for a special enrollment period in accordance with 42 U.S.C. 300gg or as prescribed by rule by the Department of Consumer and Business Services;


The individual applies for coverage during an open enrollment period;


A court issues an order that coverage be provided for a spouse or minor child under an employee’s employer sponsored health benefit plan and request for enrollment is made within 30 days after issuance of the court order;


The individual is employed by an employer that offers multiple health benefit plans and the individual elects a different health benefit plan during an open enrollment period; or


The individual’s coverage under Medicaid, Medicare, TRICARE, Indian Health Service or a publicly sponsored or subsidized health plan, including, but not limited to, the medical assistance program under ORS chapter 414, has been involuntarily terminated within 63 days after applying for coverage in a group health benefit plan.


“Multiple employer welfare arrangement” means a multiple employer welfare arrangement as defined in section 3 of the federal Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. 1002, that is subject to ORS 750.301 (Definitions for ORS 750) to 750.341 (Requirement for multiple employer welfare arrangement to become traditional insurer).


“Preexisting condition exclusion” means a limitation or exclusion of benefits or a denial of coverage based on a medical condition being present before the effective date of coverage or before the date coverage is denied, whether or not any medical advice, diagnosis, care or treatment was recommended or received for the condition before the date of coverage or denial of coverage.


“Premium” includes insurance premiums or other fees charged for a health benefit plan, including the costs of benefits paid or reimbursements made to or on behalf of enrollees covered by the plan.


“Rating period” means the 12-month calendar period for which premium rates established by a carrier are in effect, as determined by the carrier.


“Representative” does not include an insurance producer or an employee or authorized representative of an insurance producer or carrier.
(25)(a) “Short term health insurance policy” means a policy of health insurance that is in effect for a period of three months or less, including the term of a renewal of the policy.


As used in this subsection, “term of a renewal” includes the term of a new short term health insurance policy issued by an insurer to a policyholder no later than 60 days after the expiration of a short term health insurance policy issued by the insurer to the policyholder.


“Small employer” means an employer who employed an average of at least one but not more than 50 full-time equivalent employees on business days during the preceding calendar year and who employs at least one full-time equivalent employee on the first day of the plan year, determined in accordance with a methodology prescribed by the Department of Consumer and Business Services by rule. [Formerly 743.730; 2017 c.152 §§8,8a; 2021 c.205 §6; 2021 c.281 §2]


Last accessed
Mar. 11, 2023