ORS 743B.013
Requirements for small employer health benefit plans
(1)
A health benefit plan issued to a small employer:(a)
Other than a grandfathered health plan, must cover essential health benefits consistent with 42 U.S.C. 300gg-11.(b)
May require an affiliation period that does not exceed two months for an enrollee or 90 days for a late enrollee.(c)
May not apply a preexisting condition exclusion to any enrollee.(2)
Late enrollees in a small employer health benefit plan may be subjected to a group eligibility waiting period that does not exceed 90 days.(3)
Each small employer health benefit plan is renewable with respect to all eligible enrollees at the option of the policyholder, small employer or contract holder unless:(a)
The policyholder, small employer or contract holder fails to pay the required premiums.(b)
The policyholder, small employer or contract holder or, with respect to coverage of individual enrollees, an enrollee or a representative of an enrollee engages in fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan.(c)
The number of enrollees covered under the plan is less than the number or percentage of enrollees required by participation requirements under the plan.(d)
The small employer fails to comply with the contribution requirements under the health benefit plan.(e)
The carrier discontinues both offering and renewing all of the carrier’s small employer health benefit plans in this state or in a specified service area within this state. In order to discontinue plans under this paragraph, the carrier:(A)
Must give notice of the decision to the Department of Consumer and Business Services and to all policyholders covered by the plans;(B)
May not cancel coverage under the plans for 180 days after the date of the notice required under subparagraph (A) of this paragraph if coverage is discontinued in the entire state or in a specified service area, except that:(i)
The carrier shall cancel coverage in accordance with subparagraph (C) of this paragraph if the cancellation is for a specified service area in the circumstances described in subparagraph (C) of this paragraph; and(ii)
The Director of the Department of Consumer and Business Services may specify a cancellation date other than the cancellation date specified in this subparagraph if the carrier is subject to a delinquency proceeding, as defined in ORS 734.014 (Definitions); and(C)
May not cancel coverage under the plans for 90 days after the date of the notice required under subparagraph (A) of this paragraph if coverage is discontinued in a specified service area because of an inability to reach an agreement with the health care providers or organization of health care providers to provide services under the plans within the service area.(f)
The carrier discontinues both offering and renewing a small employer health benefit plan in a specified service area within this state because of an inability to reach an agreement with the health care providers or organization of health care providers to provide services under the plan within the service area. In order to discontinue a plan under this paragraph, the carrier:(A)
Must give notice to the department and to all policyholders covered by the plan;(B)
May not cancel coverage under the plan for 90 days after the date of the notice required under subparagraph (A) of this paragraph; and(C)
Must offer in writing to each small employer covered by the plan, all other small employer health benefit plans that the carrier offers to small employers in the specified service area. The carrier shall issue any such plans pursuant to the provisions of ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans). The carrier shall offer the plans at least 90 days prior to discontinuation.(g)
The carrier discontinues both offering and renewing a health benefit plan, other than a grandfathered health plan, for all small employers in this state or in a specified service area within this state, other than a plan discontinued under paragraph (f) of this subsection.(h)
The carrier discontinues both offering and renewing a grandfathered health plan for all small employers in this state or in a specified service area within this state, other than a plan discontinued under paragraph (f) of this subsection.(i)
With respect to plans that are being discontinued under paragraph (g) or (h) of this subsection, the carrier must:(A)
Offer in writing to each small employer covered by the plan, all other health benefit plans that the carrier offers to small employers in the specified service area.(B)
Issue any such plans pursuant to the provisions of ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans).(C)
Offer the plans at least 90 days prior to discontinuation.(D)
Act uniformly without regard to the claims experience of the affected policyholders or the health status of any current or prospective enrollee.(j)
The Director of the Department of Consumer and Business Services orders the carrier to discontinue coverage in accordance with procedures specified or approved by the director upon finding that the continuation of the coverage would:(A)
Not be in the best interests of the enrollees; or(B)
Impair the carrier’s ability to meet contractual obligations.(k)
In the case of a small employer health benefit plan that delivers covered services through a specified network of health care providers, there is no longer any enrollee who lives, resides or works in the service area of the provider network.(L)
In the case of a health benefit plan that is offered in the small employer market only to one or more bona fide associations, the membership of an employer in the association ceases and the termination of coverage is not related to the health status of any enrollee.(4)
A carrier may modify a small employer health benefit plan at the time of coverage renewal. The modification is not a discontinuation of the plan under subsection (3)(e), (g) and (h) of this section.(5)
Notwithstanding any provision of subsection (3) of this section to the contrary, a carrier may not rescind the coverage of an enrollee in a small employer health benefit plan unless:(a)
The enrollee or a person seeking coverage on behalf of the enrollee:(A)
Performs an act, practice or omission that constitutes fraud; or(B)
Makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan;(b)
The carrier provides at least 30 days’ advance written notice, in the form and manner prescribed by the department, to the enrollee; and(c)
The carrier provides notice of the rescission to the department in the form, manner and time frame prescribed by the department by rule.(6)
Notwithstanding any provision of subsection (3) of this section to the contrary, a carrier may not rescind a small employer health benefit plan unless:(a)
The small employer or a representative of the small employer:(A)
Performs an act, practice or omission that constitutes fraud; or(B)
Makes an intentional misrepresentation of a material fact as prohibited by the terms of the plan;(b)
The carrier provides at least 30 days’ advance written notice, in the form and manner prescribed by the department, to each plan enrollee who would be affected by the rescission of coverage; and(c)
The carrier provides notice of the rescission to the department in the form, manner and time frame prescribed by the department by rule.(7)
Intentionally left blank —Ed.(a)
A carrier may continue to enforce reasonable employer participation and contribution requirements on small employers. However, participation and contribution requirements shall be applied uniformly among all small employer groups with the same number of eligible employees applying for coverage or receiving coverage from the carrier. In determining minimum participation requirements, a carrier shall count only those employees who are not covered by an existing group health benefit plan, 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.(b)
A carrier may not deny a small employer’s application for coverage under a health benefit plan based on participation or contribution requirements but may require small employers that do not meet participation or contribution requirements to enroll during the open enrollment period beginning November 15 and ending December 15.(8)
Premium rates for small employer health benefit plans, except grandfathered health plans, are subject to the following provisions:(a)
Each carrier must file with the department the initial geographic average rate and any changes in the geographic average rate with respect to each health benefit plan issued by the carrier to small employers.(b)
Intentionally left blank —Ed.(A)
The variations in premium rates charged during a rating period for health benefit plans issued to small employers must be based solely on the factors specified in subparagraph (B) of this paragraph. A carrier may elect which of the factors specified in subparagraph (B) of this paragraph apply to premium rates for health benefit plans for small employers. All other factors must be applied in the same actuarially sound way to all small employer health benefit plans.(B)
The variations in premium rates described in subparagraph (A) of this paragraph may be based only on one or more of the following factors as prescribed by the department by rule:(i)
The ages of enrolled employees and their dependents, except that the rate for adults may not vary by more than three to one;(ii)
The level at which enrolled employees and dependents of enrolled employees engage in tobacco use, except that the rate may not vary by more than 1.5 to one; and(iii)
Adjustments to reflect differences in family composition.(C)
A carrier shall apply the carrier’s schedule of premium rate variations as approved by the department and in accordance with this paragraph. Except as otherwise provided in this section, the premium rate established by a carrier for a small employer health benefit plan applies uniformly to all employees of the small employer enrolled in that plan.(c)
Except as provided in paragraph (b) of this subsection, the variation in premium rates between different health benefit plans offered by a carrier to small employers must be based solely on objective differences in plan design or coverage, age, tobacco use and family composition and must not include differences based on the risk characteristics of groups assumed to select a particular health benefit plan.(d)
A carrier may not increase the rates of a health benefit plan issued to a small employer more than once in a 12-month period. Annual rate increases are effective on the plan anniversary date of the health benefit plan issued to a small employer. The percentage increase in the premium rate charged to a small employer for a new rating period may not exceed the sum of the following:(A)
The percentage change in the geographic average rate measured from the first day of the prior rating period to the first day of the new period; and(B)
Any adjustment attributable to changes in age and differences in family composition.(9)
Premium rates for grandfathered health plans are subject to requirements prescribed by the department by rule.(10)
In connection with the offering for sale of any health benefit plan to a small employer, each carrier shall make a reasonable disclosure as part of the carrier’s solicitation and sales materials of:(a)
The full array of health benefit plans that are offered to small employers by the carrier;(b)
The authority of the carrier to adjust rates and premiums, and the extent to which the carrier considers age, tobacco use, family composition and geographic factors in establishing and adjusting rates and premiums; and(c)
The benefits and premiums for all health insurance coverage for which the employer is qualified.(11)
Intentionally left blank —Ed.(a)
Each carrier shall maintain at the carrier’s principal place of business a complete and detailed description of the carrier’s rating practices and renewal underwriting practices relating to the carrier’s small employer health benefit plans, including information and documentation that demonstrate that the carrier’s rating methods and practices are based upon commonly accepted actuarial practices and are in accordance with sound actuarial principles.(b)
A carrier offering a small employer health benefit plan shall file with the department at least once every 12 months an actuarial certification that the carrier is in compliance with ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans) and that the rating methods of the carrier are actuarially sound. Each certification must be in a uniform form and manner and must contain such information as specified by the department. The carrier shall retain a copy of each certification at the carrier’s principal place of business. A carrier is not required to file the actuarial certification under this paragraph if the department has approved the carrier’s rate filing within the preceding 12-month period.(c)
A carrier shall make the information and documentation described in paragraph (a) of this subsection available to the department upon request. Except as provided in ORS 743.018 (Filing of rates for life and health insurance) and except in cases of violations of ORS 743B.010 (Issuance of group health benefit plan to affiliated group of employers) to 743B.013 (Requirements for small employer health benefit plans), the information is proprietary and trade secret information and is not subject to disclosure to persons outside the department except as agreed to by the carrier or as ordered by a court of competent jurisdiction.(12)
A carrier may not provide any financial or other incentive to any insurance producer that would encourage the insurance producer to sell health benefit plans of the carrier to small employer groups based on a small employer group’s anticipated claims experience.(13)
For purposes of this section, the date a small employer health benefit plan is continued is the anniversary date of the first issuance of the health benefit plan.(14)
A carrier shall include a provision that offers coverage to all eligible employees of a small employer and to all dependents of the eligible employees to the extent the employer chooses to offer coverage to dependents.(15)
All small employer health benefit plans must contain special enrollment periods during which eligible employees and dependents may enroll for coverage, as provided by federal law and rules adopted by the department.(16)
A small employer health benefit plan may not impose annual or lifetime limits on the dollar amount of essential health benefits. [Formerly 743.737; 2017 c.479 §16a; 2017 c.701 §23]
Source:
Section 743B.013 — Requirements for small employer health benefit plans, https://www.oregonlegislature.gov/bills_laws/ors/ors743B.html.
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