ORS 743B.104
Coverage in group health benefit plans

  • consideration of prospective enrollee health status restricted
  • effect of discontinuing offer of plans
  • exceptions
  • coverage by multiple employer welfare arrangements

(1)

Except in the case of a late enrollee and as otherwise provided in this section, a carrier offering a group health benefit plan to a group of two or more prospective certificate holders shall not decline to offer coverage to any eligible prospective enrollee and shall not impose different terms or conditions on the coverage, premiums or contributions of any enrollee in the group that are based on the actual or expected health status of the enrollee.

(2)

A carrier that elects to discontinue offering all of its group health benefit plans under ORS 743B.105 (Requirements for group health benefit plans other than small employer plans) (5)(e), elects to discontinue renewing all such plans or elects to discontinue offering and renewing all such plans is prohibited from offering health benefit plans in the group market in this state for a period of five years from:

(a)

The date of notice to the Director of the Department of Consumer and Business Services pursuant to ORS 743B.105 (Requirements for group health benefit plans other than small employer plans) (5)(e); or

(b)

If notice is not provided under paragraph (a) of this subsection, the date on which the director provides notice to the carrier that the director has determined that the carrier has effectively discontinued offering group health benefit plans in this state.

(3)

The Department of Consumer and Business Services may, in accordance with ORS 743B.129 (Shortening period of exclusion following discontinued offering), shorten the period of prohibition described in subsection (2) of this section if necessary to ensure, in all geographic areas of this state, that:

(a)

A competitive health insurance market exists;

(b)

Group purchasers have a reasonable number of health insurance options available to them; and

(c)

Consumers who purchase insurance are protected.

(4)

Subsection (1) of this section applies only to group health benefit plans that are not small employer health benefit plans.

(5)

Nothing in this section shall prohibit an employer from providing different group health benefit plans to various categories of employees as defined by the employer nor prohibit an employer from providing health benefit plans through different carriers so long as the employer’s categories of employees are established in a manner that does not relate to the actual or expected health status of the employees or their dependents.

(6)

A multiple employer welfare arrangement, professional or trade association, or other similar arrangement established or maintained to provide benefits to a particular trade, business, profession or industry or their subsidiaries, shall not issue coverage to a group or individual that is not in the same trade, business, profession or industry or their subsidiaries as that covered by the arrangement. The arrangement shall accept all groups and individuals in the same trade, business, profession or industry or their subsidiaries that apply for coverage under the arrangement and that meet the requirements for membership in the arrangement. For purposes of this subsection, the requirements for membership in an arrangement shall not include any requirements that relate to the actual or expected health status of the prospective enrollee. [Formerly 743.752; 2017 c.206 §5]

Source: Section 743B.104 — Coverage in group health benefit plans; consideration of prospective enrollee health status restricted; effect of discontinuing offer of plans; exceptions; coverage by multiple employer welfare arrangements, https://www.­oregonlegislature.­gov/bills_laws/ors/ors743B.­html.

743B.001
Definitions 743B.003
Purposes 743B.005
Definitions 743B.010
Issuance of group health benefit plan to affiliated group of employers 743B.011
Group health benefit plans subject to provisions of specified laws 743B.012
Requirement to offer all health benefit plans to small employers 743B.013
Requirements for small employer health benefit plans 743B.020
Eligible employees and small employers 743B.100
Department’s authority to regulate market 743B.102
Certifications and disclosure of coverage 743B.103
Use of health-related information 743B.104
Coverage in group health benefit plans 743B.105
Requirements for group health benefit plans other than small employer plans 743B.109
Short term health insurance policies 743B.110
Implementation of federal laws 743B.125
Individual health benefit plans 743B.126
Carrier marketing of individual health benefit plans 743B.127
Rules for ORS 743.022, 743B.125 and 743B.126 743B.128
Exceptions to requirement to actively market all plans 743B.129
Shortening period of exclusion following discontinued offering 743B.130
Requirement to offer bronze and silver plans 743B.195
Enforcement of Newborns’ and Mothers’ Health Protection Act of 1996 743B.197
Health Care Consumer Protection Advisory Committee 743B.200
Requirements for insurers offering managed health insurance 743B.202
Requirements for insurers offering managed health or preferred provider organization insurance 743B.204
Required managed health insurance contract provision 743B.220
Requirements for insurers that require designation of participating primary care physician 743B.222
Designation of women’s health care provider as primary care provider 743B.225
Continuity of care 743B.227
Referrals to specialists 743B.250
Required notices to applicants and enrollees 743B.252
External review 743B.253
Director to contract with independent review organizations to provide external review 743B.254
Required statements regarding external reviews 743B.255
Enrollee application for external review 743B.256
Duties of independent review organizations 743B.257
Civil penalty for failure to comply by insurer that agreed to be bound by decision 743B.258
Private right of action 743B.260
Claims and appeals of adverse benefit determinations under disability income insurance policies 743B.280
Definitions for ORS 743B.280 to 743B.285 743B.281
Estimate of costs for in-network procedure or service 743B.282
Estimate of costs for out-of-network procedure or service 743B.283
Submission of methodology used to determine insurer’s allowable charges 743B.284
Alternative mechanism for disclosure of costs and charges 743B.285
Rules 743B.287
Balance billing prohibited for health care facility services 743B.290
Hospital payment of copayment or deductible for insured patient 743B.300
Disclosure of differences in replacement health insurance policies 743B.310
Rescinding coverage 743B.320
Minimum grace period 743B.321
Applicability of ORS 743B.320 743B.323
Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium 743B.324
Rules for certain notice requirements 743B.330
Notice to policyholder required for cancellation or nonrenewal of health benefit plan 743B.340
When group health insurance policies to continue in effect upon payment of premium by insured individual 743B.341
Continuation of benefits after termination of group health insurance policy 743B.342
Continuation of benefits after injury or illness covered by workers’ compensation 743B.343
Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older 743B.344
Procedure for obtaining continuation of coverage under ORS 743B.343 743B.345
Premium for continuation of coverage under ORS 743B.344 743B.347
Continuation of coverage under group policy upon termination of membership in group health insurance policy 743B.400
Decisions regarding health care facility length of stay, level of care and follow-up care 743B.403
Insurer prohibited practices 743B.405
Medical services contract provisions 743B.406
Vision care providers 743B.407
Naturopathic physicians 743B.420
Prior authorization requirements 743B.422
Utilization review requirements for medical services contracts to which insurer not party 743B.423
Utilization review requirements for insurers offering health benefit plan 743B.424
Applicability 743B.425
Prior authorization prohibited for first 60 days of treatment for opioid or opiate withdrawal and for post-exposure prophylactic antiretroviral drugs 743B.427
Nonquantitative treatment limitations on coverage of behavioral health conditions 743B.450
Prompt payment of claims 743B.451
Refund of paid claims 743B.452
Interest on unpaid claims 743B.453
Underpayment of claims 743B.454
Claims submitted during credentialing period 743B.458
Performance-based incentive payments for primary care 743B.460
Conditions for restricting payments to only in-network providers 743B.462
Direct payments to providers 743B.470
Medicaid not considered in coverage eligibility determination 743B.475
Guidelines for coordination of benefits 743B.500
Selling and leasing of provider panels by contracting entity 743B.501
Registration of contracting entity 743B.502
Third party contracts for leasing of provider panels 743B.503
Additional requirements for third party contracts 743B.505
Provider networks 743B.550
Disclosure of information 743B.555
Confidential communications 743B.601
Synchronization of prescription drug refills 743B.602
Step therapy 743B.800
Risk adjustment procedures 743B.810
Enrollees covered by workers’ compensation
Green check means up to date. Up to date

Current through early 2024

§ 743B.104’s source at oregon​.gov