Or. Admin. Code § 836-053-0002

Current through Register Vol. 63, No. 12, December 1, 2024

Section 836-053-0002 - Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements

(1) A modification of a health benefit plan subject to the levels of coverage defined in 42 U.S.C. 18022(d) is defined in this rule for the purposes of:

(a) ORS 743B.013, regarding small employer health benefit plans; and

(b) ORS 743B.125, regarding individual health benefit plans.

(2) At the time of coverage renewal insurers may modify the coverage for a product offered to a group or an individual.

(a) The modification must be consistent with state law and effective uniformly with that product.

(b) Modifications made uniformly and solely under applicable federal or state requirements are considered a uniform modification of coverage if:

(A) The modification is made within a reasonable time period after the imposition or modification of the federal or state requirement; and

(B) The modification is directly related to the imposition or modification of the federal or state requirement.

(c) Other types of modification made uniformly are considered a uniform modification of coverage if the coverage for the product in the individual or small group market meets all of the following criteria:

(A) The product is offered by the same health insurer;

(B) The product offered has the same product network type;

(C) The product continues to cover at least a majority of the same service area;

(D) Within the product, each plan has the same cost sharing structure as before the modification, except for any variation in cost sharing solely related to changes in cost and utilization of medical care, or to maintain the same metal tier level described in 42 U.S.C. 18022(d); and

(E) The product provides the same covered benefits, except for any changes in benefits that cumulatively impact the plan-adjusted index rate for any plan within the product within an allowable variation of the plus or minus two percentage points (not including changes required under applicable federal or state law).

(3) Insurers must:

(a) Give the individual notice of a modification to which this rule applies not later than 30 days before the date of renewal of the plan to which the modification applies.

(b) Use either the standard notice created by Centers for Medicare and Medicaid Services or the standardized notice of modification or discontinuance as set forth on website for the Department of Consumer and Business Services at dfr.oregon.gov.

Or. Admin. Code § 836-053-0002

ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 14-2015(Temp), f. & cert. ef. 12-17-15 thru 5-1-16; ID 5-2016, f. & cert. ef. 4/26/2016; ID 14-2023, minor correction filed 06/23/2023, effective 6/23/2023

Statutory/Other Authority: ORS 731.244, 743B.127 & 743B.324

Statutes/Other Implemented: ORS 743B.013, 743B.105 & 743B.125