Or. Admin. Code § 836-053-0221

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

Section 836-053-0221 - Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans

(1) For every group health benefit plan, a carrier that chooses to enforce participation, contribution or eligibility requirements must:

(a) Specify in the plan all of participation, contribution and eligibility requirements that have been agreed upon by the carrier and the group; and

(b) Apply the participation and eligibility requirements uniformly to all categories of eligible members and their dependents.

(2) For a small group health benefit plan, a carrier:

(a) May establish and apply contribution requirements for different categories of members and dependents that exceed the minimum contribution;

(b) Must apply participation requirements on an aggregate basis in which all categories of eligible employees of a small employer are combined;

(c) Must apply participation and eligibility requirements uniformly to all small employers with the same number of eligible employees;

(d) If a carrier requires 100 percent participation of eligible employees in a small group health benefit plan, the carrier may not impose a contribution requirement upon the employer that exceeds 50 percent of the premium of an employee-only benefit plan; and

(e) Except as provided in this subsection, a carrier may not increase any requirement for minimum employee participation or any requirement for minimum employer contribution applicable to a small employer except at plan anniversary. At plan anniversary, the carrier may increase the requirements only to the extent those requirements are applicable to all other small employer groups of the same size. At the anniversary of a plan or at any time other than the anniversary, a small employer carrier may consider the existing small group as a new group for purposes of coverage if the eligibility requirements applicable to the group are changed by the employer.

(3) Violation of this rule is an unfair trade practice under ORS 746.240.

Or. Admin. Code § 836-053-0221

ID 12-2013, f. 12-31-13, cert. ef. 1-1-14

Stat. Auth.: ORS 731.244 & 743.751

Stats. Implemented: Sec. 7, Ch. 681, OL 2013, ORS 743.522, 743.730- 743.754 & 746.240