Or. Admin. Code § 836-053-0835

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

Section 836-053-0835 - Rescission of an Individual's Coverage under a Group Health Benefit Plan or Group Health Insurance Policy

(1) Subject to the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, P.L. 99-272, April 7, 1986, and ORS 743.601 and ORS 743.610, for purposes of rescission of an individual's coverage under a group health insurance policy, including a group health benefit plan under ORS 743B.013, ORS 743B.105 and ORS 743B.310, "rescission" does not include retroactive cancellation or discontinuance of coverage of an enrollee if:

(a) The enrollee is no longer eligible for such coverage;

(b) The enrollee has not paid required premiums or contributed to coverage or any premiums paid have been refunded; and

(c) The insurer is not notified of the enrollee's change in eligibility when the change occurs.

(2) The notice required by ORS 743B.013(5), ORS 743B.105(7) and ORS 743B.310(2) to each plan enrollee affected by rescission of coverage under a group health benefit plan or group health insurance policy must be in writing and include all of the following:

(a) Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact underlying the rescission.

(b) An explanation of why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact.

(c) A statement explaining an enrollee's right to file a grievance or request a review of the decision to rescind coverage.

(d) A description of the health carrier's applicable grievance procedures, including any time limits applicable to those procedures.

(e) A statement explaining that complaints relating to the notice of rescission required under ORS 743B.013(5), ORS 743B.105(7) and ORS 743B.310(2) may be made with the Department of Consumer and Business Services by writing to the department at PO Box 14480, Salem, OR 97309-0405; by calling 503-947-7984 or toll-free 888-877-4894; online at dfr.oregon.gov; or by electronic mail to DFR.InsuranceHelp@dcbs.oregon.gov. The statement shall also explain that complaints to the Department of Consumer and Business Services do not constitute grievances under the group health benefit plan or group health insurance policy and may not preserve an enrollee's rights under the plan or policy.

(f) The toll-free customer service number of the insurer.

(g) The effective date of the rescission and the date back to which the coverage will be rescinded.

(3) Subject to ORS 743.023, a health carrier may provide the required notice for small employer group health insurance either by first class mail or electronically.

(4)

(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. The notice required by ORS 743B.013(5), ORS 743B.105(7) and ORS 743B.310(2) must include information related to rescissions of enrollee coverage under a group health benefit plan or group health insurance policy including but not limited to the total number of enrollees affected by full or partial rescission of coverage under a group health benefit plan or group health insurance policy.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0825 and OAR 836-053-0830.

(5) An insurer may not rescind coverage for fraud if an enrollee fails to accurately comply with the requirement to provide reasonable assurance that pediatric dental coverage is separately provided.

Or. Admin. Code § 836-053-0835

ID 4-2016, f. & cert. ef. 4/8/2016; ID 35-2023, minor correction filed 07/20/2023, effective 7/20/2023

Statutory/Other Authority: ORS 743.244, ORS 743B.013, ORS 743B.105 & ORS 743B.310

Statutes/Other Implemented: ORS 743B.013, ORS 743B.105 & ORS 743B.310