Current through Register Vol. 63, No. 9, September 1, 2024
(1) A modification of a health benefit plan
is defined in this rule for the purposes of:
(a) ORS
743.737, regarding small
employer health benefit plans;
(b)
ORS 743.754, regarding group health
benefit plans covering two or more certificate holders;
(c) ORS
743.760, regarding portability
plans; and
(d) ORS
743.766, regarding individual
health benefit plans.
(2) One or more decreases or increases
described in this section in the services or benefits covered in a health
benefit plan are a modification and not a discontinuance when the decrease or
decreases, or the increase or increases, or any combination thereof, occur at
the time of renewal and the change or changes together alter the actuarial
valuation of the health benefit plan by less than ten percent in the aggregate
to the policyholder. This section applies to a decrease or increase that:
(a) Eliminates or adds benefits payable under
the plan;
(b) Decreases or
increases benefits payable under the plan, including a decrease or increase
that occurs as a result of a change in formulas, methodologies or schedules
that serve as the basis for making benefit determinations;
(c) Increases or decreases deductibles,
copayments or other amounts to be paid by an enrollee; or
(d) Establishes new conditions or
requirements, such as prior authorization requirements, to obtaining services
or benefits under the plan, or eliminates such conditions or
requirements.
(3) A
carrier must give the policyholder notice of a modification to which this rule
applies not later than the 30th day before the date of renewal of the plan to
which the modification applies.
(4)
A change in a requirement for eligibility is not a modification for purposes of
this rule but instead is a discontinuance if the change will result in the
exclusion of a class or category of enrollees covered under the current
plan.
(5) A decrease or increase
described in this section in the services or benefits covered in a health
benefit plan is a modification and not a discontinuance, but the decrease or
increase is not subject to section (2) of this rule. This section applies to
the following:
(a) A carrier's normal and
customary administrative changes that do not have an actuarial impact, such as
the following:
(A) Formulary
changes.
(B) Utilization management
protocols.
(C) Changes to pharmacy
prior authorization requirements if, at least 48 hours before a change, the
insurer prominently posts:
(i) A description
of the any pharmacy prior authorization requirement change to a page of the
insurer's website that an enrollee or provider can easily locate and access;
and
(ii) A link to the website page
described in subparagraph (i) of this paragraph on the home page of the
insurer's website.
(D)
Changes to non-pharmacy prior authorization requirements that are made other
than at renewal only when an insurer does all of the following:
(i) Makes a reasonable and good faith effort
to identify all enrollees affected by the changes.
(ii) Makes a reasonable and good faith effort
to identify providers who provide a service or treatment affected by the
changes.
(iii) Notifies all
enrollees and providers identified in subparagraphs (i) and (ii) of this
paragraph at least 60 days in advance of the effective date of the
change.
(iv) Posts a description of
any change to the non-pharmacy prior authorization requirements to a page of
the insurer's website that an enrollee or provider can easily locate and
access.
(v) Posts a link to the
website page described in subparagraph (iv) of this paragraph on the home page
of the insurer's website.
(vi)
Covers to the extent otherwise payable under the terms of the contract, and
without penalty, any claim for services or treatment affected by changes to
prior authorization requirements of an enrollee to whom the insurer fails to
provide notice of the change.
(b) A decrease or increase required by state
or federal law.
Stat. Auth.: ORS
731.244,
743.566 &
743.773
Stats Implemented: ORS
743.737,
743.754,
743.760 &
743.766
