Current through Register Vol. 63, No. 9, September 1, 2024
(1) As used in this
rule, the term "employer association" refers to an association or other group
of employers that sponsors, or wishes to sponsor one or more fully insured
group health benefit plan for its members, employees, or employees of its
members. For purposes of this rule, the term does not include a labor
union.
(2) A health insurance
carrier may not issue a policy of group health benefit coverage to an employer
association as the policyholder or offer coverage under such a policy, whether
issued in this or another state, unless the director of the Department of
Consumer and Business Services determines that:
(a) The employer association meets the
requirements of ORS 731.098(2);
and
(b) Issuance of the policy or
coverage would be consistent with the requirements of this rule and the
Insurance Code.
(3) A
carrier proposing to offer group health benefit coverage to an employer
association must submit, in the form prescribed by the director, the following
information to the department's Division of Financial Regulation for approval:
(a) A signed copy of the employer
association's current constitution and bylaws.
(b) A statement describing the purpose of the
employer association and demonstrating that the employer association is
organized and will be maintained in good faith primarily for purposes other
than that of obtaining insurance.
(c) A statement of membership requirements
describing any requirements for an employer to become and remain a member of
the employer association, including requirements related to participation in a
particular trade, business or industry and any geographic requirements.
(A) If only a subset of the employer
association's employer-members will be eligible to participate in the group
health benefit coverage, the statement of membership requirements must explain
any additional requirements that an employer-member must satisfy in order to
participate. Notwithstanding any requirements, a "working owner" is not allowed
to enroll in the group health benefit coverage. For purposes of this rule, the
term "working owner" means sole proprietors and other self-employed individuals
who do not employ at least one common law employee.
(B) If membership in the employer association
is limited to a particular trade, business or industry, the statement of
membership requirements must define the trade, business, or industry served by
the employer association and describe how the employer association determines
if the requirement is satisfied.
(d) A statement of eligibility describing the
types of individuals who will be eligible to enroll in the group health benefit
coverage sponsored by the employer association, whether as a subscriber or as a
dependent, and any terms or conditions for continued eligibility that will be
set by the carrier or by the employer association.
(e) Evidence demonstrating that the employer
association may sponsor the group health benefit coverage under section 3(5) of
the Employee Retirement Income Security Act of 1974 (29 U.S.C.
1002(5)). The filing must
include a letter from an attorney that concludes that the employer association
qualifies as an employer under
29
U.S.C. 1002(5) and explains
the basis for the conclusion using, at a minimum, the following criteria:
(A) The employer association sponsoring and
the individuals benefitting from the group health benefit coverage are tied by
a common economic or representational interest, or commonality of interest,
beyond the provision of health insurance, considering:
(i) How employer-members of the employer
association are solicited;
(ii)
Eligibility criteria to participate in the employer association;
(iii) The process by which the employer
association was formed;
(iv) The
purpose for the formation of the employer association; and
(v) Preexisting relationships of any of the
employer-members of the employer association.
(B) The members of the employer association
that participate in the group health benefit coverage will exercise control, in
both form and substance, over the administration and operation of the group
health benefit coverage.
(f) If the employer association will offer
coverage to small employer-members, evidence demonstrating that the group
health benefit coverage meets 60 percent actuarial value through:
(A) Certification by an actuary in accordance
with
45 CFR
156.145; or
(B) A plan that is the equivalent to an
Affordable Care Act bronze level plan in accordance with
45 CFR
156.140.
(g) Any additional information requested by
the division.
(4) With
respect to membership in the employer association or the ability to enroll in
group health benefit coverage, no carrier, employer association, or
employer-member of the employer association may discriminate against an
individual on the basis of the individual's health status. This section does
not prevent an employer association or carrier from charging different premium
rates to different employer groups within the employer association, provided
the methods used to establish each employer's premium rate are consistent with
45
CFR 146.121.
(5) Beginning in 2023, no later than October
31 of each year, a health insurance carrier offering group health benefit
coverage to an employer association must inform the division of changes to the
information required under section (3) of this rule, or provide confirmation to
the division that the employer association's information has not changed since
the last filing.
(6) For a carrier
that was approved to offer group health benefit coverage to an employer
association prior to the effective date of this rule, the requirements of this
rule become effective on July 1, 2023. The carrier must file the information
required under section (3) of this rule no later than October 31, 2023. If the
division determines the filing is not in compliance with the requirements of
this rule, the carrier offering coverage to the employer association may file a
transition plan no later than 60 calendar days following the disposition of the
filing, demonstrating how and when compliance will be met. The division may
allow a carrier to continue offering coverage pursuant to the terms of the
transition plan for up to two years following the final disposition regarding
the acceptability of the transition plan.
Statutory/Other Authority: ORS
731.244 & ORS
743.524
Statutes/Other Implemented: ORS
743.524 & ORS
731.098
