Current through Register Vol. 63, No. 9, September 1, 2024
(1) As used in this
rule, an "enrollee" includes an employee covered under a group health benefit
plan and a dependent of an employee covered under a group health benefit plan.
(2) A carrier issuing a group
health plan may not:
(a) Modify health
insurance with respect to an employee or any eligible dependent of an employee
by means of a rider, endorsement or otherwise, for the purpose of restricting
or excluding coverage for certain diseases or medical conditions otherwise
covered by the health benefit plan;
(b) Decline to offer coverage to any eligible
member of a group;
(c) Delay
enrollment for an otherwise eligible member of the group or dependent for
reasons related to actual or expected health status, race, color, national
origin, sex, sexual orientation as defined in ORS
174.100, age or disability; or
(d) Use a health statement when
offering a group health benefit plan.
(3) Unless otherwise required by law. a
modification to an existing group health benefit plan that is required by ORS
743.730 to
743.754 must be implemented for
each policyholder on the next renewal date. As used in this rule, "the next
renewal date" means the first renewal date of the policy issued to the
policyholder that occurs on or after January 1, 2014.
(4) A carrier must enroll a person who is
eligible in a small group health benefit plan during the plan's open enrollment
period and when a person is eligible or becomes eligible as a result of the
occurrence of an event described in this section, if:
(a) The person applies for coverage within at
least 30 calendar days after:
(A) An event
described in section 603 of the Employee Retirement Income Security Act of
1974, as amended;
(B) An event
described in
45 CFR
146.117(a)(3) if the person
is eligible for special enrollment under
45 CFR
146.117(a)(2), except for an
event described in
45 CFR
146.117(a)(3)(D) a carrier
must enroll a person who applies for coverage within 30 days, or later if
allowed by the carrier, after the first denial of a claim due to the operation
of a lifetime limit on all benefits; or
(C) Gaining a dependent, including a spouse,
or becoming a dependent through marriage, birth, adoption or placement for
adoption if the person is eligible for special enrollment under
45 CFR
146.117(b)(2); or
(b) The person applies for
coverage within 60 calendar days after:
(A)
Loss of eligibility for coverage under a Medicaid plan under title XIX of the
Social Security Act or a state child health plan under title XXI of the Social
Security Act; or
(B) An event
described in
45 CFR
155.725(j)(2)(iii).
(5) The
following effective dates apply to coverage for enrollment under section (4) of
this rule:
(a) For section (4)(a)(A),
coverage must be effective by the applicable date described in
45 CFR
155.420(b)(1).
(b) For section (4)(a)(B) coverage must be
effective no later than the first day of the first calendar month following the
date the plan or issuer receives the request for special enrollment.
(c) For section (4)(a)(C) coverage must be
effective:
(A) In the case of marriage, no
later than the first day of the first calendar month following the date the
carrier receives the request for special enrollment.
(B) In the case of birth, on the date of
birth.
(C) In the case of adoption
or placement for adoption, no later than the date of adoption or placement for
adoption.
(e) For
section (4)(b)(A) coverage must be effective by the applicable date described
in
45 CFR
155.420(b)(1).
(f) For section (8)(b)(B) coverage must be
effective no later than the first day of the first calendar month following the
date the plan or issuer receives the request for special enrollment.
(6) At or before enrollment, a
carrier must provide notice to an enrollee that complies with the requirements
of
45 CFR
146.117(c).
(7) An enrollee under section (4) of this
rule may not be considered a late enrollee.
(8) Violation of this rule is an unfair trade
practice under ORS 746.240.
Stat. Auth.: ORS
731.244 &
743.731
Stats. Implemented: Sec. 7, ch. 681, OL 2013, ORS
743.522,
743.730-743.754 &
746.240
