Current through Register Vol. 63, No. 9, September 1, 2024
(1) For purposes of ORS
743B.013 and ORS
743B.105, "representative" means
a person who, with specific authority from the employer or plan sponsor to do
so, binds the employer or plan sponsor to a contract for health benefit plan
coverage.
(2) The notice required
by ORS 743B.013(6),
ORS 743B.105(8) and
ORS 743B.310(3) to
each plan enrollee affected by the rescission 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(6),
ORS 743B.105(8) and
ORS 743B.310(3) 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 health benefit plan and may not preserve an
enrollee's rights under the plan.
(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rescinded.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(3), 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(6)(c),
ORS 743B.105(8)(c)
and ORS 743B.310(4)
must include information related to group health benefit plan rescissions
including but not limited to the total number of:
(A) Fully rescinded group health benefit
plans;
(B) Partially rescinded
group health benefit plans;
(C)
Group health benefit plans in force on December 31 of the report
year;
(D) Enrollees affected by a
fully rescinded group health benefit plan; and
(E) Enrollees affected by a partially
rescinded group health benefit plan.
(b) The notice required under this section
may be combined with the notice required under OAR
836-053-0830 and OAR
836-053-0835.
(5) An insurer may not rescind
coverage for fraud if a representative fails to accurately comply with the
requirement to provide reasonable assurance that pediatric dental coverage is
separately provided.
Statutory/Other Authority: ORS
743.018, ORS
743.019, ORS
743.020 & ORS
743B.310
Statutes/Other Implemented: ORS
743.018, ORS
743.019, ORS
743.020, ORS
743B.310, ORS
742.003, ORS
742.005, ORS
742.007, ORS
743.022, ORS
743B.005, ORS
743B.013 & ORS
743B.105
