Current through Register Vol. 63, No. 9, September 1, 2024
(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will be rescinded.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.
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
