Oregon Administrative Rules
Chapter 945 - OREGON HEALTH AUTHORITY HEALTH INSURANCE MARKETPLACE
Division 20 - QUALIFIED HEALTH PLANS; ADDENDUM FOR INDIAN HEALTH PROVIDERS
Section 945-020-0020 - Certification of QHPs and Marketplace SADPs
Current through Register Vol. 63, No. 3, March 1, 2024
(1) Each health benefit plan or dental plan offered through the Oregon Health Insurance Marketplace must have in effect a certification issued by the Marketplace. This certification evidences that the health benefit plan is a QHP and that the dental plan is a SADP providing pediatric dental benefits.
(2) The Marketplace will issue a request for applications. To be considered for participation and plan certification, an insurer must submit a completed application to the Marketplace in the form and manner, and within the timeframes specified by the Marketplace.
(3) For QHPs, the Marketplace will grant conditional approval to participate in the Marketplace to an insurer whose application demonstrates the insurer:
(4) For SADPs, the Marketplace will grant conditional approval to participate in the Marketplace to an insurer whose application demonstrates the insurer:
(5) An insurer's approval is conditioned on certification of its health benefit or dental plans. An insurer will be approved for a two-year period, subject to a decision by the Marketplace to issue another request for applications before the end of the two-year period. An insurer that did not participate in the request for application the process may not offer coverage through the Marketplace, unless the Marketplace determines that there is a significant loss of statewide coverage.
(6) A loss of statewide coverage may include, but is not limited to:
(7) Every QHP or SADP offered through the Marketplace must be filed with the Oregon Insurance Division and determined to meet applicable benefit design standards and all other insurance regulations as required under state and federal law.
(8) Benefit design standards means coverage that includes, but is not limited to, the following:
(9) Subject to the limitation on the number of QHPs that may be offered through the Marketplace in the insurer's contract with the Marketplace, the Marketplace will recertify health benefit or dental plans that are submitted by approved insurers and with benefit design standards and legal requirements in this rule.
(10) The Marketplace may at any time decertify a QHP or SADP if the Marketplace determines that the insurer or QHP or SADP is no longer in compliance with the Marketplace's certification criteria. An insurer may appeal decertification of a QHP or SADP through the informal process specified in the insurer's contract with the Marketplace. After resolution of the informal appeal, an aggrieved insurer may seek additional review through a contested case hearing as provided under ORS 183.411 to 183.471.
Stat. Auth.: ORS 741.002
Stats. Implemented: ORS 741.310