OAR 836-053-0510: Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage

(1) A carrier may use the health statement entitled, “Oregon Standard Health Statement” set forth on the website of the Department of Consumer and Business Services at dfr.oregon.gov to evaluate the health status of an applicant for coverage in a grandfathered individual health benefit plan. In all instances in which a carrier uses the Oregon Standard Health Statement, the carrier must pay for the costs associated with its use or the collection of information described in section (2) of this rule. (2) In evaluating an Oregon Standard Health Statement, a carrier may request the applicant’s medical records or a statement from the applicant’s attending physician, but such a request may be made only for questions marked "Yes" by the applicant in the numbered questionnaire portion of the statement. Although a carrier's request for additional medical information is limited to the specific questions marked "Yes," a carrier may use all of the information received in response to such a request in evaluating the applicant's health statement. (3) A carrier may use the information obtained in the Oregon Standard Health Statement from an individual enrolled in a nongrandfathered individual health benefit plan for the sole purpose of health care management, including providing or arranging for the provision of services under the plan. (4)(a) A carrier that chooses to collect health-related information from an applicant for individual grandfathered coverage before enrollment must: (A) Prominently state immediately before, and on the same page as, any health-related questions that: (i) Health-related information provided by the applicant will be used solely for health care management purposes. (ii) The applicant’s coverage cannot and will not be denied, terminated, delayed, limited or rescinded based on the applicant’s responses or failure to respond to the questions. (iii) The premium charged for the insurance policy cannot and will not change based on the applicant’s responses or failure to respond to questions. (B) Limit pre-enrollment health-related questions to whether an applicant: (i) Has a disability or a chronic health condition (ii) Has been advised by a licensed medical professional in the twelve months before application that hospitalization, surgery or treatment is necessary or pending. (iii) Is pregnant. (b) A carrier that chooses to ask questions described in paragraph (4)(a)(B) of this section may include the following as examples of a disability or chronic health condition: (A) Asthma, (B) Lung disease, (C) Depression, (D) Diabetes, (E) Heart disease, (F) Chronic back pain, (G) Chronic joint pain, (H) Obesity. (c) A carrier may not delay or refuse to issue nongrandfathered individual coverage to an applicant because the applicant has failed to respond or failed to respond completely to the questions allowed under paragraph (3)(a)(B) of this section. (d) For purposes of ORS 743B.103 and this section, “applicant” includes a prospective enrollee or dependent of a prospective enrollee. (5) Violation of any provision of this rule is an unfair trade practice under ORS 746.240.