OAR 945-020-0025: Certification of Non-Marketplace Stand-alone Dental Plans

This rule applies only to SADPs offered outside the Marketplace. The Marketplace will, upon satisfaction of the following criteria, certify as providing pediatric dental benefits a stand alone dental plan (SADP) that an insurer offers for sale outside of the Marketplace. (1) To be considered for SADP certification, a dental plan must have its rates, form, and binder filed with and approved by the Oregon Insurance Division. (2) For an SADP to be certified, the insurer must demonstrate to the Marketplace that the SADP: (a) Provides pediatric dental benefits; (b) Meets an actuarial value of 68% to 72% or 83% to 87%; (c) For individual SADPs, imposes rates that are effective for the entire policy year; (d) For small group SADPs, imposes rates that may be subject to increase every calendar quarter but that are effective for a specific group for the entire plan year; and (e) Has been approved for sale in Oregon by the Oregon Insurance Division. (3) The Marketplace will recertify an SADP that meets the criteria in paragraph (2) of this rule. (4)(a) The Marketplace may at any time decertify an SADP if the Marketplace determines that the insurer or SADP no longer meets the Marketplace’s certification criteria described in this rule. (b) The insurer may appeal decertification. Appeal requests must be submitted within 15 days from receipt of the notice from the Marketplace informing the insurer of the decertification. The insurer’s appeal request must be made in writing and must provide a thorough explanation of the grounds for appeal along with any supporting information. The Administrator of the Marketplace will rule on a valid and timely appeal request within 14 days of receipt of the request. If an insurer is unsatisfied with the Administrator’s ruling, the insurer may seek additional review through a contested case hearing as provided under ORS 183.411 to 183.471. (c) Upon decertification of an SADP, the Marketplace will provide notice of decertification to the insurer and the Insurance Division, and the insurer shall not terminate coverage before giving notice to enrollees.