OAR 836-053: Health Benefit Plans

125 rules in Division 053, Chapter 836 (Department of Consumer and Business Services, Insurance Regulation).

  1. OAR 836-053-0000: Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53
  2. OAR 836-053-0001: Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements
  3. OAR 836-053-0002: Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements
  4. OAR 836-053-0003: Prohibition of Exclusion Period for Pregnancy
  5. OAR 836-053-0004: Compliance with Federal and State Law
  6. OAR 836-053-0005: Prescription Drug Identification Cards
  7. OAR 836-053-0006: Issuance of Group Health Benefit Coverage to Employer Association
  8. OAR 836-053-0007: Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements
  9. OAR 836-053-0008: Essential Health Benefits for Plan Years 2014, 2015 and 2016
  10. OAR 836-053-0009: Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016
  11. OAR 836-053-0011: Standard Bronze Plan Health Savings Account Eligible Requirement
  12. OAR 836-053-0012: Essential Health Benefits for Plan Years Beginning on and after January 1, 2017
  13. OAR 836-053-0013: Oregon Standard Bronze and Silver Health Benefit Plans
  14. OAR 836-053-0014: Standards and Process for Shortened Period of Market Prohibition
  15. OAR 836-053-0015: Definition of Small Employer
  16. OAR 836-053-0017: Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022
  17. OAR 836-053-0019: Purpose; Statutory Authority; Enforcement
  18. OAR 836-053-0021: Plans Offered to Oregon Small Employers
  19. OAR 836-053-0027: Copayments for Certain Primary Care Visits
  20. OAR 836-053-0028: Primary Care Provider Assignment Methodology
  21. OAR 836-053-0030: Marketing of a Health Benefit Plan to Small Employers
  22. OAR 836-053-0050: Trade Practices Relating to Small Employer Health Benefit Plans
  23. OAR 836-053-0063: Rating for Nongrandfathered Small Group Plans
  24. OAR 836-053-0065: Rating for Grandfathered Small Group Plans
  25. OAR 836-053-0066: Rating for Transitional Health Benefit Plans Offered to Small Employers
  26. OAR 836-053-0070: Multiple Employer Welfare Arrangements
  27. OAR 836-053-0100: Work Related Injuries or Disease
  28. OAR 836-053-0105: Coordination of Payment for Interim Medical Services
  29. OAR 836-053-0211: Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan
  30. OAR 836-053-0221: Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans
  31. OAR 836-053-0230: Underwriting
  32. OAR 836-053-0300: Purpose; Statutory Authority; Applicability of Network Adequacy Requirements
  33. OAR 836-053-0310: Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0355
  34. OAR 836-053-0325: Network Adequacy Reporting Requirements
  35. OAR 836-053-0335: Nationally Recognized Standard for Annual Network Adequacy Evaluation
  36. OAR 836-053-0345: Quantitative Network Adequacy Access Standards
  37. OAR 836-053-0350: Provider Directory Requirements for Network Adequacy
  38. OAR 836-053-0355: Behavioral Health Network Composition and Reporting
  39. OAR 836-053-0410: Purpose; Statutory Authority; Enforcement
  40. OAR 836-053-0415: Cancellation of an Individual Health Benefit Plan Coverage
  41. OAR 836-053-0418: Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic
  42. OAR 836-053-0431: Underwriting, Enrollment and Benefit Design
  43. OAR 836-053-0435: Health Benefit Plan Coverage of Well-woman Preventive Care Services
  44. OAR 836-053-0441: Gender Affirming Treatment
  45. OAR 836-053-0444: Purpose and Statutory Authority
  46. OAR 836-053-0447: Definitions
  47. OAR 836-053-0451: Balance Billing Prohibition and Consumer Cost-Sharing for Ground Ambulance Services
  48. OAR 836-053-0454: Payments to Ground Ambulance Services Organizations
  49. OAR 836-053-0457: Ground Ambulance Service Organization Rate Reporting to the Department
  50. OAR 836-053-0461: Self-Funded Group Health Plan, Public Employees' Benefit Board and Oregon Educators Benefit Board, Election to Participate
  51. OAR 836-053-0465: Rating for Individual Health Benefit Plans
  52. OAR 836-053-0472: Statutory Authority and Implementation
  53. OAR 836-053-0473: Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans
  54. OAR 836-053-0474: Process For Rate Filing for Individual and Small Employer Health Benefit Plans
  55. OAR 836-053-0475: Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan
  56. OAR 836-053-0480: Consumer Friendly Summary Document for Rate Filings
  57. OAR 836-053-0510: Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage
  58. OAR 836-053-0600: Purpose; Statutory Authority; Applicability
  59. OAR 836-053-0605: Definitions for OAR 836-053-0600 to 836-053-0615
  60. OAR 836-053-0610: Carrier Response to Request for Confidentiality
  61. OAR 836-053-0615: Carrier Reporting Requirements
  62. OAR 836-053-0825: Rescission of a Group Health Benefit Plan
  63. OAR 836-053-0830: Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy
  64. OAR 836-053-0835: Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy
  65. OAR 836-053-0851: Purpose; Authority; Applicability; and Enforcement
  66. OAR 836-053-0857: Definitions
  67. OAR 836-053-0863: Notifications
  68. OAR 836-053-0900: Purpose; Statutory Authority
  69. OAR 836-053-0910: Rate Filing
  70. OAR 836-053-1000: Statutory Authority and Implementation
  71. OAR 836-053-1010: Insurer Policies
  72. OAR 836-053-1020: Drug Formularies
  73. OAR 836-053-1030: Written Information to Enrollees
  74. OAR 836-053-1033: Cultural and Linguistic Appropriateness
  75. OAR 836-053-1035: Summary of Benefits and Explanation of Coverage
  76. OAR 836-053-1060: Definitions
  77. OAR 836-053-1070: Reporting of Grievances and Prior Authorization; Format and Contents
  78. OAR 836-053-1080: Tracking Grievances and Prior Authorization Requests
  79. OAR 836-053-1090: Assistance in Filing Grievances
  80. OAR 836-053-1100: Internal Appeals Process
  81. OAR 836-053-1110: Notice of Complaint Filing with Director
  82. OAR 836-053-1130: Annual Summary, Utilization Review
  83. OAR 836-053-1140: Appeal and Utilization Review Determinations
  84. OAR 836-053-1170: Annual Summary, Quality Assessment Activities
  85. OAR 836-053-1180: Format and Instructions for Report Required by ORS 743.818
  86. OAR 836-053-1190: Annual Summary, Uniform Indicators of Network Adequacy
  87. OAR 836-053-1200: Prior Authorization Requirements for Health Benefit Plans
  88. OAR 836-053-1203: Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans
  89. OAR 836-053-1205: Uniform Prescription Drug Prior Authorization Request Form
  90. OAR 836-053-1300: Purpose and Scope; Application
  91. OAR 836-053-1305: Definitions; Authority to Act for Enrollee
  92. OAR 836-053-1310: Contracting Requirements
  93. OAR 836-053-1315: Performance Criteria
  94. OAR 836-053-1317: Professional Qualifications
  95. OAR 836-053-1320: Conflict of Interest
  96. OAR 836-053-1325: Procedures for Conducting External Reviews
  97. OAR 836-053-1330: Criteria and Considerations for External Review Determinations
  98. OAR 836-053-1335: Procedures for Complaint Investigation
  99. OAR 836-053-1337: Preliminary Review by Insurer
  100. OAR 836-053-1340: Timelines and Notice for Dispute That is Not Expedited
  101. OAR 836-053-1342: Timelines and Notice for Expedited Decision-Making
  102. OAR 836-053-1345: Quality Assurance Mechanisms
  103. OAR 836-053-1350: Ongoing Requirements for Independent Review Organizations
  104. OAR 836-053-1355: Synopses
  105. OAR 836-053-1360: External Review Reporting
  106. OAR 836-053-1365: Fees for External Reviews
  107. OAR 836-053-1400: Format and Instructions for Report Required by ORS 743.748
  108. OAR 836-053-1403: Definitions of Coordinated Care and Case Management for Behavioral Health Care Services
  109. OAR 836-053-1404: Definitions; Noncontracting Providers; Co-Morbidity Disorders
  110. OAR 836-053-1405: General Requirements for Coverage of Behavioral Health Conditions
  111. OAR 836-053-1407: Prohibited Exclusions
  112. OAR 836-053-1408: Required Disclosures
  113. OAR 836-053-1409: Definitions
  114. OAR 836-053-1410: Procedures
  115. OAR 836-053-1415: Instructions
  116. OAR 836-053-1420: Purpose and statutory authority
  117. OAR 836-053-1425: Definitions for behavioral health benefits reporting
  118. OAR 836-053-1430: Form and Manner for Behavioral Health Benefits Reporting
  119. OAR 836-053-1500: Purpose; Statutory Authority; Applicability
  120. OAR 836-053-1505: Definitions for OAR 836-053-1500 to 836-053-1510
  121. OAR 836-053-1510: Prominent Carrier Reporting Requirements
  122. OAR 836-053-1520: Purpose; Statutory Authority; Applicability
  123. OAR 836-053-1525: Definitions
  124. OAR 836-053-1530: Reporting Requirements
  125. OAR 836-053-1630: Drug Price Transparency Insurer Reporting