Bill Text: OR HB3458 | 2013 | Regular Session | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to insurance; and declaring an emergency.
Spectrum: Committee Bill
Status: (Passed) 2013-07-29 - Chapter 698, (2013 Laws): Effective date July 29, 2013. [HB3458 Detail]
Download: Oregon-2013-HB3458-Introduced.html
Bill Title: Relating to insurance; and declaring an emergency.
Spectrum: Committee Bill
Status: (Passed) 2013-07-29 - Chapter 698, (2013 Laws): Effective date July 29, 2013. [HB3458 Detail]
Download: Oregon-2013-HB3458-Introduced.html
77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 3718
House Bill 3458
Sponsored by COMMITTEE ON HEALTH CARE
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Establishes Oregon Supplemental Reinsurance Program to be
administered by Oregon Medical Insurance Pool Board. Terminates
Oregon Medical Insurance Pool and Temporary High Risk Pool
Program. Ends Oregon Supplemental Reinsurance Program on December
31, 2016, and abolishes board on July 1, 2017.
Declares emergency, effective on passage.
A BILL FOR AN ACT
Relating to insurance; creating new provisions; amending ORS
65.957, 192.556, 291.055, 414.841, 705.145, 731.036, 731.509,
734.790, 735.610, 735.612, 735.616, 735.625, 735.630, 735.635,
735.645, 735.650, 743.402, 743.730, 743.748, 743.766, 743.767,
743.769, 744.704, 746.600, 748.603 and 750.055 and section 5,
chapter 47, Oregon Laws 2010; repealing ORS 414.866, 414.868,
414.870, 414.872, 735.600, 735.605, 735.610, 735.612, 735.614,
735.615, 735.616, 735.620, 735.625, 735.630, 735.635, 735.640,
735.645, 735.650 and 746.222 and section 1, chapter 803, Oregon
Laws 2009; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
{ +
ESTABLISHMENT OF THE + }
{ +
OREGON SUPPLEMENTAL REINSURANCE PROGRAM + }
SECTION 1. { + The Oregon Supplemental Reinsurance Program is
established in the Oregon Health Authority. The program shall be
administered by the Oregon Medical Insurance Pool Board, created
in ORS 735.610, for the purposes of stabilizing the rates and
premiums for individual health benefit plans and providing
greater financial certainty to consumers of health insurance in
this state by providing state supplemental reinsurance payments
to insurers from assessments described in section 2 of this 2013
Act. + }
SECTION 2. { + (1) As used in this section, section 1 of this
2013 Act and ORS 735.610:
(a) 'Health benefit plan' has the meaning given in ORS 743.730.
(b) 'Insurer' has the meaning given that term in ORS 735.605.
(c) 'Program' means the Oregon Supplemental Reinsurance Program
established in section 1 of this 2013 Act.
(d) 'Reinsurance eligible health benefit plan' means a health
benefit plan providing individual coverage that is not a
grandfathered health plan as defined in ORS 743.730 and that
meets the criteria prescribed by the Oregon Medical Insurance
Pool Board under subsection (2) of this section.
(e) 'Reinsurance eligible individual' means an individual
insured under a reinsurance eligible health benefit plan:
(A) Who, on December 31, 2013, was:
(i) Enrolled in the Oregon Medical Insurance Pool, created by
ORS 735.610, the Temporary High Risk Pool Program, established by
section 1, chapter 47, Oregon Laws 2010, or a federally
administered medical insurance pool for high risk individuals; or
(ii) Insured under a portability health benefit plan as defined
in ORS 743.760; or
(B) Whose coverage was reinsured under the reinsurance program
for children's coverage described in ORS 735.614 (1)(b).
(2) The board shall prescribe by rule the criteria for a health
benefit plan to qualify for reinsurance payments under the
program. The criteria must be consistent with requirements for:
(a) Premium rates under 42 U.S.C. 300gg;
(b) Guaranteed availability under 42 U.S.C. 300gg-1;
(c) Guaranteed renewability under 42 U.S.C. 300gg-2;
(d) Coverage of essential health benefits under 42 U.S.C.
18022; and
(e) Using a single risk pool under 42 U.S.C. 18032(c).
(3) An issuer of a reinsurance eligible health benefit plan
becomes eligible for a reinsurance payment when the claims costs
for a reinsurance eligible individual's covered benefits in a
calendar year exceed the attachment point. The amount of the
payment shall be the product of the coinsurance rate and the
issuer's claims costs for the reinsurance eligible individual's
claims costs that exceed the attachment point, up to the
reinsurance cap, as follows:
(a) For 2014:
(A) The attachment point is $30,000.
(B) The coinsurance rate is:
(i) 10 percent of the amount of the claims costs above $60,000
and up to and including $250,000; and
(ii) 90 percent of the amount of the claims costs from $30,000
and up to and including $60,000 and above $250,000.
(C) The reinsurance cap is $300,000.
(b) The board shall adopt by rule an attachment point,
coinsurance rate and reinsurance cap for calendar years 2015 and
2016, consistent with federal requirements, so that assessments
collected under subsection (4) of this section will be sufficient
to pay all reinsurance payments that are due. After the rules
required under this paragraph are adopted for a calendar year,
the board may not:
(A) Decrease the attachment point adopted for that calendar
year;
(B) Increase the coinsurance rate adopted for that calendar
year; or
(C) Increase the reinsurance cap adopted for that calendar
year.
(4) The board shall impose an assessment on all insurers at a
rate that is expected to produce an amount of funds equal to
reinsurance payments that are due to issuers of reinsurance
eligible health benefit plans in a calendar year, but not greater
than the rate that would be expected to produce funds totalling
the lesser of:
(a) An amount per month multiplied by the number of insureds
and certificate holders in this state who are insured or
reinsured, other than through the program or a federal
reinsurance program; or
(b) The total assessment set forth in subsection (5) of this
section.
(5) The amount per month and total assessment are as follows:
(a) For calendar year 2014, the amount per month is $4 and the
total assessment is $72 million.
(b) For calendar year 2015, the amount per month is $3.50 and
the total assessment is $63 million.
(c) For calendar year 2016, the amount per month is $2.20 and
the total assessment is $40 million.
(6) If the board collects assessments that exceed the amount
necessary to make all of the reinsurance payments that are due to
issuers of reinsurance eligible health benefit plans in a
calendar year, the board shall reduce the amount of the
prospective assessments or refund the excess to issuers of
reinsurance eligible health benefit plans on a pro rata basis.
(7) The board may not impose an assessment under subsection (4)
of this section for calendar years beginning with 2017.
(8) The board, in consultation with the Department of Consumer
and Business Services, may adopt rules necessary to carry out the
provisions of this section in a manner consistent with federal
requirements under 42 U.S.C. 18061, including, but not limited to
rules prescribing:
(a) The eligibility requirements for participation in the
program by an issuer of a reinsurance eligible health benefit
plan;
(b) The form and manner of issuing notices of assessment
amounts;
(c) The amount, manner and frequency of the payment and
collection of assessments;
(d) The amount, manner and frequency of reinsurance payments;
and
(e) Reporting requirements for insurers subject to the
assessment and for issuers of reinsurance eligible health benefit
plans.
(9) The board shall comply will all reporting, notification,
record-keeping and record retention requirements under 42 U.S.C.
18061. + }
SECTION 3. { + Section 4 of this 2013 Act is added to and made
a part of the Insurance Code. + }
SECTION 4. { + (1) As used in this section:
(a) 'Health benefit plan' has the meaning given that term in
ORS 743.730.
(b) 'Oregon Medical Insurance Pool Board' means the board
created in ORS 735.610.
(c) 'Oregon Supplemental Reinsurance Program' means the program
created in section 1 of this 2013 Act.
(d) 'Reinsurance eligible individual' has the meaning given
that term in section 2 of this 2013 Act.
(2) An insurer that offers a health benefit plan must report to
the Oregon Medical Insurance Pool Board, in the form and manner
prescribed by the board by rule, information about reinsurance
eligible individuals insured by the health benefit plan, as
necessary for the board to calculate reinsurance payments under
the Oregon Supplemental Reinsurance Program. + }
SECTION 5. ORS 731.509 is amended to read:
731.509. (1) The purpose of ORS 731.509, 731.510, 731.511,
731.512 and 731.516 is to protect the interests of insureds,
claimants, ceding insurers, assuming insurers and the public
generally. The Legislative Assembly declares that its intent is
to ensure adequate regulation of insurers and reinsurers and
adequate protection for those to whom they owe obligations. In
furtherance of that state interest, the Legislative Assembly
mandates that upon the insolvency of an alien insurer or
reinsurer that provides security to fund its United States
obligations in accordance with ORS 731.509, 731.510, 731.511,
731.512 and 731.516, the assets representing the security shall
be maintained in the United States and claims shall be filed with
and valued by the state insurance commissioner with regulatory
oversight, and the assets shall be distributed in accordance with
the insurance laws of the state in which the trust is domiciled
that are applicable to the liquidation of domestic United States
insurers. The Legislative Assembly declares that the laws
contained in ORS 731.509, 731.510, 731.511, 731.512 and 731.516
are fundamental to the business of insurance in accordance with
15 U.S.C. 1011 and 1012.
(2) The Director of the Department of Consumer and Business
Services shall not allow credit for reinsurance to a domestic
ceding insurer as either an asset or a reduction from liability
on account of reinsurance ceded unless credit is allowed as
provided under ORS 731.508 and unless the reinsurer meets the
requirements of:
(a) Subsection (3) of this section;
(b) Subsection (4) of this section;
(c) Subsections (5) and (8) of this section;
(d) Subsections (6) and (8) of this section; { - or - }
(e) Subsection (7) of this section { - . - } { + ; or
(f) Subsection (9) of this section. + }
(3) Credit shall be allowed when the reinsurance is ceded to an
authorized assuming insurer that accepts reinsurance of risks,
and retains risk thereon within such limits, as the assuming
insurer is otherwise authorized to insure in this state as
provided in ORS 731.508.
(4) Credit shall be allowed when the reinsurance is ceded to an
assuming insurer that is accredited as a reinsurer in this state
as provided in ORS 731.511. The director shall not allow credit
to a domestic ceding insurer if the accreditation of the assuming
insurer has been revoked by the director after notice and
opportunity for hearing.
(5) Credit shall be allowed when the reinsurance is ceded to a
foreign assuming insurer or a United States branch of an alien
assuming insurer meeting all of the following requirements:
(a) The foreign assuming insurer must be domiciled in a state
employing standards regarding credit for reinsurance that equal
or exceed the standards applicable under this section. The United
States branch of an alien assuming insurer must be entered
through a state employing such standards.
(b) The foreign assuming insurer or United States branch of an
alien assuming insurer must maintain a combined capital and
surplus in an amount not less than $20,000,000. The requirement
of this paragraph does not apply to reinsurance ceded and assumed
pursuant to pooling arrangements among insurers in the same
holding company system.
(c) The foreign assuming insurer or United States branch of an
alien assuming insurer must submit to the authority of the
director to examine its books and records.
(6) Credit shall be allowed when the reinsurance is ceded to an
assuming insurer that maintains a trust fund meeting the
requirements of this subsection and additionally complies with
other requirements of this subsection. The trust fund must be
maintained in a qualified United States financial institution, as
defined in ORS 731.510 (1), for the payment of the valid claims
of its United States policyholders and ceding insurers and their
assigns and successors in interest. The assuming insurer must
report annually to the director information substantially the
same as that required to be reported on the annual statement form
by ORS 731.574 by authorized insurers, in order to enable the
director to determine the sufficiency of the trust fund. The
following requirements apply to such a trust fund:
(a) In the case of a single assuming insurer, the trust fund
must consist of funds in trust in an amount not less than the
assuming insurer's liabilities attributable to reinsurance ceded
by United States ceding insurers. In addition, the assuming
insurer must maintain a trusteed surplus of not less than
$20,000,000.
(b) In the case of a group including incorporated and
individual unincorporated underwriters:
(A) For reinsurance ceded under reinsurance agreements with an
inception, amendment or renewal date on or after August 1, 1995,
the trust shall consist of a trusteed account in an amount not
less than the group's several liabilities attributable to
business ceded by United States domiciled ceding insurers to any
member of the group.
(B) For reinsurance ceded under reinsurance agreements with an
inception date on or before July 31, 1995, and not amended or
renewed after that date, notwithstanding the other provisions of
ORS 731.509, 731.510, 731.511, 731.512 and 731.516, the trust
shall consist of a trusteed account in an amount not less than
the group's several insurance and reinsurance liabilities
attributable to business written in the United States.
(C) In addition to the trusts described in subparagraphs (A)
and (B) of this paragraph, the group shall maintain in trust a
trusteed surplus of which $100,000,000 shall be held jointly for
the benefit of the United States domiciled ceding insurers of any
member of the group for all years of account.
(D) The incorporated members of the group shall not be engaged
in any business other than underwriting as a member of the group
and shall be subject to the same level of regulation and solvency
control by the group's domiciliary regulator as are the
unincorporated members.
(E) Within 90 days after the group's financial statements are
due to be filed with the group's domiciliary regulator, the group
shall provide to the director an annual certification by the
group's domiciliary regulator of the solvency of each underwriter
member or, if certification is unavailable, financial statements
of each underwriter member of the group prepared by independent
certified public accountants.
(c) In the case of a group of incorporated insurers described
in this paragraph, the trust must be in an amount equal to the
group's several liabilities attributable to business ceded by
United States ceding insurers to any member of the group pursuant
to reinsurance contracts issued in the name of the group. This
paragraph applies to a group of incorporated insurers under
common administration that complies with the annual reporting
requirements contained in this subsection and that has
continuously transacted an insurance business outside the United
States for at least three years immediately prior to making
application for accreditation. Such a group must have an
aggregate policyholders' surplus of $10,000,000,000 and must
submit to the authority of this state to examine its books and
records and bear the expense of the examination. The group shall
also maintain a joint trusteed surplus of which $100,000,000 must
be held jointly for the benefit of United States ceding insurers
of any member of the group as additional security for any such
liabilities. Each member of the group shall make available to the
director an annual certification of the member's solvency by the
member's domiciliary regulator and its independent certified
public accountant.
(d) The form of the trust and any amendment to the trust shall
have been approved by the insurance commissioner of the state in
which the trust is domiciled or by the insurance commissioner of
another state who, pursuant to the terms of the trust instrument,
has accepted principal regulatory oversight of the trust.
(e) The form of the trust and any trust amendments also shall
be filed with the insurance commissioner of every state in which
the ceding insurer beneficiaries of the trust are domiciled. The
trust instrument must provide that contested claims shall be
valid and enforceable upon the final order of any court of
competent jurisdiction in the United States. The trust must vest
legal title to its assets in its trustees for the benefit of the
assuming insurer's United States ceding insurers and their
assigns and successors in interest. The trust and the assuming
insurer are subject to examination as determined by the director.
The trust must remain in effect for as long as the assuming
insurer has outstanding obligations due under the reinsurance
agreements subject to the trust.
(f) Not later than March 1 of each year, the trustees of each
trust shall report to the director in writing the balance of the
trust and listing the trust's investments at the preceding year
end, and shall certify the date of termination of the trust, if
so planned, or certify that the trust will not expire prior to
the following December 31.
(7) Credit shall be allowed when the reinsurance is ceded to an
assuming insurer not meeting the requirements of subsection (3),
(4), (5) or (6) of this section, but only as to the insurance of
risks located in jurisdictions in which the reinsurance is
required by applicable law or regulation of that jurisdiction.
(8) If the assuming insurer is not authorized to transact
insurance in this state or accredited as a reinsurer in this
state, the director shall not allow the credit permitted by
subsections (5) and (6) of this section unless the assuming
insurer agrees in the reinsurance agreement to the provisions
stated in this subsection. This subsection is not intended to
conflict with or override the obligation of the parties to a
reinsurance agreement to arbitrate their disputes, if such an
obligation is created in the agreement. The assuming insurer must
agree in the reinsurance agreement:
(a) That in the event of the failure of the assuming insurer to
perform its obligations under the terms of the reinsurance
agreement, the assuming insurer, at the request of the ceding
insurer, shall submit to the jurisdiction of any court of
competent jurisdiction in any state of the United States, will
comply with all requirements necessary to give the court
jurisdiction and will abide by the final decision of the court or
of any appellate court in the event of an appeal; and
(b) To designate the director or a designated attorney as its
true and lawful attorney upon whom any lawful process in any
action, suit or proceeding instituted by or on behalf of the
ceding company may be served.
{ + (9) Credit shall be allowed when the reinsurance is ceded
to the Oregon Supplemental Reinsurance Program established in
section 1 of this 2013 Act. + }
{ - (9) - } { + (10) + } If the assuming insurer does not
meet the requirements of subsection (3), (4) or (5) of this
section, the credit permitted by subsection (6) of this section
shall not be allowed unless the assuming insurer agrees in the
trust agreements to the following conditions:
(a) Notwithstanding any other provisions in the trust
instrument, if the trust fund is inadequate because it contains
an amount less than the applicable amount required by subsection
(6)(a), (b) or (c) of this section, or if the grantor of the
trust has been declared insolvent or placed into receivership,
rehabilitation, liquidation or similar proceedings under the laws
of the grantor's state or country of domicile, the trustee shall
comply with an order of the insurance commissioner with
regulatory oversight over the trust or with an order of a court
of competent jurisdiction directing the trustee to transfer to
the insurance commissioner with regulatory oversight all the
assets of the trust fund.
(b) The assets shall be distributed by and claims shall be
filed with and valued by the insurance commissioner with
regulatory oversight in accordance with the laws of the state in
which the trust is domiciled that are applicable to the
liquidation of domestic insurance companies.
(c) If the insurance commissioner with regulatory oversight
determines that the assets of the trust fund or any part thereof
are not necessary to satisfy the claims of the United States
ceding insurers of the grantor of the trust, the assets or part
thereof shall be returned by the insurance commissioner according
to the laws of that state and according to the terms of the trust
agreement not inconsistent with the laws of that state.
(d) The grantor shall waive any right otherwise available to it
under United States law that is inconsistent with this
subsection.
SECTION 6. ORS 735.610 is amended to read:
735.610. (1) There is created in the Oregon Health Authority
the Oregon Medical Insurance Pool Board. The board shall
establish the Oregon Medical Insurance Pool and otherwise carry
out the responsibilities of the board under ORS 735.600 to
735.650 { + and sections 1, 2 and 4 of this 2013 Act + }.
(2) The board shall consist of { - 10 - } { + 11 + }
individuals, eight of whom shall be appointed by the Director of
the Oregon Health Authority. The Director of the Department of
Consumer and Business Services or the director's designee and the
Director of the Oregon Health Authority or the director's
designee shall be members of the board. The chair of the board
shall be elected from among the members of the board. The board
shall at all times, to the extent possible, include at least one
representative of a domestic insurance company licensed to
transact health insurance, one representative of a domestic
not-for-profit health care service contractor, one representative
of a health maintenance organization, one representative of
reinsurers and { - two - } { + three + } members of the
general public who are not associated with the medical
profession, a hospital or an insurer. { + One of the members of
the general public must be a representative of business. + } A
majority of the voting members of the board constitutes a quorum
for the transaction of business. An act by a majority of a quorum
is an official act of the board.
(3) The Director of the Oregon Health Authority may fill any
vacancy on the board by appointment.
(4) The board shall have the { - general powers and authority
under the laws of this state granted to insurance companies with
a certificate of authority to transact health insurance and
the - } specific authority to:
(a) Enter into such contracts as are necessary or proper to
carry out the provisions and purposes of ORS 735.600 to 735.650
including the authority to enter into contracts with similar
pools of other states for the joint performance of common
administrative functions, or with persons or other organizations
for the performance of administrative functions;
(b) Recover any assessments for, on behalf of, or against
insurers;
(c) Take such legal action as is necessary to avoid the payment
of improper claims against the pool or the coverage provided by
or through the pool;
{ - (d) Establish appropriate rates, rate schedules, rate
adjustments, expense allowances, insurance producers' referral
fees, claim reserves or formulas and perform any other actuarial
function appropriate to the operation of the pool. Rates may not
be unreasonable in relation to the coverage provided, the risk
experience and expenses of providing the coverage. Rates and rate
schedules may be adjusted for appropriate risk factors such as
age and area variation in claim costs and shall take into
consideration appropriate risk factors in accordance with
established actuarial and underwriting practices; - }
{ - (e) Issue policies of insurance in accordance with the
requirements of ORS 735.600 to 735.650; - }
{ - (f) - } { + (d) + } Appoint from among insurers
appropriate actuarial and other committees as necessary to
provide technical assistance in the operation of the pool { - ,
policy and other contract design - } { + and the Oregon
Supplemental Reinsurance Program + }, and { + for + } any other
function within the authority of the board;
{ - (g) - } { + (e) + } Seek advances to effect the
purposes of the pool { + and the program + }; and
{ - (h) - } { + (f) + } Establish rules, conditions and
procedures for reinsuring risks under ORS 735.600 to 735.650 { +
and the operation of and participation of issuers of reinsurance
eligible health benefit plans in the program + }.
(5) Each member of the board is entitled to compensation and
expenses as provided in ORS 292.495.
(6) The Director of the Oregon Health Authority shall adopt
rules, as provided under ORS chapter 183, implementing policies
recommended by the board for the purpose of carrying out ORS
735.600 to 735.650 { + and sections 1, 2 and 4 of this 2013
Act + }.
(7) In consultation with the board, the Director of the Oregon
Health Authority shall employ such staff and consultants as may
be necessary for the purpose of carrying out responsibilities
under ORS 735.600 to 735.650 { + and sections 1, 2 and 4 of this
2013 Act + }.
SECTION 7. ORS 735.630 is amended to read:
735.630. Neither participation in the { + Oregon Medical
Insurance + } Pool { + or the Oregon Supplemental Reinsurance
Program + } as members, the establishment of rates, forms or
procedures, nor any other action taken in the performance of the
powers and duties under ORS 735.600 to 735.650 { + and sections
1, 2 and 4 of this 2013 Act, + } shall be the basis of any legal
action, criminal or civil liability or penalty against the Oregon
Medical Insurance Pool Board, any members, the Director of the
Oregon Health Authority { + , the Director of the Department of
Consumer and Business Services + } or any of their agents or
employees.
SECTION 8. ORS 735.635 is amended to read:
735.635. The { + Oregon Medical Insurance + } Pool established
pursuant to ORS 735.600 to 735.650 { + and the Oregon
Supplemental Reinsurance Program established in section 1 of this
2013 Act + } shall be exempt from any and all taxes assessed by
the State of Oregon.
{ +
TERMINATION OF OREGON + }
{ +
MEDICAL INSURANCE POOL COVERAGE + }
SECTION 9. ORS 291.055 is amended to read:
291.055. (1) Notwithstanding any other law that grants to a
state agency the authority to establish fees, all new state
agency fees or fee increases adopted during the period beginning
on the date of adjournment sine die of a regular session of the
Legislative Assembly and ending on the date of adjournment sine
die of the next regular session of the Legislative Assembly:
(a) Are not effective for agencies in the executive department
of government unless approved in writing by the Director of the
Oregon Department of Administrative Services;
(b) Are not effective for agencies in the judicial department
of government unless approved in writing by the Chief Justice of
the Supreme Court;
(c) Are not effective for agencies in the legislative
department of government unless approved in writing by the
President of the Senate and the Speaker of the House of
Representatives;
(d) Shall be reported by the state agency to the Oregon
Department of Administrative Services within 10 days of their
adoption; and
(e) Are rescinded on adjournment sine die of the next regular
session of the Legislative Assembly as described in this
subsection, unless otherwise authorized by enabling legislation
setting forth the approved fees.
(2) This section does not apply to:
(a) Any tuition or fees charged by the State Board of Higher
Education and the public universities listed in ORS 352.002.
(b) Taxes or other payments made or collected from employers
for unemployment insurance required by ORS chapter 657 or premium
assessments required by ORS 656.612 and 656.614 or contributions
and assessments calculated by cents per hour for workers'
compensation coverage required by ORS 656.506.
(c) Fees or payments required for:
(A) Health care services provided by the Oregon Health and
Science University, by the Oregon Veterans' Homes and by other
state agencies and institutions pursuant to ORS 179.610 to
179.770.
{ - (B) Assessments and premiums paid to the Oregon Medical
Insurance Pool established by ORS 735.614 and 735.625. - }
{ - (C) - } { + (B) + } Copayments and premiums paid to the
Oregon medical assistance program.
{ - (D) - } { + (C) + } Assessments paid to the Department
of Consumer and Business Services under ORS 743.951 and 743.961.
(d) Fees created or authorized by statute that have no
established rate or amount but are calculated for each separate
instance for each fee payer and are based on actual cost of
services provided.
(e) State agency charges on employees for benefits and
services.
(f) Any intergovernmental charges.
(g) Forest protection district assessment rates established by
ORS 477.210 to 477.265 and the Oregon Forest Land Protection Fund
fees established by ORS 477.760.
(h) State Department of Energy assessments required by ORS
469.421 (8) and 469.681.
(i) Any charges established by the State Parks and Recreation
Director in accordance with ORS 565.080 (3).
(j) Assessments on premiums charged by the Department of
Consumer and Business Services pursuant to ORS 731.804 or fees
charged by the Division of Finance and Corporate Securities of
the Department of Consumer and Business Services to banks, trusts
and credit unions pursuant to ORS 706.530 and 723.114.
(k) Public Utility Commission operating assessments required by
ORS 756.310 or charges paid to the Residential Service Protection
Fund required by chapter 290, Oregon Laws 1987.
(L) Fees charged by the Housing and Community Services
Department for intellectual property pursuant to ORS 456.562.
(m) New or increased fees that are anticipated in the
legislative budgeting process for an agency, revenues from which
are included, explicitly or implicitly, in the legislatively
adopted budget or the legislatively approved budget for the
agency.
(n) Tolls approved by the Oregon Transportation Commission
pursuant to ORS 383.004.
(o) Convenience fees as defined in ORS 182.126 and established
by the Oregon Department of Administrative Services under ORS
182.132 (3) and recommended by the Electronic Government Portal
Advisory Board.
(3)(a) Fees temporarily decreased for competitive or
promotional reasons or because of unexpected and temporary
revenue surpluses may be increased to not more than their prior
level without compliance with subsection (1) of this section if,
at the time the fee is decreased, the state agency specifies the
following:
(A) The reason for the fee decrease; and
(B) The conditions under which the fee will be increased to not
more than its prior level.
(b) Fees that are decreased for reasons other than those
described in paragraph (a) of this subsection may not be
subsequently increased except as allowed by ORS 291.050 to
291.060 and 294.160.
SECTION 10. ORS 414.841 is amended to read:
414.841. For purposes of ORS 414.841 to 414.864:
(1) 'Carrier' has the meaning given that term in ORS 735.700.
(2) 'Dental plan' means a policy or certificate of group or
individual health insurance, as defined in ORS 731.162, providing
payment or reimbursement only for the expenses of dental care.
(3) 'Eligible individual' means an individual who:
(a) Is a resident of the State of Oregon;
(b) Is not eligible for Medicare;
(c) Is either:
(A) For health benefit plan coverage other than dental plans, a
person who has been without health benefit plan coverage for a
period of time established by the Office of Private Health
Partnerships or meets exception criteria established by the
office; or
(B) For dental plan coverage, an individual under 19 years of
age who is uninsured or underinsured with respect to dental plan
coverage;
(d) Except as otherwise provided by the office, has family
income that is at or below 200 percent of the federal poverty
level; and
(e) Meets other eligibility criteria established by the office.
(4) 'Family' means an eligible individual and all other related
individuals, as prescribed by the office by rule.
(5)(a) 'Health benefit plan' means a policy or certificate of
group or individual health insurance, as defined in ORS 731.162,
providing payment or reimbursement for hospital, medical and
surgical expenses or for dental care expenses. 'Health benefit
plan' includes a health care service contractor or health
maintenance organization subscriber contract { - , the Oregon
Medical Insurance Pool - } and any plan provided by a less than
fully insured multiple employer welfare arrangement or by another
benefit arrangement defined in the federal Employee Retirement
Income Security Act of 1974, as amended.
(b) 'Health benefit plan' does not include coverage for
accident only, specific disease or condition only, credit,
disability income, coverage of Medicare services pursuant to
contracts with the federal government, Medicare supplement
insurance, student accident and health insurance, long term care
insurance, hospital indemnity only, vision only, coverage issued
as a supplement to liability insurance, insurance arising out of
a workers' compensation or similar law, automobile medical
payment insurance, insurance under which the benefits are payable
with or without regard to fault and that is legally required to
be contained in any liability insurance policy or equivalent
self-insurance or coverage obtained or provided in another state
but not available in Oregon.
(6) 'Income' means gross income in cash or kind available to
the applicant or the applicant's family. Income does not include
earned income of the applicant's children or income earned by a
spouse if there is a legal separation.
(7) 'Resident' means an individual who meets the residency
requirements established by rule by the office.
(8) 'Subsidy' means payment or reimbursement to an eligible
individual toward the purchase of a health benefit plan, and may
include a net billing arrangement with carriers or a prospective
or retrospective payment for health benefit plan premiums and
eligible copayments or deductible expenses directly related to
the eligible individual.
(9) 'Third party administrator' means any insurance company or
other entity licensed under the Insurance Code to administer
health benefit plans.
SECTION 11. ORS 705.145 is amended to read:
705.145. (1) There is created in the State Treasury a fund to
be known as the Consumer and Business Services Fund, separate and
distinct from the General Fund. All moneys collected or received
by the Department of Consumer and Business Services, except
moneys
{ - collected pursuant to ORS 735.612 and those moneys - }
required to be paid into the Workers' Benefit Fund, shall be paid
into the State Treasury and credited to the Consumer and Business
Services Fund. Moneys in the fund may be invested in the same
manner as other state moneys and any interest earned shall be
credited to the fund.
(2) The department shall keep a record of all moneys deposited
in the Consumer and Business Services Fund that shall indicate,
by separate account, the source from which the moneys are
derived, the interest earned and the activity or program against
which any withdrawal is charged.
(3) If moneys credited to any one account are withdrawn,
transferred or otherwise used for purposes other than the program
or activity for which the account is established, interest shall
accrue on the amount withdrawn from the date of withdrawal and
until such funds are restored.
(4) Moneys in the fund are continuously appropriated to the
department for its administrative expenses and for its expenses
in carrying out its functions and duties under any provision of
law.
(5) Except as provided in ORS 705.165, it is the intention of
the Legislative Assembly that the performance of the various
duties and functions of the department in connection with each of
its programs shall be financed by the fees, assessments and
charges established and collected in connection with those
programs.
(6) There is created by transfer from the Consumer and Business
Services Fund a revolving administrative account in the amount of
$100,000. The revolving account shall be disbursed by checks or
orders issued by the director or the Workers' Compensation Board
and drawn upon the State Treasury, to carry on the duties and
functions of the department and the board. All checks or orders
paid from the revolving account shall be reimbursed by a warrant
drawn in favor of the department charged against the Consumer and
Business Services Fund and recorded in the appropriate subsidiary
record.
(7) For the purposes of ORS chapter 656, the revolving account
created pursuant to subsection (6) of this section may also be
used to:
(a) Pay compensation benefits; and
(b) Refund to employers amounts paid to the Consumer and
Business Services Fund in excess of the amounts required by ORS
chapter 656.
(8) Notwithstanding subsections (2), (3) and (5) of this
section and except as provided in ORS 455.220 (1), the moneys
derived pursuant to ORS 446.003 to 446.200, 446.210, 446.225 to
446.285, 446.395 to 446.420, 446.566 to 446.646, 446.661 to
446.756 and 455.220 (1) and deposited to the fund, interest
earned on those moneys and withdrawals of moneys for activities
or programs under ORS 446.003 to 446.200, 446.210, 446.225 to
446.285, 446.395 to 446.420, 446.566 to 446.646 and 446.661 to
446.756, or education and training programs pertaining thereto,
must be assigned to a single account within the fund.
(9) Notwithstanding subsections (2), (3) and (5) of this
section, the moneys derived pursuant to ORS 455.240 or 460.370 or
from state building code or specialty code program fees for which
the amount is established by department rule pursuant to ORS
455.020 (2) and deposited to the fund, interest earned on those
moneys and withdrawals of moneys for activities or programs
described under ORS 455.240 or 446.566 to 446.646, 446.661 to
446.756 and 460.310 to 460.370, structural or mechanical
specialty code programs or activities for which a fee is
collected under ORS 455.020 (2), or programs described under
subsection (10) of this section that provide training and
education for persons employed in producing, selling, installing,
delivering or inspecting manufactured structures or manufactured
dwelling parks or recreation parks, must be assigned to a single
account within the fund.
(10) Notwithstanding ORS 279.835 to 279.855 and ORS chapters
279A and 279B, the department may, after consultation with the
appropriate specialty code advisory boards established under ORS
455.132, 455.135, 455.138, 480.535 and 693.115, contract for
public or private parties to develop or provide training and
education programs relating to the state building code and
associated licensing or certification programs.
SECTION 12. ORS 731.036 is amended to read:
731.036. Except as provided in ORS 743.061 or as specifically
provided by law, the Insurance Code does not apply to any of the
following to the extent of the subject matter of the exemption:
(1) A bail bondsman, other than a corporate surety and its
agents.
(2) A fraternal benefit society that has maintained lodges in
this state and other states for 50 years prior to January 1,
1961, and for which a certificate of authority was not required
on that date.
(3) A religious organization providing insurance benefits only
to its employees, if the organization is in existence and exempt
from taxation under section 501(c)(3) of the federal Internal
Revenue Code on September 13, 1975.
(4) Public bodies, as defined in ORS 30.260, that either
individually or jointly establish a self-insurance program for
tort liability in accordance with ORS 30.282.
(5) Public bodies, as defined in ORS 30.260, that either
individually or jointly establish a self-insurance program for
property damage in accordance with ORS 30.282.
(6) Cities, counties, school districts, community college
districts, community college service districts or districts, as
defined in ORS 198.010 and 198.180, that either individually or
jointly insure for health insurance coverage, excluding
disability insurance, their employees or retired employees, or
their dependents, or students engaged in school activities, or
combination of employees and dependents, with or without employee
or student contributions, if all of the following conditions are
met:
(a) The individual or jointly self-insured program meets the
following minimum requirements:
(A) In the case of a school district, community college
district or community college service district, the number of
covered employees and dependents and retired employees and
dependents aggregates at least 500 individuals;
(B) In the case of an individual public body program other than
a school district, community college district or community
college service district, the number of covered employees and
dependents and retired employees and dependents aggregates at
least 500 individuals; and
(C) In the case of a joint program of two or more public
bodies, the number of covered employees and dependents and
retired employees and dependents aggregates at least 1,000
individuals;
(b) The individual or jointly self-insured health insurance
program includes all coverages and benefits required of group
health insurance policies under ORS chapters 743 and 743A;
(c) The individual or jointly self-insured program must have
program documents that define program benefits and
administration;
(d) Enrollees must be provided copies of summary plan
descriptions including:
(A) Written general information about services provided, access
to services, charges and scheduling applicable to each enrollee's
coverage;
(B) The program's grievance and appeal process; and
(C) Other group health plan enrollee rights, disclosure or
written procedure requirements established under ORS chapters 743
and 743A;
(e) The financial administration of an individual or jointly
self-insured program must include the following requirements:
(A) Program contributions and reserves must be held in separate
accounts and used for the exclusive benefit of the program;
(B) The program must maintain adequate reserves. Reserves may
be invested in accordance with the provisions of ORS chapter 293.
Reserve adequacy must be calculated annually with proper
actuarial calculations including the following:
(i) Known claims, paid and outstanding;
(ii) A history of incurred but not reported claims;
(iii) Claims handling expenses;
(iv) Unearned contributions; and
(v) A claims trend factor; and
(C) The program must maintain adequate reinsurance against the
risk of economic loss in accordance with the provisions of ORS
742.065 unless the program has received written approval for an
alternative arrangement for protection against economic loss from
the Director of the Department of Consumer and Business Services;
(f) The individual or jointly self-insured program must have
sufficient personnel to service the employee benefit program or
must contract with a third party administrator licensed under ORS
chapter 744 as a third party administrator to provide such
services;
{ - (g) The individual or jointly self-insured program shall
be subject to assessment in accordance with ORS 735.614 and
former enrollees shall be eligible for portability coverage in
accordance with ORS 735.616; - }
{ - (h) - } { + (g) + } The public body, or the program
administrator in the case of a joint insurance program of two or
more public bodies, files with the Director of the Department of
Consumer and Business Services copies of all documents creating
and governing the program, all forms used to communicate the
coverage to beneficiaries, the schedule of payments established
to support the program and, annually, a financial report showing
the total incurred cost of the program for the preceding year. A
copy of the annual audit required by ORS 297.425 may be used to
satisfy the financial report filing requirement; and
{ - (i) - } { + (h) + } Each public body in a joint
insurance program is liable only to its own employees and no
others for benefits under the program in the event, and to the
extent, that no further funds, including funds from insurance
policies obtained by the pool, are available in the joint
insurance pool.
(7) All ambulance services.
(8) A person providing any of the services described in this
subsection. The exemption under this subsection does not apply to
an authorized insurer providing such services under an insurance
policy. This subsection applies to the following services:
(a) Towing service.
(b) Emergency road service, which means adjustment, repair or
replacement of the equipment, tires or mechanical parts of a
motor vehicle in order to permit the motor vehicle to be operated
under its own power.
(c) Transportation and arrangements for the transportation of
human remains, including all necessary and appropriate
preparations for and actual transportation provided to return a
decedent's remains from the decedent's place of death to a
location designated by a person with valid legal authority under
ORS 97.130.
(9)(a) A person described in this subsection who, in an
agreement to lease or to finance the purchase of a motor vehicle,
agrees to waive for no additional charge the amount specified in
paragraph (b) of this subsection upon total loss of the motor
vehicle because of physical damage, theft or other occurrence, as
specified in the agreement. The exemption established in this
subsection applies to the following persons:
(A) The seller of the motor vehicle, if the sale is made
pursuant to a motor vehicle retail installment contract.
(B) The lessor of the motor vehicle.
(C) The lender who finances the purchase of the motor vehicle.
(D) The assignee of a person described in this paragraph.
(b) The amount waived pursuant to the agreement shall be the
difference, or portion thereof, between the amount received by
the seller, lessor, lender or assignee, as applicable, that
represents the actual cash value of the motor vehicle at the date
of loss, and the amount owed under the agreement.
(10) A self-insurance program for tort liability or property
damage that is established by two or more affordable housing
entities and that complies with the same requirements that public
bodies must meet under ORS 30.282 (6). As used in this
subsection:
(a) 'Affordable housing' means housing projects in which some
of the dwelling units may be purchased or rented, with or without
government assistance, on a basis that is affordable to
individuals of low income.
(b) 'Affordable housing entity' means any of the following:
(A) A housing authority created under the laws of this state or
another jurisdiction and any agency or instrumentality of a
housing authority, including but not limited to a legal entity
created to conduct a self-insurance program for housing
authorities that complies with ORS 30.282 (6).
(B) A nonprofit corporation that is engaged in providing
affordable housing.
(C) A partnership or limited liability company that is engaged
in providing affordable housing and that is affiliated with a
housing authority described in subparagraph (A) of this paragraph
or a nonprofit corporation described in subparagraph (B) of this
paragraph if the housing authority or nonprofit corporation:
(i) Has, or has the right to acquire, a financial or ownership
interest in the partnership or limited liability company;
(ii) Has the power to direct the management or policies of the
partnership or limited liability company;
(iii) Has entered into a contract to lease, manage or operate
the affordable housing owned by the partnership or limited
liability company; or
(iv) Has any other material relationship with the partnership
or limited liability company.
(11) A community-based health care initiative approved by the
Administrator of the Office for Oregon Health Policy and Research
under ORS 735.723 operating a community-based health care
improvement program approved by the administrator.
(12) Except as provided in ORS 735.500 and 735.510, a person
certified by the Department of Consumer and Business Services to
operate a retainer medical practice.
SECTION 13. ORS 734.790 is amended to read:
734.790. (1) ORS 734.750 to 734.890 provide coverage for
policies and contracts specified in subsection (2) of this
section to the following persons who are not provided coverage
under the laws of another state:
(a) To a person who is a resident, if the person is an owner of
or a certificate holder under the policy or contract other than a
structured settlement annuity or, in the case of an unallocated
annuity contract, an employee participating in a governmental
retirement plan established under section 401, 403(b) or 457 of
the United States Internal Revenue Code or the beneficiaries of
each such individual if deceased.
(b) To a person who is not a resident, if the person is an
owner of or a certificate holder under the policy or contract
other than a structured settlement annuity or, in the case of an
unallocated annuity contract, an employee participating in a
governmental retirement plan established under section 401,
403(b) or 457 of the United States Internal Revenue Code or the
beneficiaries of each such individual if deceased. This paragraph
applies to a person who is not a resident only if all of the
following conditions are met:
(A) The insurer that issued the policy or contract must be a
member insurer.
(B) The state in which the person resides must have an
association similar to the Oregon Life and Health Insurance
Guaranty Association.
(C) The person must not be eligible for coverage by an
association in the state in which the person resides, as
described in subparagraph (B) of this paragraph, due to the fact
that the insurer was not authorized to transact insurance or
licensed in that state at the time specified in the state's
guaranty association law.
(c) To a person who, regardless of where the person resides, is
a beneficiary, assignee or payee of the persons covered under
paragraph (a) or (b) of this subsection. This paragraph does not
include a nonresident certificate holder under a group policy or
contract.
(d) To a person who is a payee under a structured settlement
annuity, or to the beneficiary of a payee if the payee is
deceased, if the payee:
(A) Is a resident, regardless of where the contract owner
resides; or
(B) Is not a resident, but only under both of the following
conditions:
(i) The contract owner of the structured settlement annuity is
a resident and is not afforded any coverage by an association in
another state that is similar to the association created under
ORS 734.800, or the contract owner of the structured settlement
annuity is not a resident but the insurer that issued the
structured settlement annuity is domiciled in this state and the
state in which the contract owner resides has an association
similar to the association created under ORS 734.800; and
(ii) Neither the payee or beneficiary nor the contract owner of
the structured settlement annuity is eligible for coverage by the
association of the state in which the payee or contract owner
resides.
(2) Except as limited by ORS 734.750 to 734.890, the
association shall provide coverage to the persons specified in
subsection (1) of this section for direct nongroup life or health
insurance policies or annuity contracts, for certificates under
direct group policies or contracts, and for supplemental
contracts to any of these, in each case issued by member
insurers.
(3) ORS 734.750 to 734.890 do not provide coverage for:
(a) That portion of any policy or contract not guaranteed by
the member insurer or under which the risk is borne by the
policyholder or contract owner.
(b) Any policy or contract or part thereof assumed by the
impaired or insolvent insurer under a contract of reinsurance,
other than reinsurance for which assumption certificates have
been issued.
(c) Any policy or contract issued by a health care service
contractor complying with ORS 750.005 to 750.095.
(d) Any policy or contract issued by a fraternal benefit
society.
(e) Any portion of a policy or contract to the extent that the
interest rate on which the policy or contract is based, or to the
extent that the interest rate, crediting rate or similar factor
determined by use of an index or other external reference stated
in the policy or contract for the purpose of calculating returns
or changes in value:
(A) Exceeds, when averaged over the period of four years prior
to the date on which the member insurer becomes either an
impaired or insolvent insurer under ORS 734.750 to 734.890,
whichever occurs first, a rate of interest determined by
subtracting four percentage points from Moody's Corporate Bond
Yield Average averaged for that same four-year period or for a
lesser period if the policy or contract was issued less than four
years before the member insurer becomes either an impaired or
insolvent insurer under ORS 734.750 to 734.890, whichever
occurred first; and
(B) Exceeds, on and after the date on which the member insurer
becomes either an impaired or insolvent insurer under ORS 734.750
to 734.890, whichever occurs first, the rate of interest
determined by subtracting three percentage points from Moody's
Corporate Bond Yield Average as most recently available.
(f) Any portion of a policy or contract issued to a plan or
program of an employer, association or similar entity to provide
life insurance, health insurance or annuity benefits to its
employees or members to the extent that the plan or program is
self-funded or uninsured, including benefits payable by an
employer, association or similar entity under any of the
following:
(A) A multiple employer welfare arrangement as defined in
section 3(40) (29 U.S.C. 1002(40)) of the Employee Retirement
Income Security Act of 1974, as amended.
(B) A minimum premium group insurance plan.
(C) A stop-loss group insurance plan.
(D) An administrative services only contract.
(g) Any portion of a policy or contract to the extent that it
provides dividends or experience rating credits or voting rights,
or provides that any fees or allowances be paid to any person,
including the policyholder or contract owner, in connection with
the service to or administration of the policy or contract.
(h) Any policy or contract issued in this state by a member
insurer at a time that the insurer did not have a certificate of
authority to issue the policy or contract in this state.
(i) Any unallocated annuity contract issued to or in connection
with an employee benefit plan protected under the federal Pension
Benefit Guaranty Corporation, regardless of whether the federal
Pension Benefit Guaranty Corporation has yet become liable to
make any payments with respect to the benefit plan.
(j) Any portion of any unallocated annuity contract that is not
issued to or in connection with a government retirement plan
referred to in subsection (1) of this section, or a government
lottery.
{ - (k) Any coverage issued by the Oregon Medical Insurance
Pool. - }
{ - (L) - } { + (k) + } Any portion of a policy or contract
to the extent that the assessments required by ORS 734.815 with
respect to the policy or contract are preempted by federal or
state law.
{ - (m) - } { + (L) + } An obligation that does not arise
under the express written terms of the policy or contract issued
by the insurer to the policyholder or contract owner, including
but not limited to:
(A) Claims based on marketing materials;
(B) Claims based on side letters, riders or other documents
that were issued by the insurer without meeting applicable policy
or contract form filing or approval requirements;
(C) Misrepresentations of, or regarding, policy or contract
benefits;
(D) Extracontractual claims, including but not limited to
claims related to bad faith in the payment of claims, punitive or
exemplary damages or attorney fees or costs; or
(E) A claim for penalties or consequential or incidental
damages.
{ - (n) - } { + (m) + } A contractual agreement that
establishes the member insurer's obligations to provide a book
value accounting guaranty for defined contribution benefit plan
participants by reference to a portfolio of assets that is owned
by the benefit plan or its trustee that in either case is not an
affiliate of the member insurer.
{ - (o) - } { + (n) + } Any portion of a policy or contract
to the extent that portion provides for interest or other changes
in value to be determined by the use of an index or other
external reference stated in the policy or contract, but the
changes in value have not been credited to the policy or
contract, or as to which the policyholder's or contract owner's
rights are subject to forfeiture, as of the date on which the
member insurer becomes either an impaired or insolvent insurer,
whichever occurs first. If the interest or changes in value in a
policy or contract are credited less frequently than annually,
for purposes of determining the values that have been credited
and are not subject to forfeiture under this paragraph, the
interest or change in value that is determined by using the
procedures specified in the policy or contract shall be credited
as if the contractual date of crediting interest or changing
value was the date of the impairment or insolvency, whichever is
earlier, and may not be subject to forfeiture.
{ - (p) - } { + (o) + } Any policy or contract providing
any hospital, medical, prescription drug or other health care
benefits under Part C or Part D of subchapter XVIII, chapter 7,
Title 42 of the United States Code, or any regulations issued
under those provisions.
(4) As used in this section, 'Moody's Corporate Bond Yield
Average' means the Monthly Average Corporates as published by
Moody's Investors Service, Inc., or any successor thereto.
SECTION 14. ORS 735.612 is amended to read:
735.612. (1) There is established in the State Treasury, the
Oregon Medical Insurance Pool Account, which shall consist of:
(a) Moneys appropriated to the account by the Legislative
Assembly { - to obtain the coverage described in ORS
735.625 - } .
(b) Interest earnings from the investment of moneys in the
account.
(c) Assessments and other revenues collected or received by the
Oregon Medical Insurance Pool Board.
(2) All moneys in the Oregon Medical Insurance Pool Account are
continuously appropriated to the Oregon Medical Insurance Pool
Board to carry out the provisions of ORS 735.600 to 735.650.
(3) The Oregon Medical Insurance Pool Board shall transfer to
the Oregon Health Authority Fund established in ORS 413.101 an
amount equal to the operating budget authorized by the
Legislative Assembly or as that budget may be modified by the
Emergency Board or the Oregon Department of Administrative
Services, for operation of the Oregon Medical Insurance Pool
Board.
SECTION 15. ORS 735.616 is amended to read:
735.616. (1) An applicant may qualify for portability health
insurance coverage under the Oregon Medical Insurance Pool if:
(a) An application for coverage is made not later than the 63rd
day after the date of first eligibility { + and is made before
December 1, 2013 + }; and
(b) The individual is an Oregon resident at the time of the
application.
(2) In addition to individuals otherwise qualified under ORS
735.615, the following individuals qualify for portability health
insurance coverage under the Oregon Medical Insurance Pool:
(a) An individual who has left coverage that was in effect for
a minimum of 180 consecutive days under one or more group health
benefit plans, if the terminated coverage was in a plan issued or
established in a state other than Oregon;
(b) An eligible individual, as defined in ORS 743.760, who has
left coverage under a group health benefit plan or a portability
health benefit plan and whose carrier cannot offer a portability
plan under ORS 743.760 (6) because of:
(A) A change in residence of the eligible individual within
Oregon;
(B) A change in the geographic area served by the group
carrier; or
(C) The carrier's withdrawal from the group market in Oregon in
accordance with ORS 743.737 and 743.754;
(c) An individual who has left coverage that was in effect for
an uninterrupted period of 180 days or more under one or more
Oregon group health benefit plans and the terminated coverage was
provided by:
(A) An employee welfare benefit plan that is exempt from state
regulation under the federal Employee Retirement Income Security
Act of 1974, as amended;
(B) A multiple employer welfare arrangement subject to ORS
750.301 to 750.341; or
(C) A public body of this state in accordance with ORS 731.036;
and
(d) On or after January 1, 1998, an individual who meets the
eligibility requirements of 42 U.S.C. 300gg-41, as amended and in
effect on January 1, 1998, and does not otherwise qualify to
obtain portability coverage from an Oregon group carrier in
accordance with ORS 743.760.
(3) Eligibility for coverage pursuant to subsections (1) and
(2) of this section is subject to the following provisions:
(a) An eligible individual does not include:
(A) An individual who remains eligible for the individual's
prior group coverage or would remain eligible for prior group
coverage in a plan under the federal Employee Retirement Income
Security Act of 1974, as amended, were it not for action by the
plan sponsor relating to the actual or expected health condition
of the individual;
(B) An individual who is covered under another health benefit
plan at the time that portability coverage would commence;
(C) An individual who is eligible to enroll in another health
benefit plan offered by the employer, other than as a late
enrollee, at the time that portability coverage would commence;
or
(D) An individual who is eligible for the federal Medicare
program.
(b) If an eligible individual has left group coverage issued by
an insurance company, a health care service contractor or a
health maintenance organization, the date of first eligibility is
the day following the termination date of the group coverage,
including any period of continuation coverage that was elected by
the individual under federal law or under ORS 743.600 or 743.610.
(c) If an eligible individual has left group coverage issued by
an entity other than an insurance company, a health care service
contractor or a health maintenance organization, the date of
first eligibility is the day following the termination date of
the group coverage, including the full extent of continuation
coverage available to the individual under federal law and ORS
743.600 and 743.610.
(d) If an individual is eligible for coverage pursuant to
subsection (2)(b) of this section, the date of first eligibility
is the day following the loss of the group or portability
coverage.
(4) Coverage under the Oregon Medical Insurance Pool pursuant
to subsections (1) and (2) of this section shall be offered
according to the following provisions:
(a) Coverage is subject to ORS 743.760 (2) and (8);
(b) Coverage may not be subject to a preexisting conditions
provision, exclusion period, waiting period, residency period or
other similar limitation on coverage; and
(c) The individual shall be required to pay a premium rate not
more than the applicable portability risk rate determined by the
Oregon Medical Insurance Pool Board pursuant to ORS 735.625.
SECTION 16. ORS 735.625 is amended to read:
735.625. (1) Except as provided in subsection (3)(c) of this
section, the Oregon Medical Insurance Pool Board shall offer
major medical expense coverage to every eligible person { +
until December 31, 2013 + }.
(2) The coverage to be issued by the board, its schedule of
benefits, exclusions and other limitations, shall be established
through rules adopted by the board, taking into consideration the
advice and recommendations of the pool members. In the absence of
such rules, the pool shall adopt by rule the minimum benefits
prescribed by section 6 (Alternative 1) of the Model Health
Insurance Pooling Mechanism Act of the National Association of
Insurance Commissioners (1984).
(3)(a) In establishing portability coverage under the pool, the
board shall consider the levels of medical insurance provided in
this state and medical economic factors identified by the board.
The board may adopt rules to establish benefit levels,
deductibles, coinsurance factors, exclusions and limitations that
the board determines are equivalent to the portability health
benefit plans established under ORS 743.760.
(b) In establishing medical insurance coverage under the pool,
the board shall consider the levels of medical insurance provided
in this state and medical economic factors identified by the
board. The board may adopt rules to establish benefit levels,
deductibles, coinsurance factors, exclusions and limitations that
the board determines are equivalent to those found in the
commercial group or employer-based medical insurance market.
(c) The board may provide a separate Medicare supplement policy
for individuals under the age of 65 who are receiving Medicare
disability benefits. The board shall adopt rules to establish
benefits, deductibles, coinsurance, exclusions and limitations,
premiums and eligibility requirements for the Medicare supplement
policy.
(d) In establishing medical insurance coverage for persons
eligible for coverage under ORS 735.615 (1)(d), the board shall
consider the levels of medical insurance provided in this state
and medical economic factors identified by the board. The board
may adopt rules to establish benefit levels, deductibles,
coinsurance factors, exclusions and limitations to create benefit
plans that qualify the person for the credit for health insurance
costs under section 35 of the federal Internal Revenue Code, as
amended and in effect on December 31, 2004.
(4)(a) Premiums charged for coverages issued by the board may
not be unreasonable in relation to the benefits provided, the
risk experience and the reasonable expenses of providing the
coverage.
(b) Separate schedules of premium rates based on age and
geographical location may apply for individual risks.
(c) The board shall determine the applicable medical and
portability risk rates either by calculating the average rate
charged by insurers offering coverages in the state comparable to
the pool coverage or by using reasonable actuarial techniques.
The risk rates shall reflect anticipated experience and expenses
for such coverage. Rates for pool coverage may not be more than
125 percent of rates established as applicable for medically
eligible individuals or for persons eligible for pool coverage
under ORS 735.615 (1)(d), or 100 percent of rates established as
applicable for portability eligible individuals.
(d) The board shall annually determine adjusted benefits and
premiums. The adjustments shall be in keeping with the purposes
of ORS 735.600 to 735.650, subject to a limitation of keeping
pool losses under one percent of the total of all medical
insurance premiums, subscriber contract charges and 110 percent
of all benefits paid by member self-insurance arrangements. The
board may determine the total number of persons that may be
enrolled for coverage at any time and may permit and prohibit
enrollment in order to maintain the number authorized. Nothing in
this paragraph authorizes the board to prohibit enrollment for
any reason other than to control the number of persons in the
pool.
(5)(a) The board may apply:
(A) A waiting period of not more than 90 days during which the
person has no available coverage; or
(B) Except as provided in paragraph (c) of this subsection, a
preexisting conditions provision of not more than six months from
the effective date of coverage under the pool.
(b) In determining whether a preexisting conditions provision
applies to an eligible enrollee, except as provided in this
subsection, the board shall credit the time the eligible enrollee
was covered under a previous health benefit plan if the previous
health benefit plan was continuous to a date not more than 63
days prior to the effective date of the new coverage under the
Oregon Medical Insurance Pool, exclusive of any applicable
waiting period. The Oregon Medical Insurance Pool Board need not
credit the time for previous coverage to which the insured or
dependent is otherwise entitled under this subsection with
respect to benefits and services covered in the pool coverage
that were not covered in the previous coverage.
(c) The board may adopt rules applying a preexisting conditions
provision to a person who is eligible for coverage under ORS
735.615 (1)(d).
(d) For purposes of this subsection, a 'preexisting conditions
provision' means a provision that excludes coverage for services,
charges or expenses incurred during a specified period not to
exceed six months following the insured's effective date of
coverage, for a condition for which medical advice, diagnosis,
care or treatment was recommended or received during the
six-month period immediately preceding the insured's effective
date of coverage.
(6)(a) Benefits otherwise payable under pool coverage shall be
reduced by all amounts paid or payable through any other health
insurance, or self-insurance arrangement, and by all hospital and
medical expense benefits paid or payable under any workers'
compensation coverage, automobile medical payment or liability
insurance whether provided on the basis of fault or nonfault, and
by any hospital or medical benefits paid or payable under or
provided pursuant to any state or federal law or program except
the Medicaid portion of the medical assistance program offering a
level of health services described in ORS 414.707.
(b) The board shall have a cause of action against an eligible
person for the recovery of the amount of benefits paid which are
not for covered expenses. Benefits due from the pool may be
reduced or refused as a setoff against any amount recoverable
under this paragraph.
(7) Except as provided in ORS 735.616, no mandated benefit
statutes apply to pool coverage under ORS 735.600 to 735.650.
(8) Pool coverage may be furnished through a health care
service contractor or such alternative delivery system as will
contain costs while maintaining quality of care.
SECTION 17. ORS 735.645 is amended to read:
735.645. Every insurer shall include a notice of the existence
of the Oregon Medical Insurance Pool in any adverse underwriting
decision { + , issued on or before November 30, 2013, + } on
individual medical insurance for reasons of the health of the
applicant, as described in ORS 735.615 (1)(a).
SECTION 18. ORS 735.650 is amended to read:
735.650. { - (1) - } The following provisions of the
Insurance Code shall apply to the pool to the extent applicable
and not inconsistent with the express provisions of ORS 735.600
to 735.650: ORS 731.004 to 731.022, 731.052 to 731.146, 731.162,
731.216 to 731.328, 742.023, 742.028, 742.046, 742.051, 742.056,
743.024, 743.027, 743.028, 743.041, 743.050, 743.100 to 743.106,
743.402, 743.801, 743.803, 743.804, 743.806, 743.807, 743.808,
743.811, 743.814, 743.817, 743.819, 743.821, 743.823, 743.827,
743.829, 743.834, 743.837, 743.839, 743.845, 743A.084, 743A.090,
746.005 to 746.370, 746.600, 746.605, 746.607, 746.608, 746.610,
746.615, 746.625, 746.635, 746.650, 746.655, 746.660, 746.668,
746.670, 746.675, 746.680 and 746.690.
{ - (2) For the purposes of this section only, the pool shall
be deemed an insurer, pool coverage shall be deemed individual
health insurance and pool coverage contracts shall be deemed
policies. - }
SECTION 19. ORS 743.402 is amended to read:
743.402. Nothing in ORS 743.405 to 743.498, 743A.160 and
743A.164 shall apply to or affect:
(1) Any workers' compensation insurance policy or any liability
insurance policy with or without supplementary expense coverage
therein;
(2) Any policy of reinsurance;
(3) Any blanket or group policy of insurance; or
(4) Any life insurance policy, or policy supplemental thereto
which contains only such provisions relating to health insurance
as:
(a) Provide additional benefits in case of death or
dismemberment or loss of sight by accident; or
(b) Operate to safeguard such policy against lapse, or to give
a special surrender value or special benefit or an annuity in the
event the insured shall become totally and permanently disabled,
as defined by the policy or supplemental policy.
{ - (5) Coverage under ORS 735.600 to 735.650. - }
SECTION 20. ORS 743.730, as amended by section 49, chapter 500,
Oregon Laws 2011, and section 20, chapter 38, Oregon Laws 2012,
is amended to read:
743.730. For purposes of ORS 743.730 to 743.773:
(1) 'Actuarial certification' means a written statement by a
member of the American Academy of Actuaries or other individual
acceptable to the Director of the Department of Consumer and
Business Services that a carrier is in compliance with the
provisions of ORS 743.736, 743.760 or 743.761, based upon the
person's examination, including a review of the appropriate
records and of the actuarial assumptions and methods used by the
carrier in establishing premium rates for small employer and
portability health benefit plans.
(2) 'Affiliate' of, or person 'affiliated' with, a specified
person means any carrier who, directly or indirectly through one
or more intermediaries, controls or is controlled by or is under
common control with a specified person. For purposes of this
definition, 'control' has the meaning given that term in ORS
732.548.
(3) 'Affiliation period' means, under the terms of a group
health benefit plan issued by a health care service contractor, a
period:
(a) That is applied uniformly and without regard to any health
status related factors to an enrollee or late enrollee in lieu of
a preexisting condition exclusion;
(b) That must expire before any coverage becomes effective
under the plan for the enrollee or late enrollee;
(c) During which no premium shall be charged to the enrollee or
late enrollee; and
(d) That begins on the enrollee's or late enrollee's first date
of eligibility for coverage and runs concurrently with any
eligibility waiting period under the plan.
(4) 'Basic health benefit plan' means a health benefit plan
that provides bronze plan coverage and that is approved by the
Department of Consumer and Business Services under ORS 743.736.
(5) 'Bona fide association' means an association that meets the
requirements of 42 U.S.C. 300gg-91 as amended and in effect on
March 23, 2010.
(6) 'Bronze plan' means a health benefit plan that meets the
criteria for a bronze plan prescribed by the director by rule
pursuant to ORS 743.822 (2).
(7) 'Carrier,' except as provided in ORS 743.760, means any
person who provides health benefit plans in this state,
including:
(a) A licensed insurance company;
(b) A health care service contractor;
(c) A health maintenance organization;
(d) An association or group of employers that provides benefits
by means of a multiple employer welfare arrangement and that:
(A) Is subject to ORS 750.301 to 750.341; or
(B) Is fully insured and otherwise exempt under ORS 750.303 (4)
but elects to be governed by ORS 743.733 to 743.737; or
(e) Any other person or corporation responsible for the payment
of benefits or provision of services.
(8) 'Catastrophic plan' means a health benefit plan that meets
the requirements for a catastrophic plan under 42 U.S.C.
18022(e) and that is offered through the Oregon Health Insurance
Exchange.
(9) 'Creditable coverage' means prior health care coverage as
defined in 42 U.S.C. 300gg as amended and in effect on February
17, 2009, and includes coverage remaining in force at the time
the enrollee obtains new coverage.
(10) 'Dependent' means the spouse or child of an eligible
employee, subject to applicable terms of the health benefit plan
covering the employee.
(11) 'Eligible employee' means an employee who works on a
regularly scheduled basis, with a normal work week of 17.5 or
more hours. The employer may determine hours worked for
eligibility between 17.5 and 40 hours per week subject to rules
of the carrier. 'Eligible employee' does not include employees
who work on a temporary, seasonal or substitute basis. Employees
who have been employed by the employer for fewer than 90 days are
not eligible employees unless the employer so allows.
(12) 'Employee' means any individual employed by an employer.
(13) 'Enrollee' means an employee, dependent of the employee or
an individual otherwise eligible for a group, individual or
portability health benefit plan who has enrolled for coverage
under the terms of the plan.
(14) 'Exchange' means the health insurance exchange
administered by the Oregon Health Insurance Exchange Corporation
in accordance with ORS 741.310.
(15) 'Exclusion period' means a period during which specified
treatments or services are excluded from coverage.
(16) 'Financial impairment' means that a carrier is not
insolvent and is:
(a) Considered by the director to be potentially unable to
fulfill its contractual obligations; or
(b) Placed under an order of rehabilitation or conservation by
a court of competent jurisdiction.
(17)(a) 'Geographic average rate' means the arithmetical
average of the lowest premium and the corresponding highest
premium to be charged by a carrier in a geographic area
established by the director for the carrier's:
(A) Group health benefit plans offered to small employers;
(B) Individual health benefit plans; or
(C) Portability health benefit plans.
(b) 'Geographic average rate' does not include premium
differences that are due to differences in benefit design or
family composition.
(18) 'Grandfathered health plan' has the meaning prescribed by
the United States Secretaries of Labor, Health and Human Services
and the Treasury pursuant to 42 U.S.C. 18011(e).
(19) 'Group eligibility waiting period' means, with respect to
a group health benefit plan, the period of employment or
membership with the group that a prospective enrollee must
complete before plan coverage begins.
(20)(a) 'Health benefit plan' means any:
(A) Hospital expense, medical expense or hospital or medical
expense policy or certificate;
(B) Health care service contractor or health maintenance
organization subscriber contract; or
(C) Plan provided by a multiple employer welfare arrangement or
by another benefit arrangement defined in the federal Employee
Retirement Income Security Act of 1974, as amended, to the extent
that the plan is subject to state regulation.
(b) 'Health benefit plan' does not include:
(A) Coverage for accident only, specific disease or condition
only, credit or disability income;
(B) Coverage of Medicare services pursuant to contracts with
the federal government;
(C) Medicare supplement insurance policies;
(D) Coverage of TRICARE services pursuant to contracts with the
federal government;
(E) Benefits delivered through a flexible spending arrangement
established pursuant to section 125 of the Internal Revenue Code
of 1986, as amended, when the benefits are provided in addition
to a group health benefit plan;
(F) Separately offered long term care insurance, including, but
not limited to, coverage of nursing home care, home health care
and community-based care;
(G) Independent, noncoordinated, hospital-only indemnity
insurance or other fixed indemnity insurance;
(H) Short term health insurance policies that are in effect for
periods of 12 months or less, including the term of a renewal of
the policy;
(I) Dental only coverage;
(J) Vision only coverage;
(K) Stop-loss coverage that meets the requirements of ORS
742.065;
(L) Coverage issued as a supplement to liability insurance;
(M) Insurance arising out of a workers' compensation or similar
law;
(N) Automobile medical payment insurance or insurance under
which benefits are payable with or without regard to fault and
that is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance; or
(O) Any employee welfare benefit plan that is exempt from state
regulation because of the federal Employee Retirement Income
Security Act of 1974, as amended.
(c) For purposes of this subsection, renewal of a short term
health insurance policy includes the issuance of a new short term
health insurance policy by an insurer to a policyholder within 60
days after the expiration of a policy previously issued by the
insurer to the policyholder.
(21) 'Health statement' means any information that is intended
to inform the carrier or insurance producer of the health status
of an enrollee or prospective enrollee in a health benefit plan.
'Health statement' includes the standard health statement
approved by the director under ORS 743.745.
(22) 'Individual coverage waiting period' means a period in an
individual health benefit plan during which no premiums may be
collected and health benefit plan coverage issued is not
effective.
(23) 'Initial enrollment period' means a period of at least 30
days following commencement of the first eligibility period for
an individual.
(24) 'Late enrollee' means an individual who enrolls in a group
health benefit plan subsequent to the initial enrollment period
during which the individual was eligible for coverage but
declined to enroll. However, an eligible individual shall not be
considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg as amended and in effect on
February 17, 2009;
(b) The individual applies for coverage during an open
enrollment period;
(c) A court issues an order that coverage be provided for a
spouse or minor child under an employee's employer sponsored
health benefit plan and request for enrollment is made within 30
days after issuance of the court order;
(d) The individual is employed by an employer that offers
multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period;
or
(e) The individual's coverage under Medicaid, Medicare,
TRICARE, Indian Health Service or a publicly sponsored or
subsidized health plan, including, but not limited to, the
medical assistance program under ORS chapter 414, has been
involuntarily terminated within 63 days after applying for
coverage in a group health benefit plan.
(25) 'Minimal essential coverage' has the meaning given that
term in section 5000A(f) of the Internal Revenue Code.
(26) 'Multiple employer welfare arrangement' means a multiple
employer welfare arrangement as defined in section 3 of the
federal Employee Retirement Income Security Act of 1974, as
amended, 29 U.S.C. 1002, that is subject to ORS 750.301 to
750.341.
{ - (27) 'Oregon Medical Insurance Pool' means the pool
created under ORS 735.610. - }
{ - (28) - } { + (27) + } 'Preexisting condition exclusion'
means a health benefit plan provision applicable to an enrollee
or late enrollee that excludes coverage for services, charges or
expenses incurred during a specified period immediately following
enrollment for a condition for which medical advice, diagnosis,
care or treatment was recommended or received during a specified
period immediately preceding enrollment. For purposes of ORS
743.730 to 743.773:
(a) Pregnancy does not constitute a preexisting condition
except as provided in ORS 743.766;
(b) Genetic information does not constitute a preexisting
condition in the absence of a diagnosis of the condition related
to such information; and
(c) Except for coverage under an individual grandfathered
health plan, a preexisting condition exclusion may not exclude
coverage for services, charges or expenses incurred by an
individual who is under 19 years of age.
{ - (29) - } { + (28) + } 'Premium' includes insurance
premiums or other fees charged for a health benefit plan,
including the costs of benefits paid or reimbursements made to or
on behalf of enrollees covered by the plan.
{ - (30) - } { + (29) + } 'Rating period' means the
12-month calendar period for which premium rates established by a
carrier are in effect, as determined by the carrier.
{ - (31) - } { + (30) + } 'Representative' does not include
an insurance producer or an employee or authorized representative
of an insurance producer or carrier.
{ - (32) - } { + (31) + } 'Silver plan' means an individual
or small group health benefit plan that meets the criteria for a
silver plan prescribed by the director by rule pursuant to ORS
743.822 (2).
{ - (33)(a) - } { + (32)(a) + } 'Small employer' means an
employer that employed an average of at least two but not more
than 50 employees on business days during the preceding calendar
year, the majority of whom are employed within this state, and
that employs at least two eligible employees on the date on which
coverage takes effect under a health benefit plan offered by the
employer.
(b) Any person that is treated as a single employer under
subsection (b), (c), (m) or (o) of section 414 of the Internal
Revenue Code of 1986 shall be treated as one employer for
purposes of this subsection.
(c) The determination of whether an employer that was not in
existence throughout the preceding calendar year is a small
employer shall be based on the average number of employees that
it is reasonably expected the employer will employ on business
days in the current calendar year.
SECTION 21. ORS 743.748, as amended by section 18, chapter 500,
Oregon Laws 2011, is amended to read:
743.748. (1) Each carrier offering a health benefit plan shall
submit to the Director of the Department of Consumer and Business
Services on or before April 1 of each year a report that
contains:
(a) The following information for the preceding year that is
derived from the exhibit of premiums, enrollment and utilization
included in the carrier's annual report:
(A) The total number of members;
(B) The total amount of premiums;
(C) The total amount of costs for claims;
(D) The medical loss ratio;
(E) The average amount of premiums per member per month; and
(F) The percentage change in the average premium per member per
month, measured from the previous year.
(b) The following aggregate financial information for the
preceding year that is derived from the carrier's annual report:
(A) The total amount of general administrative expenses,
including identification of the five largest nonmedical
administrative expenses { - and the assessment against the
carrier for the Oregon Medical Insurance Pool - } ;
(B) The total amount of the surplus maintained;
(C) The total amount of the reserves maintained for unpaid
claims;
(D) The total net underwriting gain or loss; and
(E) The carrier's net income after taxes.
(2) A carrier shall electronically submit the information
described in subsection (1) of this section in a format and
according to instructions prescribed by the Department of
Consumer and Business Services by rule.
(3) The department shall evaluate the reporting requirements
under subsection (1)(a) of this section by the following market
segments:
(a) Individual health benefit plans;
(b) Health benefit plans for small employers;
(c) Health benefit plans for employers described in ORS
743.733; and
(d) Health benefit plans for employers with more than 50
employees.
(4) The department shall make the information reported under
this section available to the public through a searchable public
website on the Internet.
SECTION 22. ORS 743.766, as amended by section 4, chapter 24,
Oregon Laws 2012, is amended to read:
743.766. (1) All carriers that offer an individual health
benefit plan and evaluate the health status of individuals for
purposes of eligibility shall use the standard health statement
established under ORS 743.745 and may not use any other method to
determine the health status of an individual. Nothing in this
subsection shall prevent a carrier from using health information
after enrollment for the purpose of providing services or
arranging for the provision of services under a health benefit
plan.
(2)(a) If an individual is accepted for coverage under an
individual health benefit plan, the carrier shall not impose
exclusions or limitations other than:
(A) A preexisting condition exclusion that complies with the
following requirements:
(i) The exclusion applies only to a condition for which medical
advice, diagnosis, care or treatment was recommended or received
during the six-month period immediately preceding the
individual's effective date of coverage;
(ii) The exclusion expires no later than six months after the
individual's effective date of coverage; and
(iii) Except for grandfathered health plans, the exclusion does
not apply to individuals who are under 19 years of age;
(B) An individual coverage waiting period of 90 days; or
(C) An exclusion period for specified covered services
applicable to all individuals enrolling for the first time in the
individual health benefit plan.
(b) Except for grandfathered health plans, pregnancy of
individuals who are under 19 years of age may not constitute a
preexisting condition for purposes of this section.
(3) If the carrier elects to restrict coverage through the
application of a preexisting condition exclusion or an individual
coverage waiting period provision, the carrier shall reduce the
duration of the provision by an amount equal to the individual's
aggregate periods of creditable coverage if the most recent
period of creditable coverage is ongoing or ended within 63 days
after the effective date of coverage in the new individual health
benefit plan. The crediting of prior coverage in accordance with
this subsection shall be applied without regard to the specific
benefits covered during the prior period.
{ - (4) If an eligible prospective enrollee is rejected for
coverage under an individual health benefit plan, the prospective
enrollee shall be eligible to apply for coverage under the Oregon
Medical Insurance Pool. - }
{ - (5) - } { + (4) + } If a carrier accepts an individual
for coverage under an individual health benefit plan, the carrier
shall renew the policy unless:
(a) The policyholder fails to pay the required premiums.
(b) The policyholder or a representative of the policyholder
engages in fraud or makes an intentional misrepresentation of a
material fact as prohibited by the terms of the policy.
(c) The carrier discontinues offering or renewing, or offering
and renewing, all of its individual health benefit plans in this
state or in a specified service area within this state. In order
to discontinue the plans under this paragraph, the carrier:
(A) Must give notice of the decision to the Department of
Consumer and Business Services and to all policyholders covered
by the plans;
(B) May not cancel coverage under the plans for 180 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in the entire state or,
except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel coverage under the plans for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in a specified service area
because of an inability to reach an agreement with the health
care providers or organization of health care providers to
provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and
renewing, all health benefit plans issued by the carrier in the
individual market in this state or in the specified service area.
(d) The carrier discontinues offering and renewing an
individual health benefit plan in a specified service area within
this state because of an inability to reach an agreement with the
health care providers or organization of health care providers to
provide services under the plan within the service area. In order
to discontinue a plan under this paragraph, the carrier:
(A) Must give notice of the decision to the department and to
all policyholders covered by the plan;
(B) May not cancel coverage under the plan for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph; and
(C) Must offer in writing to each policyholder covered by the
plan, all other individual health benefit plans that the carrier
offers in the specified service area. The carrier shall offer the
plans at least 90 days prior to discontinuation.
(e) The carrier discontinues offering or renewing, or offering
and renewing, an individual health benefit plan, other than a
grandfathered health plan, for all individuals in this state or
in a specified service area within this state, other than a plan
discontinued under paragraph (d) of this subsection.
(f) The carrier discontinues renewing or offering and renewing
a grandfathered health plan for all individuals in this state or
in a specified service area within this state, other than a plan
discontinued under paragraph (d) of this subsection.
(g) With respect to plans that are being discontinued under
paragraph (e) or (f) of this subsection, the carrier must:
(A) Offer in writing to each policyholder covered by the plan,
all health benefit plans that the carrier offers to individuals
in the specified service area.
(B) Offer the plans at least 90 days prior to discontinuation.
(C) Act uniformly without regard to the claims experience of
the affected policyholders or the health status of any current or
prospective enrollee.
(h) The Director of the Department of Consumer and Business
Services orders the carrier to discontinue coverage in accordance
with procedures specified or approved by the director upon
finding that the continuation of the coverage would:
(A) Not be in the best interests of the enrollee; or
(B) Impair the carrier's ability to meet its contractual
obligations.
(i) In the case of an individual health benefit plan that
delivers covered services through a specified network of health
care providers, the enrollee no longer lives, resides or works in
the service area of the provider network and the termination of
coverage is not related to the health status of any enrollee.
(j) In the case of a health benefit plan that is offered in the
individual market only through one or more bona fide
associations, the membership of an individual in the association
ceases and the termination of coverage is not related to the
health status of any enrollee.
{ - (6) - } { + (5) + } A carrier may modify an individual
health benefit plan at the time of coverage renewal. The
modification is not a discontinuation of the plan under
subsection { - (5)(c) - } { + (4)(c) + }, (e) and (f) of this
section.
{ - (7) - } { + (6) + } Notwithstanding any other provision
of this section, and subject to the provisions of ORS 743.894 (2)
and (4), a carrier may rescind an individual health benefit plan
if the policyholder or a representative of the policyholder:
(a) Performs an act, practice or omission that constitutes
fraud; or
(b) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the policy.
{ - (8) - } { + (7) + } A carrier that withdraws from the
market for individual health benefit plans must continue to renew
its portability health benefit plans that have been approved
pursuant to ORS 743.761.
{ - (9) - } { + (8) + } A carrier that continues to offer
coverage in the individual market in this state is not required
to offer coverage in all of the carrier's individual health
benefit plans. However, if a carrier elects to continue a plan
that is closed to new individual policyholders instead of
offering alternative coverage in its other individual health
benefit plans, the coverage for all existing policyholders in the
closed plan is renewable in accordance with subsection
{ - (5) - } { + (4) + } of this section.
{ - (10) - } { + (9) + } An individual health benefit plan
may not impose annual or lifetime limits on the dollar amount of
the essential health benefits prescribed by the United States
Secretary of Health and Human Services pursuant to 42 U.S.C.
300gg-11, except as permitted by federal law.
{ - (11) - } { + (10) + } This section does not require a
carrier to actively market, offer, issue or accept applications
for a grandfathered health plan or from an individual not
eligible for coverage under such a plan as provided by the
Patient Protection and Affordable Care Act (P.L. 111-148) as
amended by the Health Care and Education Reconciliation Act (P.L.
111-152).
SECTION 23. ORS 743.767 is amended to read:
743.767. Premium rates for individual health benefit plans
shall be subject to the following provisions:
(1) Each carrier must file the carrier's initial geographic
average rate and any changes to the geographic average rate for
its individual health benefit plans with the Director of the
Department of Consumer and Business Services.
(2) The premium rates charged during a rating period for
individual health benefit plans issued to individuals shall not
vary from the individual geographic average rate, except that the
premium rate may be adjusted to reflect differences in benefit
design, family composition and age. For age adjustments to the
individual plans, a carrier shall apply uniformly its schedule of
age adjustments for individual health benefit plans as approved
by the director.
(3) A carrier may not increase the rates of an individual
health benefit plan more than once in a 12-month period except as
approved by the director. Annual rate increases shall be
effective on the anniversary date of the individual health
benefit plan's issuance. The percentage increase in the premium
rate charged for an individual health benefit plan for a new
rating period may not exceed the sum of the following:
(a) The percentage change in the carrier's geographic average
rate for its individual health benefit plan measured from the
first day of the prior rating period to the first day of the new
period; and
(b) Any adjustment attributable to changes in age and
differences in benefit design and family composition.
{ - (4) Notwithstanding any other provision of this section,
a carrier that imposes an individual coverage waiting period
pursuant to ORS 743.766 may impose a monthly premium rate
surcharge for a period not to exceed six months and in an amount
not to exceed the percentage by which the rates for coverage
under the Oregon Medical Insurance Pool exceed the rates
established by the Oregon Medical Insurance Pool Board as
applicable for individual risks under ORS 735.625. The surcharge
shall be approved by the Director of the Department of Consumer
and Business Services and, in combination with the waiting
period, shall not exceed the actuarial value of a six-month
preexisting condition exclusion. - }
SECTION 24. ORS 746.600 is amended to read:
746.600. As used in ORS 746.600 to 746.690:
(1)(a) 'Adverse underwriting decision' means any of the
following actions with respect to insurance transactions
involving insurance coverage that is individually underwritten:
(A) A declination of insurance coverage.
(B) A termination of insurance coverage.
(C) Failure of an insurance producer to apply for insurance
coverage with a specific insurer that the insurance producer
represents and that is requested by an applicant.
(D) In the case of life or health insurance coverage, an offer
to insure at higher than standard rates.
(E) In the case of insurance coverage other than life or health
insurance coverage:
(i) Placement by an insurer or insurance producer of a risk
with a residual market mechanism, an unauthorized insurer or an
insurer that specializes in substandard risks.
(ii) The charging of a higher rate on the basis of information
that differs from that which the applicant or policyholder
furnished.
(iii) An increase in any charge imposed by the insurer for any
personal insurance in connection with the underwriting of
insurance. For purposes of this sub-subparagraph, the imposition
of a service fee is not a charge.
(b) 'Adverse underwriting decision' does not mean any of the
following actions, but the insurer or insurance producer
responsible for the occurrence of the action must nevertheless
provide the applicant or policyholder with the specific reason or
reasons for the occurrence:
(A) The termination of an individual policy form on a class or
statewide basis.
(B) A declination of insurance coverage solely because the
coverage is not available on a class or statewide basis.
(C) The rescission of a policy.
(2) 'Affiliate of' a specified person or 'person affiliated
with' a specified person means a person who directly, or
indirectly, through one or more intermediaries, controls, or is
controlled by, or is under common control with, the person
specified.
(3) 'Applicant' means a person who seeks to contract for
insurance coverage, other than a person seeking group insurance
coverage that is not individually underwritten.
(4) 'Consumer' means an individual, or the personal
representative of the individual, who seeks to obtain, obtains or
has obtained one or more insurance products or services from a
licensee that are to be used primarily for personal, family or
household purposes, and about whom the licensee has personal
information.
(5) 'Consumer report' means any written, oral or other
communication of information bearing on a natural person's
creditworthiness, credit standing, credit capacity, character,
general reputation, personal characteristics or mode of living
that is used or expected to be used in connection with an
insurance transaction.
(6) 'Consumer reporting agency' means a person that, for
monetary fees or dues, or on a cooperative or nonprofit basis:
(a) Regularly engages, in whole or in part, in assembling or
preparing consumer reports;
(b) Obtains information primarily from sources other than
insurers; and
(c) Furnishes consumer reports to other persons.
(7) 'Control' means, and the terms 'controlled by' or ' under
common control with' refer to, the possession, directly or
indirectly, of the power to direct or cause the direction of the
management and policies of a person, whether through the
ownership of voting securities, by contract other than a
commercial contract for goods or nonmanagement services, or
otherwise, unless the power of the person is the result of a
corporate office held in, or an official position held with, the
controlled person.
(8) 'Covered entity' means:
(a) A health insurer;
(b) A health care provider that transmits any health
information in electronic form to carry out financial or
administrative activities in connection with a transaction
covered by ORS 746.607 or by rules adopted under ORS 746.608; or
(c) A health care clearinghouse.
(9) 'Credit history' means any written or other communication
of any information by a consumer reporting agency that:
(a) Bears on a consumer's creditworthiness, credit standing or
credit capacity; and
(b) Is used or expected to be used, or collected in whole or in
part, as a factor in determining eligibility, premiums or rates
for personal insurance.
(10) 'Customer' means a consumer who has a continuing
relationship with a licensee under which the licensee provides
one or more insurance products or services to the consumer that
are to be used primarily for personal, family or household
purposes.
(11) 'Declination of insurance coverage' or 'decline coverage'
means a denial, in whole or in part, by an insurer or insurance
producer of an application for requested insurance coverage.
(12) 'Health care' means care, services or supplies related to
the health of an individual.
(13) 'Health care operations' includes but is not limited to:
(a) Quality assessment, accreditation, auditing and improvement
activities;
(b) Case management and care coordination;
(c) Reviewing the competence, qualifications or performance of
health care providers or health insurers;
(d) Underwriting activities;
(e) Arranging for legal services;
(f) Business planning;
(g) Customer services;
(h) Resolving internal grievances;
(i) Creating deidentified information; and
(j) Fundraising.
(14) 'Health care provider' includes but is not limited to:
(a) A psychologist, occupational therapist, regulated social
worker, professional counselor or marriage and family therapist
licensed or otherwise authorized to practice under ORS chapter
675 or an employee of the psychologist, occupational therapist,
regulated social worker, professional counselor or marriage and
family therapist;
(b) A physician, podiatric physician and surgeon, physician
assistant or acupuncturist licensed under ORS chapter 677 or an
employee of the physician, podiatric physician and surgeon,
physician assistant or acupuncturist;
(c) A nurse or nursing home administrator licensed under ORS
chapter 678 or an employee of the nurse or nursing home
administrator;
(d) A dentist licensed under ORS chapter 679 or an employee of
the dentist;
(e) A dental hygienist or denturist licensed under ORS chapter
680 or an employee of the dental hygienist or denturist;
(f) A speech-language pathologist or audiologist licensed under
ORS chapter 681 or an employee of the speech-language pathologist
or audiologist;
(g) An emergency medical services provider licensed under ORS
chapter 682;
(h) An optometrist licensed under ORS chapter 683 or an
employee of the optometrist;
(i) A chiropractic physician licensed under ORS chapter 684 or
an employee of the chiropractic physician;
(j) A naturopathic physician licensed under ORS chapter 685 or
an employee of the naturopathic physician;
(k) A massage therapist licensed under ORS 687.011 to 687.250
or an employee of the massage therapist;
(L) A direct entry midwife licensed under ORS 687.405 to
687.495 or an employee of the direct entry midwife;
(m) A physical therapist licensed under ORS 688.010 to 688.201
or an employee of the physical therapist;
(n) A medical imaging licensee under ORS 688.405 to 688.605 or
an employee of the medical imaging licensee;
(o) A respiratory care practitioner licensed under ORS 688.815
or an employee of the respiratory care practitioner;
(p) A polysomnographic technologist licensed under ORS 688.819
or an employee of the polysomnographic technologist;
(q) A pharmacist licensed under ORS chapter 689 or an employee
of the pharmacist;
(r) A dietitian licensed under ORS 691.405 to 691.485 or an
employee of the dietitian;
(s) A funeral service practitioner licensed under ORS chapter
692 or an employee of the funeral service practitioner;
(t) A health care facility as defined in ORS 442.015;
(u) A home health agency as defined in ORS 443.005;
(v) A hospice program as defined in ORS 443.850;
(w) A clinical laboratory as defined in ORS 438.010;
(x) A pharmacy as defined in ORS 689.005;
(y) A diabetes self-management program as defined in ORS
743.694; and
(z) Any other person or entity that furnishes, bills for or is
paid for health care in the normal course of business.
(15) 'Health information' means any oral or written information
in any form or medium that:
(a) Is created or received by a covered entity, a public health
authority, a life insurer, a school, a university or a health
care provider that is not a covered entity; and
(b) Relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(16) 'Health insurer' means { - : - }
{ - (a) - } an insurer who offers:
{ - (A) - } { + (a) + } A health benefit plan as defined in
ORS 743.730;
{ - (B) - } { + (b) + } A short term health insurance
policy, the duration of which does not exceed six months
including renewals;
{ - (C) - } { + (c) + } A student health insurance policy;
{ - (D) - } { + (d) + } A Medicare supplemental policy; or
{ - (E) - } { + (e) + } A dental only policy.
{ - (b) The Oregon Medical Insurance Pool operated by the
Oregon Medical Insurance Pool Board under ORS 735.600 to
735.650. - }
(17) 'Homeowner insurance' means insurance for residential
property consisting of a combination of property insurance and
casualty insurance that provides coverage for the risks of owning
or occupying a dwelling and that is not intended to cover an
owner's interest in rental property or commercial exposures.
(18) 'Individual' means a natural person who:
(a) In the case of life or health insurance, is a past, present
or proposed principal insured or certificate holder;
(b) In the case of other kinds of insurance, is a past, present
or proposed named insured or certificate holder;
(c) Is a past, present or proposed policyowner;
(d) Is a past or present applicant;
(e) Is a past or present claimant; or
(f) Derived, derives or is proposed to derive insurance
coverage under an insurance policy or certificate that is subject
to ORS 746.600 to 746.690.
(19) 'Individually identifiable health information' means any
oral or written health information that is:
(a) Created or received by a covered entity or a health care
provider that is not a covered entity; and
(b) Identifiable to an individual, including demographic
information that identifies the individual, or for which there is
a reasonable basis to believe the information can be used to
identify an individual, and that relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(20) 'Institutional source' means a person or governmental
entity that provides information about an individual to an
insurer, insurance producer or insurance-support organization,
other than:
(a) An insurance producer;
(b) The individual who is the subject of the information; or
(c) A natural person acting in a personal capacity rather than
in a business or professional capacity.
(21) 'Insurance producer' or 'producer' means a person licensed
by the Director of the Department of Consumer and Business
Services as a resident or nonresident insurance producer.
(22) 'Insurance score' means a number or rating that is derived
from an algorithm, computer application, model or other process
that is based in whole or in part on credit history.
(23)(a) 'Insurance-support organization' means a person who
regularly engages, in whole or in part, in assembling or
collecting information about natural persons for the primary
purpose of providing the information to an insurer or insurance
producer for insurance transactions, including:
(A) The furnishing of consumer reports to an insurer or
insurance producer for use in connection with insurance
transactions; and
(B) The collection of personal information from insurers,
insurance producers or other insurance-support organizations for
the purpose of detecting or preventing fraud, material
misrepresentation or material nondisclosure in connection with
insurance underwriting or insurance claim activity.
(b) 'Insurance-support organization' does not mean insurers,
insurance producers, governmental institutions or health care
providers.
(24) 'Insurance transaction' means any transaction that
involves insurance primarily for personal, family or household
needs rather than business or professional needs and that
entails:
(a) The determination of an individual's eligibility for an
insurance coverage, benefit or payment; or
(b) The servicing of an insurance application, policy or
certificate.
(25) 'Insurer' has the meaning given that term in ORS 731.106.
(26) 'Investigative consumer report' means a consumer report,
or portion of a consumer report, for which information about a
natural person's character, general reputation, personal
characteristics or mode of living is obtained through personal
interviews with the person's neighbors, friends, associates,
acquaintances or others who may have knowledge concerning such
items of information.
(27) 'Licensee' means an insurer, insurance producer or other
person authorized or required to be authorized, or licensed or
required to be licensed, pursuant to the Insurance Code.
(28) 'Loss history report' means a report provided by, or a
database maintained by, an insurance-support organization or
consumer reporting agency that contains information regarding the
claims history of the individual property that is the subject of
the application for a homeowner insurance policy or the consumer
applying for a homeowner insurance policy.
(29) 'Nonaffiliated third party' means any person except:
(a) An affiliate of a licensee;
(b) A person that is employed jointly by a licensee and by a
person that is not an affiliate of the licensee; and
(c) As designated by the director by rule.
(30) 'Payment' includes but is not limited to:
(a) Efforts to obtain premiums or reimbursement;
(b) Determining eligibility or coverage;
(c) Billing activities;
(d) Claims management;
(e) Reviewing health care to determine medical necessity;
(f) Utilization review; and
(g) Disclosures to consumer reporting agencies.
(31)(a) 'Personal financial information' means:
(A) Information that is identifiable with an individual,
gathered in connection with an insurance transaction from which
judgments can be made about the individual's character, habits,
avocations, finances, occupations, general reputation, credit or
any other personal characteristics; or
(B) An individual's name, address and policy number or similar
form of access code for the individual's policy.
(b) 'Personal financial information' does not mean information
that a licensee has a reasonable basis to believe is lawfully
made available to the general public from federal, state or local
government records, widely distributed media or disclosures to
the public that are required by federal, state or local law.
(32) 'Personal information' means:
(a) Personal financial information;
(b) Individually identifiable health information; or
(c) Protected health information.
(33) 'Personal insurance' means the following types of
insurance products or services that are to be used primarily for
personal, family or household purposes:
(a) Private passenger automobile coverage;
(b) Homeowner, mobile homeowners, manufactured homeowners,
condominium owners and renters coverage;
(c) Personal dwelling property coverage;
(d) Personal liability and theft coverage, including excess
personal liability and theft coverage; and
(e) Personal inland marine coverage.
(34) 'Personal representative' includes but is not limited to:
(a) A person appointed as a guardian under ORS 125.305,
419B.370, 419C.481 or 419C.555 with authority to make medical and
health care decisions;
(b) A person appointed as a health care representative under
ORS 127.505 to 127.660 or 127.700 to 127.737 to make health care
decisions or mental health treatment decisions;
(c) A person appointed as a personal representative under ORS
chapter 113; and
(d) A person described in ORS 746.611.
(35) 'Policyholder' means a person who:
(a) In the case of individual policies of life or health
insurance, is a current policyowner;
(b) In the case of individual policies of other kinds of
insurance, is currently a named insured; or
(c) In the case of group policies of insurance under which
coverage is individually underwritten, is a current certificate
holder.
(36) 'Pretext interview' means an interview wherein the
interviewer, in an attempt to obtain personal information about a
natural person, does one or more of the following:
(a) Pretends to be someone the interviewer is not.
(b) Pretends to represent a person the interviewer is not in
fact representing.
(c) Misrepresents the true purpose of the interview.
(d) Refuses upon request to identify the interviewer.
(37) 'Privileged information' means information that is
identifiable with an individual and that:
(a) Relates to a claim for insurance benefits or a civil or
criminal proceeding involving the individual; and
(b) Is collected in connection with or in reasonable
anticipation of a claim for insurance benefits or a civil or
criminal proceeding involving the individual.
(38)(a) 'Protected health information' means individually
identifiable health information that is transmitted or maintained
in any form of electronic or other medium by a covered entity.
(b) 'Protected health information' does not mean individually
identifiable health information in:
(A) Education records covered by the federal Family Educational
Rights and Privacy Act (20 U.S.C. 1232g);
(B) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); or
(C) Employment records held by a covered entity in its role as
employer.
(39) 'Residual market mechanism' means an association,
organization or other entity involved in the insuring of risks
under ORS 735.005 to 735.145, 737.312 or other provisions of the
Insurance Code relating to insurance applicants who are unable to
procure insurance through normal insurance markets.
(40) 'Termination of insurance coverage' or 'termination of an
insurance policy' means either a cancellation or a nonrenewal of
an insurance policy, in whole or in part, for any reason other
than the failure of a premium to be paid as required by the
policy.
(41) 'Treatment' includes but is not limited to:
(a) The provision, coordination or management of health care;
and
(b) Consultations and referrals between health care providers.
{ +
TERMINATION OF TEMPORARY HIGH + }
{ +
RISK POOL PROGRAM + }
SECTION 25. Section 5, chapter 47, Oregon Laws 2010, is amended
to read:
{ + Sec. 5. + } Sections 1 to 3 { - of this 2010 Act - }
{ + , chapter 47, Oregon Laws 2010, + } are repealed on
{ - January 2, 2016 - } { + January 1, 2014 + }.
{ +
ABOLISHMENT OF OREGON + }
{ +
MEDICAL INSURANCE POOL BOARD + }
SECTION 26. { + The Oregon Medical Insurance Pool and the
Oregon Medical Insurance Pool Account are abolished. On the
operative date of this section, the tenure of office of the
members of the Oregon Medical Insurance Pool Board ceases. + }
SECTION 27. { + Before the operative date of section 26 of
this 2013 Act, the Oregon Medical Insurance Pool Board shall pay
all valid outstanding claims against the Oregon Medical Insurance
Pool. Any balances of amounts remaining in the Oregon Medical
Insurance Pool Account after the payment of claims shall be
refunded to insurers in a manner determined by the board to be
fair and equitable. + }
SECTION 28. { + (1) Nothing in section 26 or 27 of this 2013
Act, the amendments to statutes and session law by sections 9 to
25, 29 to 33, 35 and 36 of this 2013 Act or the repeal of
statutes and session law by section 39 of this 2013 Act relieves
a person of a liability, duty or obligation accruing under or
with respect to the duties, functions and powers of the Oregon
Medical Insurance Pool Board. The Oregon Health Authority may
undertake the collection or enforcement of any such liability,
duty or obligation.
(2) The rights and obligations of the board legally incurred
under contracts, leases and business transactions executed,
entered into or begun before the operative date of section 26 of
this 2013 Act are transferred to the authority. For the purpose
of succession to these rights and obligations, the authority is a
continuation of the board and not a new authority.
(3) Notwithstanding the abolishment of the Oregon Medical
Insurance Pool by section 26 of this 2013 Act, the rules of the
board in effect on the effective date of this 2013 Act continue
in effect until superseded or repealed by rules of the authority.
References in rules of the board to the board or an officer or
employee of the board are considered to be references to the
authority or an officer or employee of the authority.
(4) Whenever, in any statutory law or resolution of the
Legislative Assembly or in any rule, document, record or
proceeding authorized by the Legislative Assembly, reference is
made to the board or an officer or employee of the board, the
reference is considered to be a reference to the authority or an
officer or employee of the authority. + }
SECTION 29. ORS 65.957 is amended to read:
65.957. (1) This chapter applies to all domestic corporations
in existence on October 3, 1989, that were incorporated under any
general statute of this state providing for incorporation of
nonprofit corporations if power to amend or repeal the statute
under which the corporation was incorporated was reserved.
(2) Without limitation as to any other corporations that may be
outside the scope of subsection (1) of this section, this chapter
does not apply to the following:
(a) The Oregon State Bar and the Oregon State Bar Professional
Liability Fund created under ORS 9.005 to 9.755;
(b) The State Accident Insurance Fund Corporation created under
ORS chapter 656;
(c) The Oregon Insurance Guaranty Association and the Oregon
Life and Health Insurance Guaranty Association created under ORS
chapter 734; and
(d) The Oregon FAIR Plan Association { - and the Oregon
Medical Insurance Pool - } created under ORS { - chapter
735 - } { + 735.045 + }.
SECTION 30. ORS 192.556 is amended to read:
192.556. As used in ORS 192.553 to 192.581:
(1) 'Authorization' means a document written in plain language
that contains at least the following:
(a) A description of the information to be used or disclosed
that identifies the information in a specific and meaningful way;
(b) The name or other specific identification of the person or
persons authorized to make the requested use or disclosure;
(c) The name or other specific identification of the person or
persons to whom the covered entity may make the requested use or
disclosure;
(d) A description of each purpose of the requested use or
disclosure, including but not limited to a statement that the use
or disclosure is at the request of the individual;
(e) An expiration date or an expiration event that relates to
the individual or the purpose of the use or disclosure;
(f) The signature of the individual or personal representative
of the individual and the date;
(g) A description of the authority of the personal
representative, if applicable; and
(h) Statements adequate to place the individual on notice of
the following:
(A) The individual's right to revoke the authorization in
writing;
(B) The exceptions to the right to revoke the authorization;
(C) The ability or inability to condition treatment, payment,
enrollment or eligibility for benefits on whether the individual
signs the authorization; and
(D) The potential for information disclosed pursuant to the
authorization to be subject to redisclosure by the recipient and
no longer protected.
(2) 'Covered entity' means:
(a) A state health plan;
(b) A health insurer;
(c) A health care provider that transmits any health
information in electronic form to carry out financial or
administrative activities in connection with a transaction
covered by ORS 192.553 to 192.581; or
(d) A health care clearinghouse.
(3) 'Health care' means care, services or supplies related to
the health of an individual.
(4) 'Health care operations' includes but is not limited to:
(a) Quality assessment, accreditation, auditing and improvement
activities;
(b) Case management and care coordination;
(c) Reviewing the competence, qualifications or performance of
health care providers or health insurers;
(d) Underwriting activities;
(e) Arranging for legal services;
(f) Business planning;
(g) Customer services;
(h) Resolving internal grievances;
(i) Creating deidentified information; and
(j) Fundraising.
(5) 'Health care provider' includes but is not limited to:
(a) A psychologist, occupational therapist, regulated social
worker, professional counselor or marriage and family therapist
licensed or otherwise authorized to practice under ORS chapter
675 or an employee of the psychologist, occupational therapist,
regulated social worker, professional counselor or marriage and
family therapist;
(b) A physician, podiatric physician and surgeon, physician
assistant or acupuncturist licensed under ORS chapter 677 or an
employee of the physician, podiatric physician and surgeon,
physician assistant or acupuncturist;
(c) A nurse or nursing home administrator licensed under ORS
chapter 678 or an employee of the nurse or nursing home
administrator;
(d) A dentist licensed under ORS chapter 679 or an employee of
the dentist;
(e) A dental hygienist or denturist licensed under ORS chapter
680 or an employee of the dental hygienist or denturist;
(f) A speech-language pathologist or audiologist licensed under
ORS chapter 681 or an employee of the speech-language pathologist
or audiologist;
(g) An emergency medical services provider licensed under ORS
chapter 682;
(h) An optometrist licensed under ORS chapter 683 or an
employee of the optometrist;
(i) A chiropractic physician licensed under ORS chapter 684 or
an employee of the chiropractic physician;
(j) A naturopathic physician licensed under ORS chapter 685 or
an employee of the naturopathic physician;
(k) A massage therapist licensed under ORS 687.011 to 687.250
or an employee of the massage therapist;
(L) A direct entry midwife licensed under ORS 687.405 to
687.495 or an employee of the direct entry midwife;
(m) A physical therapist licensed under ORS 688.010 to 688.201
or an employee of the physical therapist;
(n) A medical imaging licensee under ORS 688.405 to 688.605 or
an employee of the medical imaging licensee;
(o) A respiratory care practitioner licensed under ORS 688.815
or an employee of the respiratory care practitioner;
(p) A polysomnographic technologist licensed under ORS 688.819
or an employee of the polysomnographic technologist;
(q) A pharmacist licensed under ORS chapter 689 or an employee
of the pharmacist;
(r) A dietitian licensed under ORS 691.405 to 691.485 or an
employee of the dietitian;
(s) A funeral service practitioner licensed under ORS chapter
692 or an employee of the funeral service practitioner;
(t) A health care facility as defined in ORS 442.015;
(u) A home health agency as defined in ORS 443.005;
(v) A hospice program as defined in ORS 443.850;
(w) A clinical laboratory as defined in ORS 438.010;
(x) A pharmacy as defined in ORS 689.005;
(y) A diabetes self-management program as defined in ORS
743A.184; and
(z) Any other person or entity that furnishes, bills for or is
paid for health care in the normal course of business.
(6) 'Health information' means any oral or written information
in any form or medium that:
(a) Is created or received by a covered entity, a public health
authority, an employer, a life insurer, a school, a university or
a health care provider that is not a covered entity; and
(b) Relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(7) 'Health insurer' means { - : - }
{ - (a) - } an insurer as defined in ORS 731.106 who offers:
{ - (A) - } { + (a) + } A health benefit plan as defined in
ORS 743.730;
{ - (B) - } { + (b) + } A short term health insurance
policy, the duration of which does not exceed six months
including renewals;
{ - (C) - } { + (c) + } A student health insurance policy;
{ - (D) - } { + (d) + } A Medicare supplemental policy; or
{ - (E) - } { + (e) + } A dental only policy.
{ - (b) The Oregon Medical Insurance Pool operated by the
Oregon Medical Insurance Pool Board under ORS 735.600 to
735.650. - }
(8) 'Individually identifiable health information' means any
oral or written health information in any form or medium that is:
(a) Created or received by a covered entity, an employer or a
health care provider that is not a covered entity; and
(b) Identifiable to an individual, including demographic
information that identifies the individual, or for which there is
a reasonable basis to believe the information can be used to
identify an individual, and that relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(9) 'Payment' includes but is not limited to:
(a) Efforts to obtain premiums or reimbursement;
(b) Determining eligibility or coverage;
(c) Billing activities;
(d) Claims management;
(e) Reviewing health care to determine medical necessity;
(f) Utilization review; and
(g) Disclosures to consumer reporting agencies.
(10) 'Personal representative' includes but is not limited to:
(a) A person appointed as a guardian under ORS 125.305,
419B.370, 419C.481 or 419C.555 with authority to make medical and
health care decisions;
(b) A person appointed as a health care representative under
ORS 127.505 to 127.660 or a representative under ORS 127.700 to
127.737 to make health care decisions or mental health treatment
decisions;
(c) A person appointed as a personal representative under ORS
chapter 113; and
(d) A person described in ORS 192.573.
(11)(a) 'Protected health information' means individually
identifiable health information that is maintained or transmitted
in any form of electronic or other medium by a covered entity.
(b) 'Protected health information' does not mean individually
identifiable health information in:
(A) Education records covered by the federal Family Educational
Rights and Privacy Act (20 U.S.C. 1232g);
(B) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); or
(C) Employment records held by a covered entity in its role as
employer.
(12) 'State health plan' means:
(a) Medical assistance as defined in ORS 414.025;
(b) The Health Care for All Oregon Children program;
(c) The Family Health Insurance Assistance Program established
in ORS 414.841 to 414.864; or
(d) Any medical assistance or premium assistance program
operated by the Oregon Health Authority.
(13) 'Treatment' includes but is not limited to:
(a) The provision, coordination or management of health care;
and
(b) Consultations and referrals between health care providers.
SECTION 31. ORS 744.704 is amended to read:
744.704. (1) The following persons are exempt from the
licensing requirement for third party administrators in ORS
744.702 and from all other provisions of ORS 744.700 to 744.740
applicable to third party administrators:
(a) A person licensed under ORS 744.002 as an adjuster, whose
activities are limited to adjustment of claims and whose
activities do not include the activities of a third party
administrator.
(b) A person licensed as an insurance producer as required by
ORS 744.053 and authorized to transact life or health insurance
in this state, whose activities are limited exclusively to the
sale of insurance and whose activities do not include the
activities of a third party administrator.
(c) An employer acting as a third party administrator on behalf
of:
(A) Its employees;
(B) The employees of one or more subsidiary or affiliated
corporations of the employer; or
(C) The employees of one or more persons with a dealership,
franchise, distributorship or other similar arrangement with the
employers.
(d) A union, or an affiliate thereof, acting as a third party
administrator on behalf of its members.
(e) An insurer that is authorized to transact insurance in this
state with respect to a policy issued and delivered in and
pursuant to the laws of this state or another state.
(f) A creditor acting on behalf of its debtors with respect to
insurance covering a debt between the creditor and its debtors.
(g) A trust and the trustees, agents and employees of the
trust, when acting pursuant to the trust, if the trust is
established in conformity with 29 U.S.C. 186.
(h) A trust exempt from taxation under section 501(a) of the
Internal Revenue Code, its trustees and employees acting pursuant
to the trust, or a voluntary employees beneficiary association
described in section 501(c) of the Internal Revenue Code, its
agents and employees and a custodian and the custodian's agents
and employees acting pursuant to a custodian account meeting the
requirements of section 401(f) of the Internal Revenue Code.
(i) A financial institution that is subject to supervision or
examination by federal or state financial institution regulatory
authorities, or a mortgage lender, to the extent the financial
institution or mortgage lender collects and remits premiums to
licensed insurance producers or authorized insurers in connection
with loan payments.
(j) A company that issues credit cards and advances for and
collects premiums or charges from its credit card holders who
have authorized collection. The exemption under this paragraph
applies only if the company does not adjust or settle claims.
(k) A person who adjusts or settles claims in the normal course
of practice or employment as an attorney at law. The exemption
under this subsection applies only if the person does not collect
charges or premiums in connection with life insurance or health
insurance coverage.
(L) A person who acts solely as an administrator of one or more
bona fide employee benefit plans established by an employer or an
employee organization, or both, for which the Insurance Code is
preempted pursuant to the Employee Retirement Income Security Act
of 1974. A person to whom this paragraph applies must comply with
the requirements of ORS 744.714.
{ - (m) The Oregon Medical Insurance Pool Board, established
under ORS 735.600 to 735.650, and the administering insurer or
insurers for the board, for services provided pursuant to ORS
735.600 to 735.650. - }
{ - (n) - } { + (m) + } An entity or association owned by
or composed of like employers who administer partially or fully
self-insured plans for employees of the employers or association
members.
{ - (o) - } { + (n) + } A trust established by a
cooperative body formed between cities, counties, districts or
other political subdivisions of this state, or between any
combination of such entities, and the trustees, agents and
employees acting pursuant to the trust.
{ - (p) - } { + (o) + } Any person designated by the
Director of the Department of Consumer and Business Services by
rule.
(2) A third party administrator is not required to be licensed
as a third party administrator in this state if the following
conditions are met:
(a) The third party administrator has its principal place of
business in another state;
(b) The third party administrator is not soliciting business as
a third party administrator in this state; and
(c) In the case of any group policy or plan of insurance
serviced by the third party administrator, the lesser of five
percent or 100 certificate holders reside in this state.
SECTION 32. ORS 748.603 is amended to read:
748.603. (1) Societies are governed by this chapter and are
exempt from all other provisions of the insurance laws of this
state unless expressly designated therein, or unless specifically
made applicable by this chapter.
(2) ORS 705.137, 705.139, 731.004 to 731.026, 731.036 to
731.136, 731.146 to 731.156, 731.162, 731.166, 731.170, 731.216
to 731.268, 731.296, 731.324, 731.328, 731.354, 731.356, 731.358,
731.378, 731.380, 731.381, 731.382, 731.385, 731.386, 731.390,
731.394, 731.396, 731.398, 731.402, 731.406, 731.410, 731.422 to
731.434, 731.446 to 731.454, 731.488, 731.504, 731.508, 731.509,
731.510, 731.511, 731.512, 731.592, 731.594, 731.730, 731.731,
731.735, 731.737, 731.750, 731.804, 731.844 to 731.992, 731.870,
732.245, 732.250, 732.320, 732.325, 733.010 to 733.050, 733.080,
733.140 to 733.210, 733.220, 733.510, 733.652 to 733.658, 733.730
to 733.750, { - 735.600 to 735.650, - } 742.001, 742.003,
742.005, 742.007, 742.009, 742.013 to 742.021, 742.028, 742.038,
742.041, 742.046, 742.051, 742.150 to 742.162 and 744.700 to
744.740 and ORS chapters 734, 743 and 743A apply to fraternal
benefit societies to the extent not inconsistent with the express
provisions of this chapter.
(3) For the purposes of this subsection and subsection (2) of
this section, fraternal benefit societies shall be deemed
insurers, and benefit certificates issued by fraternal benefit
societies shall be deemed policies.
(4) Every society authorized to do business in this state shall
be subject to the provisions of ORS chapter 746 relating to
unfair trade practices. However, nothing in ORS chapter 746 shall
be construed as applying to or affecting the right of any society
to determine its eligibility requirements for membership, or be
construed as applying to or affecting the offering of benefits
exclusively to members or persons eligible for membership in the
society by a subsidiary corporation or affiliated organization of
the society.
SECTION 33. ORS 750.055, as amended by section 3, chapter 21,
Oregon Laws 2012, is amended to read:
750.055. (1) The following provisions of the Insurance Code
apply to health care service contractors to the extent not
inconsistent with the express provisions of ORS 750.005 to
750.095:
(a) ORS 705.137, 705.139, 731.004 to 731.150, 731.162, 731.216
to 731.362, 731.382, 731.385, 731.386, 731.390, 731.398 to
731.430, 731.428, 731.450, 731.454, 731.488, 731.504, 731.508,
731.509, 731.510, 731.511, 731.512, 731.574 to 731.620, 731.592,
731.594, 731.640 to 731.652, 731.730, 731.731, 731.735, 731.737,
731.750, 731.752, 731.804, 731.844 to 731.992, 731.870 and
743.061.
(b) ORS 732.215, 732.220, 732.230, 732.245, 732.250, 732.320,
732.325 and 732.517 to 732.592, not including ORS 732.582.
(c) ORS 733.010 to 733.050, 733.080, 733.140 to 733.170,
733.210, 733.510 to 733.680 and 733.695 to 733.780.
(d) ORS chapter 734.
(e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065, 742.150
to 742.162, 742.400, 742.520 to 742.540, 743.010, 743.013,
743.018 to 743.030, 743.050, 743.100 to 743.109, 743.402,
743.472, 743.492, 743.495, 743.498, 743.499, 743.522, 743.523,
743.524, 743.526, 743.527, 743.528, 743.529, 743.549 to 743.552,
743.560, 743.600 to 743.610, 743.650 to 743.656, 743.764,
743.804, 743.807, 743.808, 743.814 to 743.839, 743.842, 743.845,
743.847, 743.854, 743.856, 743.857, 743.858, 743.859, 743.861,
743.862, 743.863, 743.864, 743.894, 743.911, 743.912, 743.913,
743.917, 743A.010, 743A.012, 743A.020, 743A.034, 743A.036,
743A.048, 743A.058, 743A.062, 743A.064, 743A.065, 743A.066,
743A.068, 743A.070, 743A.080, 743A.084, 743A.088, 743A.090,
743A.100, 743A.104, 743A.105, 743A.110, 743A.140, 743A.141,
743A.144, 743A.148, 743A.160, 743A.164, 743A.168, 743A.170,
743A.175, 743A.184, 743A.185, 743A.188, 743A.190 and 743A.192 and
section 2, chapter 21, Oregon Laws 2012.
(f) The provisions of ORS chapter 744 relating to the
regulation of insurance producers.
(g) ORS 746.005 to 746.140, 746.160, 746.220 to 746.370,
746.600, 746.605, 746.607, 746.608, 746.610, 746.615, 746.625,
746.635, 746.650, 746.655, 746.660, 746.668, 746.670, 746.675,
746.680 and 746.690.
(h) ORS 743A.024, except in the case of group practice health
maintenance organizations that are federally qualified pursuant
to Title XIII of the Public Health Service Act unless the patient
is referred by a physician associated with a group practice
health maintenance organization.
{ - (i) ORS 735.600 to 735.650. - }
{ - (j) - } { + (i) + } ORS 743.680 to 743.689.
{ - (k) - } { + (j) + } ORS 744.700 to 744.740.
{ - (L) - } { + (k) + } ORS 743.730 to 743.773.
{ - (m) - } { + (L) + } ORS 731.485, except in the case of
a group practice health maintenance organization that is
federally qualified pursuant to Title XIII of the Public Health
Service Act and that wholly owns and operates an in-house drug
outlet.
(2) For the purposes of this section, health care service
contractors shall be deemed insurers.
(3) Any for-profit health care service contractor organized
under the laws of any other state that is not governed by the
insurance laws of the other state is subject to all requirements
of ORS chapter 732.
(4) The Director of the Department of Consumer and Business
Services may, after notice and hearing, adopt reasonable rules
not inconsistent with this section and ORS 750.003, 750.005,
750.025 and 750.045 that are deemed necessary for the proper
administration of these provisions.
SECTION 34. { + The Oregon Health Authority may take any
action prior to July 1, 2017, that is necessary to enable the
authority to implement section 26 of this 2013 Act and to abolish
the Oregon Medical Insurance Pool on the operative date specified
in section 38 of this 2013 Act. + }
{ +
SUNSET OF OREGON + }
{ +
SUPPLEMENTAL REINSURANCE PROGRAM + }
SECTION 35. ORS 731.509, as amended by section 5 of this 2013
Act, is amended to read:
731.509. (1) The purpose of ORS 731.509, 731.510, 731.511,
731.512 and 731.516 is to protect the interests of insureds,
claimants, ceding insurers, assuming insurers and the public
generally. The Legislative Assembly declares that its intent is
to ensure adequate regulation of insurers and reinsurers and
adequate protection for those to whom they owe obligations. In
furtherance of that state interest, the Legislative Assembly
mandates that upon the insolvency of an alien insurer or
reinsurer that provides security to fund its United States
obligations in accordance with ORS 731.509, 731.510, 731.511,
731.512 and 731.516, the assets representing the security shall
be maintained in the United States and claims shall be filed with
and valued by the state insurance commissioner with regulatory
oversight, and the assets shall be distributed in accordance with
the insurance laws of the state in which the trust is domiciled
that are applicable to the liquidation of domestic United States
insurers. The Legislative Assembly declares that the laws
contained in ORS 731.509, 731.510, 731.511, 731.512 and 731.516
are fundamental to the business of insurance in accordance with
15 U.S.C. 1011 and 1012.
(2) The Director of the Department of Consumer and Business
Services shall not allow credit for reinsurance to a domestic
ceding insurer as either an asset or a reduction from liability
on account of reinsurance ceded unless credit is allowed as
provided under ORS 731.508 and unless the reinsurer meets the
requirements of:
(a) Subsection (3) of this section;
(b) Subsection (4) of this section;
(c) Subsections (5) and (8) of this section;
(d) Subsections (6) and (8) of this section; { + or + }
(e) Subsection (7) of this section { - ; or - } { + . + }
{ - (f) Subsection (9) of this section. - }
(3) Credit shall be allowed when the reinsurance is ceded to an
authorized assuming insurer that accepts reinsurance of risks,
and retains risk thereon within such limits, as the assuming
insurer is otherwise authorized to insure in this state as
provided in ORS 731.508.
(4) Credit shall be allowed when the reinsurance is ceded to an
assuming insurer that is accredited as a reinsurer in this state
as provided in ORS 731.511. The director shall not allow credit
to a domestic ceding insurer if the accreditation of the assuming
insurer has been revoked by the director after notice and
opportunity for hearing.
(5) Credit shall be allowed when the reinsurance is ceded to a
foreign assuming insurer or a United States branch of an alien
assuming insurer meeting all of the following requirements:
(a) The foreign assuming insurer must be domiciled in a state
employing standards regarding credit for reinsurance that equal
or exceed the standards applicable under this section. The United
States branch of an alien assuming insurer must be entered
through a state employing such standards.
(b) The foreign assuming insurer or United States branch of an
alien assuming insurer must maintain a combined capital and
surplus in an amount not less than $20,000,000. The requirement
of this paragraph does not apply to reinsurance ceded and assumed
pursuant to pooling arrangements among insurers in the same
holding company system.
(c) The foreign assuming insurer or United States branch of an
alien assuming insurer must submit to the authority of the
director to examine its books and records.
(6) Credit shall be allowed when the reinsurance is ceded to an
assuming insurer that maintains a trust fund meeting the
requirements of this subsection and additionally complies with
other requirements of this subsection. The trust fund must be
maintained in a qualified United States financial institution, as
defined in ORS 731.510 (1), for the payment of the valid claims
of its United States policyholders and ceding insurers and their
assigns and successors in interest. The assuming insurer must
report annually to the director information substantially the
same as that required to be reported on the annual statement form
by ORS 731.574 by authorized insurers, in order to enable the
director to determine the sufficiency of the trust fund. The
following requirements apply to such a trust fund:
(a) In the case of a single assuming insurer, the trust fund
must consist of funds in trust in an amount not less than the
assuming insurer's liabilities attributable to reinsurance ceded
by United States ceding insurers. In addition, the assuming
insurer must maintain a trusteed surplus of not less than
$20,000,000.
(b) In the case of a group including incorporated and
individual unincorporated underwriters:
(A) For reinsurance ceded under reinsurance agreements with an
inception, amendment or renewal date on or after August 1, 1995,
the trust shall consist of a trusteed account in an amount not
less than the group's several liabilities attributable to
business ceded by United States domiciled ceding insurers to any
member of the group.
(B) For reinsurance ceded under reinsurance agreements with an
inception date on or before July 31, 1995, and not amended or
renewed after that date, notwithstanding the other provisions of
ORS 731.509, 731.510, 731.511, 731.512 and 731.516, the trust
shall consist of a trusteed account in an amount not less than
the group's several insurance and reinsurance liabilities
attributable to business written in the United States.
(C) In addition to the trusts described in subparagraphs (A)
and (B) of this paragraph, the group shall maintain in trust a
trusteed surplus of which $100,000,000 shall be held jointly for
the benefit of the United States domiciled ceding insurers of any
member of the group for all years of account.
(D) The incorporated members of the group shall not be engaged
in any business other than underwriting as a member of the group
and shall be subject to the same level of regulation and solvency
control by the group's domiciliary regulator as are the
unincorporated members.
(E) Within 90 days after the group's financial statements are
due to be filed with the group's domiciliary regulator, the group
shall provide to the director an annual certification by the
group's domiciliary regulator of the solvency of each underwriter
member or, if certification is unavailable, financial statements
of each underwriter member of the group prepared by independent
certified public accountants.
(c) In the case of a group of incorporated insurers described
in this paragraph, the trust must be in an amount equal to the
group's several liabilities attributable to business ceded by
United States ceding insurers to any member of the group pursuant
to reinsurance contracts issued in the name of the group. This
paragraph applies to a group of incorporated insurers under
common administration that complies with the annual reporting
requirements contained in this subsection and that has
continuously transacted an insurance business outside the United
States for at least three years immediately prior to making
application for accreditation. Such a group must have an
aggregate policyholders' surplus of $10,000,000,000 and must
submit to the authority of this state to examine its books and
records and bear the expense of the examination. The group shall
also maintain a joint trusteed surplus of which $100,000,000 must
be held jointly for the benefit of United States ceding insurers
of any member of the group as additional security for any such
liabilities. Each member of the group shall make available to the
director an annual certification of the member's solvency by the
member's domiciliary regulator and its independent certified
public accountant.
(d) The form of the trust and any amendment to the trust shall
have been approved by the insurance commissioner of the state in
which the trust is domiciled or by the insurance commissioner of
another state who, pursuant to the terms of the trust instrument,
has accepted principal regulatory oversight of the trust.
(e) The form of the trust and any trust amendments also shall
be filed with the insurance commissioner of every state in which
the ceding insurer beneficiaries of the trust are domiciled. The
trust instrument must provide that contested claims shall be
valid and enforceable upon the final order of any court of
competent jurisdiction in the United States. The trust must vest
legal title to its assets in its trustees for the benefit of the
assuming insurer's United States ceding insurers and their
assigns and successors in interest. The trust and the assuming
insurer are subject to examination as determined by the director.
The trust must remain in effect for as long as the assuming
insurer has outstanding obligations due under the reinsurance
agreements subject to the trust.
(f) Not later than March 1 of each year, the trustees of each
trust shall report to the director in writing the balance of the
trust and listing the trust's investments at the preceding year
end, and shall certify the date of termination of the trust, if
so planned, or certify that the trust will not expire prior to
the following December 31.
(7) Credit shall be allowed when the reinsurance is ceded to an
assuming insurer not meeting the requirements of subsection (3),
(4), (5) or (6) of this section, but only as to the insurance of
risks located in jurisdictions in which the reinsurance is
required by applicable law or regulation of that jurisdiction.
(8) If the assuming insurer is not authorized to transact
insurance in this state or accredited as a reinsurer in this
state, the director shall not allow the credit permitted by
subsections (5) and (6) of this section unless the assuming
insurer agrees in the reinsurance agreement to the provisions
stated in this subsection. This subsection is not intended to
conflict with or override the obligation of the parties to a
reinsurance agreement to arbitrate their disputes, if such an
obligation is created in the agreement. The assuming insurer must
agree in the reinsurance agreement:
(a) That in the event of the failure of the assuming insurer to
perform its obligations under the terms of the reinsurance
agreement, the assuming insurer, at the request of the ceding
insurer, shall submit to the jurisdiction of any court of
competent jurisdiction in any state of the United States, will
comply with all requirements necessary to give the court
jurisdiction and will abide by the final decision of the court or
of any appellate court in the event of an appeal; and
(b) To designate the director or a designated attorney as its
true and lawful attorney upon whom any lawful process in any
action, suit or proceeding instituted by or on behalf of the
ceding company may be served.
{ - (9) Credit shall be allowed when the reinsurance is ceded
to the Oregon Supplemental Reinsurance Program established in
section 1 of this 2013 Act. - }
{ - (10) - } { + (9) + } If the assuming insurer does not
meet the requirements of subsection (3), (4) or (5) of this
section, the credit permitted by subsection (6) of this section
shall not be allowed unless the assuming insurer agrees in the
trust agreements to the following conditions:
(a) Notwithstanding any other provisions in the trust
instrument, if the trust fund is inadequate because it contains
an amount less than the applicable amount required by subsection
(6)(a), (b) or (c) of this section, or if the grantor of the
trust has been declared insolvent or placed into receivership,
rehabilitation, liquidation or similar proceedings under the laws
of the grantor's state or country of domicile, the trustee shall
comply with an order of the insurance commissioner with
regulatory oversight over the trust or with an order of a court
of competent jurisdiction directing the trustee to transfer to
the insurance commissioner with regulatory oversight all the
assets of the trust fund.
(b) The assets shall be distributed by and claims shall be
filed with and valued by the insurance commissioner with
regulatory oversight in accordance with the laws of the state in
which the trust is domiciled that are applicable to the
liquidation of domestic insurance companies.
(c) If the insurance commissioner with regulatory oversight
determines that the assets of the trust fund or any part thereof
are not necessary to satisfy the claims of the United States
ceding insurers of the grantor of the trust, the assets or part
thereof shall be returned by the insurance commissioner according
to the laws of that state and according to the terms of the trust
agreement not inconsistent with the laws of that state.
(d) The grantor shall waive any right otherwise available to it
under United States law that is inconsistent with this
subsection.
{ +
CONFORMING AMENDMENTS + }
SECTION 36. ORS 743.769 is amended to read:
743.769. (1) Each carrier shall actively market all individual
health benefit plans sold by the carrier.
(2) Except as provided in subsection (3) of this section, no
carrier or insurance producer shall, directly or indirectly,
discourage an individual from filing an application for coverage
because of the health status, claims experience, occupation or
geographic location of the individual.
(3) Subsection (2) of this section does not apply with respect
to information provided by a carrier to an individual regarding
the established geographic service area or a restricted network
provision of a carrier.
(4) Rejection by a carrier of an application for coverage shall
be in writing and shall state the reason or reasons for the
rejection.
(5) The Director of the Department of Consumer and Business
Services may establish by rule additional standards to provide
for the fair marketing and broad availability of individual
health benefit plans.
(6) A carrier that elects to discontinue offering all of its
individual health benefit plans under ORS 743.766
{ - (5)(c) - } { + (4)(c) + } or to discontinue offering and
renewing all such plans is prohibited from offering and renewing
health benefit plans in the individual market in this state for a
period of five years from the date of notice to the director
pursuant to ORS 743.766
{ - (5)(c) - } { + (4)(c) + } or, if such notice is not
provided, from the date on which the director provides notice to
the carrier that the director has determined that the carrier has
effectively discontinued offering individual health benefit plans
in this state. This subsection does not apply with respect to a
health benefit plan discontinued in a specified service area by a
carrier that covers services provided only by a particular
organization of health care providers or only by health care
providers who are under contract with the carrier.
{ +
CAPTIONS + }
SECTION 37. { + The unit captions used in this 2013 Act are
provided only for the convenience of the reader and do not become
part of the statutory law of this state or express any
legislative intent in the enactment of this 2013 Act. + }
{ +
OPERATIVE DATES AND REPEALS + }
SECTION 38. { + (1) Sections 1, 2 and 4 of this 2013 Act and
the amendments to statutes and session law by sections 5 to 25
and 36 of this 2013 Act become operative January 1, 2014.
(2) Section 26 of this 2013 Act and the amendments to statutes
by sections 29 to 33 and 35 of this 2013 Act become operative
July 1, 2017. + }
SECTION 39. { + (1) ORS 414.868, 414.872, 735.614, 735.640 and
746.222 and section 1, chapter 803, Oregon Laws 2009, are
repealed January 1, 2014.
(2) Sections 1, 2 and 4 of this 2013 Act and ORS 414.866,
414.870, 735.600, 735.605, 735.610, 735.612, 735.615, 735.616,
735.620, 735.625, 735.630, 735.635, 735.645 and 735.650 are
repealed July 1, 2017. + }
{ +
EMERGENCY CLAUSE + }
SECTION 40. { + This 2013 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2013 Act takes effect on
its passage. + }
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