Bill Text: OR SB89 | 2011 | Regular Session | Engrossed

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Relating to health insurance; and declaring an emergency.

Sponsorship: Unknown

Status: (Passed) 2011-06-24 - Effective date, June 23, 2011. [SB89 Detail]

Download: Oregon-2011-SB89-Engrossed.html

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     76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session

HA to A-Eng. SB 89 (A to RC)

LC 572/SB 89-A12

                       HOUSE AMENDMENTS TO
                   A-ENGROSSED SENATE BILL 89
           (INCLUDING AMENDMENTS TO RESOLVE CONFLICTS)

                   By COMMITTEE ON HEALTH CARE

                             June 2

  On page 1 of the printed A-engrossed bill, line 2, after '
743.405,' insert '743.601, 743.610,'.
  In line 5, after '743A.110,' insert '743A.141,'.
  In line 6, delete the third 'and' and insert 'section 2,
chapter 73, Oregon Laws 2009,'.
  In line 7, after '2010' insert ', and section 6, chapter ___,
Oregon Laws 2011 (Enrolled Senate Bill 91); repealing sections 2
and 5, chapter 73, Oregon Laws 2009, and section 5, chapter ___,
Oregon Laws 2011 (Enrolled Senate Bill 91)'.
  On page 2, line 9, delete 'Section 4' and insert 'Sections 4
and 4a' and delete 'is' and insert 'are'.
  In line 14, after 'individual' delete the rest of the line.
  In line 15, delete 'vidual belongs'.
  Delete lines 17 through 20 and insert:
  ' (a) The individual or a person seeking coverage on behalf of
the individual:
  ' (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 plan or policy; and
  ' (b) The insurer provides at least 30 days' advance written
notice, in the form and manner prescribed by the Department of
Consumer and Business Services, to the individual.
  ' (3) An insurer may not rescind coverage of a group under a
health benefit plan unless:
  ' (a) The plan sponsor:
  ' (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 plan; and'.
  In line 22, delete 'of Consumer and Business Services'.
  In line 24, delete '(3)' and insert '(4)'.
  After line 25, insert:
  '  { +  SECTION 4a. + }  { + (1) As used in this section,
'health benefit plan' has the meaning given that term in ORS
743.730.
  ' (2) An insurer shall notify a policyholder in writing if the
insurer cancels or does not renew the policyholder's individual
health benefit plan. The notice shall be sent to the
policyholder's last-known mailing address by first class mail in
a specially marked envelope or, if the policyholder has elected
to receive communications from the insurer electronically, to the
policyholder's last-known electronic mail address using a
mechanism that will confirm delivery to the address.
  ' (3) If the cancellation or nonrenewal results in a refund to
the policyholder of all or part of a premium, the insurer must
mail with the refund a written explanation that includes:
  ' (a) The effective date of the cancellation;
  ' (b) The reason for the cancellation; and
  ' (c) The time period to which the refund is applicable.
  ' (4) For any cancellation or nonrenewal due to a reported
death of the policyholder, the insurer must:
  ' (a) Confirm the accuracy of the reported death.
  ' (b) If the death is confirmed:
  ' (A) Provide any dependents covered by the plan with
information about how to continue coverage or obtain alternative
coverage; and
  ' (B) Issue any refund that is due to the estate of the
deceased in accordance with subsection (3) of this section.
  ' (5) If an insurer cancels or does not renew an individual
health benefit plan and fails to comply with the requirements of
this section, the insurer shall continue the coverage under the
plan for the policyholder and any dependents covered by the plan
until the date that the insurer has complied with the
requirements of this section. The insurer shall waive any
premiums owed for the period during which the coverage was
continued under this subsection and shall process all claims
incurred by the policyholder or any covered dependents according
to the terms of the plan.
  ' (6) This section does not apply:
  ' (a) To a cancellation requested by the policyholder if the
insurer documents the request and confirms the request with the
policyholder; or
  ' (b) To a cancellation or nonrenewal that results from a
policyholder making a change in coverage with the same
insurer. + } ' .
  On page 4, after line 19, insert:
  '  { +  SECTION 6a. + } ORS 743.601 is amended to read:
  ' 743.601. (1) As used in subsections (1) to (6) of this
section, 'plan administrator' means:
  ' (a) The person designated as the plan administrator by the
instrument under which the group health insurance plan is
operated; or
  ' (b) If no plan administrator is designated, the plan sponsor.
  ' (2) Within 60 days of legal separation or the entry of a
judgment of dissolution of marriage, a legally separated or
divorced spouse eligible for continued coverage under ORS 743.600
who seeks such coverage shall give the plan administrator written
notice of the legal separation or dissolution. The notice shall
include the mailing address of the legally separated or divorced
spouse.
  ' (3) Within 30 days of the death of a   { - certificate
holder - }  { + covered person + } whose surviving spouse is
eligible for continued coverage under ORS 743.600, the group
policyholder shall give the plan administrator written notice of
the death and of the mailing address of the surviving spouse.
  ' (4) Within 14 days of receipt of notice under subsection (2)
or (3) of this section, the plan administrator shall notify the
legally separated, divorced or surviving spouse that the policy
may be continued. The notice shall be mailed to the mailing
address provided to the plan administrator and shall include:
  ' (a) A form for election to continue the coverage;
  ' (b) A statement of the amount of periodic premiums to be
charged for the continuation of coverage and of the method and
place of payment; and
  ' (c) Instructions for returning the election form by mail
within 60 days after the date of mailing of the notice by the
plan administrator.
  ' (5) Failure of the legally separated, divorced or surviving
spouse to exercise the election in accordance with subsection (4)
of this section shall terminate the right to continuation of
benefits.
  ' (6) If a plan administrator fails to notify the legally
separated, divorced or surviving spouse as required by subsection
(4) of this section, premiums shall be waived from the date the
notice was required until the date notice is received by the
legally separated, divorced or surviving spouse.
  ' (7) The provisions of  { + this section and + } ORS 743.600
 { - to - }  { +  and + } 743.602 apply only to employers with 20
or more employees and group health insurance plans with 20 or
more   { - certificate holders - }  { +  enrollees on a typical
business day during the preceding calendar year + }.
  '  { +  SECTION 6b. + } ORS 743.610 is amended to read:
  ' 743.610.  { + (1) As used in this section and section 2,
chapter 73, Oregon Laws 2009:
  ' (a) 'Covered person' means an individual who was a
certificate holder under a group health insurance policy:
  ' (A) On the day before a qualifying event; and
  ' (B) During the three-month period ending on the date of the
qualifying event.
  ' (b) 'Qualified beneficiary' means:
  ' (A) A spouse or dependent child of a covered person who, on
the day before a qualifying event, was insured under the covered
person's group health insurance policy; or
  ' (B) A child born to or adopted by a covered person during the
period of the continuation of coverage under this section who
would have been insured under the covered person's policy if the
child had been born or adopted on the day before the qualifying
event.
  ' (c) 'Qualifying event' means the loss of membership in a
group health insurance policy caused by:
  ' (A) Voluntary or involuntary termination of the employment of
a covered person;
  ' (B) A reduction in hours worked by a covered person;
  ' (C) A covered person becoming eligible for Medicare;
  ' (D) A qualified beneficiary losing dependent child status
under a covered person's group health insurance policy;
  ' (E) Termination of membership in the group covered by the
group health insurance policy; or
  ' (F) The death of a covered person. + }
  '  { - (1) - }   { + (2) + } A group health insurance policy
providing coverage for hospital or medical expenses, other than
coverage limited to expenses from accidents or specific diseases,
must contain a provision that   { - certificate holders whose
coverage under the policy otherwise would terminate because of
termination of employment or membership may continue coverage
under the policy for themselves and their eligible dependents as
provided in this section - }  { +  a covered person and any
qualified beneficiary may continue coverage under the policy as
provided in this section + }.
  '  { - (2) Continuation of coverage is available only to a
certificate holder who has been insured continuously under the
policy or similar predecessor policy during the three-month
period ending on the date of the termination of employment or
membership. - }
  ' (3) Continuation of coverage is not available to a
  { - certificate holder - }  { +  covered person or qualified
beneficiary + } who is eligible for:
  ' (a)   { - Federal - }  Medicare   { - coverage - } ; or
  ' (b) Coverage for hospital or medical expenses under any other
program   { - which was not covering the certificate holder
immediately before the certificate holder's termination of
employment or membership - }  { +  that was not covering the
covered person or qualified beneficiary on the day before a
qualifying event + }.
  ' (4) The continued coverage need not include benefits for
dental, vision care or prescription drug expense, or any other
benefits under the policy   { - additional to - }  { +  other
than + } hospital and medical expense benefits.
  ' (5) Except as provided by rule by the Director of the
Department of Consumer and Business Services under section 2,
chapter 73, Oregon Laws 2009,   { - a certificate holder who has
terminated employment or membership and who wishes to continue
coverage must request continuation in writing: - }
  '  { - (a) not later than 10 days after the later of the date
on which employment or membership terminated and the date on
which the employer or group policyholder gave the certificate
holder notice of the right to continue coverage; and - }
  '  { - (b) Not more than 31 days after the date of termination
of employment or membership. - }  { +  a covered person or
qualified beneficiary who wishes to continue coverage must
provide the insurer with a written request for continuation no
later than 10 days after the later of the date of a qualifying
event or the date the insurer provides the notice required by
subsection (10) of this section. + }
  ' (6) A   { - certificate holder - }  { +  covered person or
qualified beneficiary + } who requests continuation of coverage
shall pay the premium on a monthly basis and in advance  { - , as
provided in this subsection. The certificate holder shall pay the
premium - }  to the insurer or to the employer or policyholder,
whichever the group policy provides. The required premium payment
may not exceed the group premium rate for the insurance being
continued under the group policy as of the date the premium
payment is due.   { - Except as otherwise provided by rule by the
director under section 2, chapter 73, Oregon Laws 2009, the
certificate holder must pay the first premium not later than 31
days after the date on which the certificate holder's coverage
under the policy otherwise would end. - }
  ' (7) Except as otherwise provided by rule by the director
under section 2, chapter 73, Oregon Laws 2009, continuation of
coverage as provided under this section ends on the earliest of
the following dates:
  '  { - (a) Nine months after the date on which the certificate
holder's coverage under the policy otherwise would have ended
because of termination of employment or membership. - }
  '  { - (b) The end of the period for which the certificate
holder last made timely premium payment, if the certificate
holder fails to make timely payment of a required premium
payment. - }
  '  { - (c) The premium payment due date coinciding with or next
following the date the certificate holder becomes eligible for
federal Medicare coverage. - }
  '  { - (d) The date on which the policy is terminated or the
certificate holder's employer terminates participation under the
policy. However, if the employer replaces the coverage which is
terminating for the certificate holder with similar coverage
under another group policy: - }
  '  { - (A) The certificate holder may obtain coverage under the
replacement group policy for the balance of the period that the
certificate holder would have remained covered under the replaced
group policy under this section; - }
  '  { - (B) The replacement group policy must provide, at a
minimum, the applicable level of benefits of the replaced policy
reduced by any benefits still payable under that policy; and - }
  '  { - (C) The replaced policy must continue to provide
benefits to the certificate holder to the extent of that policy's
accrued liabilities and extensions of benefits as if the
replacement had not occurred. - }
  '  { +  (a) Nine months after the date of the qualifying event
that was the basis for the continuation of coverage.
  ' (b) The end of the period for which the last timely premium
payment for the coverage is received by the insurer.
  ' (c) The premium payment due date coinciding with or next
following the date that continuation of coverage ceases to be
available in accordance with subsection (3) of this section.

  ' (d) The date that the policy is terminated. However, if the
policyholder replaces the terminated policy with similar coverage
under another group health insurance policy:
  ' (A) The covered person and qualified beneficiaries may obtain
coverage under the replacement policy for the balance of the
period that the covered person or qualified beneficiary would
have remained covered under the terminated policy in accordance
with this section; and
  ' (B) The terminated policy must continue to provide benefits
to the covered person and qualified beneficiaries to the extent
of that policy's accrued liabilities and extensions of benefits
as if the replacement had not occurred. + }
  '  { - (8) The group health insurance policy must contain a
provision that: - }
  '  { - (a) The surviving spouse of a certificate holder, if
any, who is not eligible for continuation of coverage under ORS
743.600 may continue coverage under the policy, at the death of
the certificate holder, with respect to the spouse and any
dependent children whose coverage under the policy otherwise
would terminate because of the death, in the same manner that a
certificate holder may exercise the right under this section. - }

  '  { - (b) The spouse of a certificate holder, if any, who is
not eligible for continuation of coverage under ORS 743.600 may
continue coverage under the policy, upon dissolution of marriage
with the certificate holder, with respect to the spouse and any
children whose coverage under the policy otherwise would
terminate because of the dissolution of marriage, in the same
manner that a certificate holder may exercise the right under
this section. - }
  '  { - (c) A spouse who requests continuation of coverage under
this subsection must pay the premium for the spouse and any
dependent children, on a monthly basis and in advance, as
provided in this paragraph. The spouse shall pay the premium to
the insurer or to the employer or policyholder, whichever the
group policy provides. The required premium payment under this
subsection may not exceed the group premium rate, for the
insurance being continued under the group policy, as of the date
the premium payment is due. - }
  '  { +  (8) A qualified beneficiary who is not eligible for
continuation of coverage under ORS 743.600 may continue coverage
under this section upon the dissolution of marriage with or the
death of the covered person in the same manner that a covered
person may exercise the right to continue coverage under this
section. + }
  ' (9)   { - A certificate holder who has terminated employment
by reason of layoff may not be subject upon any rehire that
occurs within nine months of the time of the layoff to any
waiting period prerequisite to - }  { +  A covered person rehired
by an employer no later than nine months after the layoff of the
covered person by the employer may not be subjected to a waiting
period for  + }coverage under the employer's group health
insurance policy if the
  { - certificate holder - }  { +  covered person + } was
eligible for coverage at the time of the   { - termination
and - }  { +  layoff, + } regardless of whether the
 { - certificate holder - }  { +  covered person + } continued
coverage during the layoff.
  '  { +  (10) If an insurer terminates the group health
insurance coverage of a covered person or qualified beneficiary
without providing replacement coverage that meets the criteria in
subsection (7)(d) of this section, the insurer shall provide
written notice to the covered person and any qualified
beneficiary no later than 10 days after the insurer is notified
of the qualifying event under subsection (5) of this section. The
notice shall include at least the following information:
  ' (a) Contact information for the insurer;
  ' (b) Forms necessary to request continuation of coverage and
instructions for completing the forms;
  ' (c) Information sufficient to determine premium rates for
continuation of coverage and instructions for paying premiums;
  ' (d) A clear statement of who is eligible to continue
coverage;
  ' (e) Enrollment information relating to other coverage issued
by the insurer that is held by the employer or group and for
which the covered person or a qualified beneficiary may be
eligible;
  ' (f) An explanation of the process to appeal a denial of a
claim under the continuation of coverage;
  ' (g) Information, in a form approved by the director, about
how to contact the consumer advocacy unit of the Insurance
Division of the Department of Consumer and Business Services; and
  ' (h) Other information required by the director. + }
  '  { - (10) - }  { +  (11) + } This section applies only to
employers who are not required to make available continuation of
health insurance benefits under Titles X and XXII of the
Consolidated Omnibus Budget Reconciliation Act of 1985, as
amended, P.L. 99-272, April 7, 1986.
  '  { +  SECTION 6c. + } ORS 743.610, as amended by section 4,
chapter 73, Oregon Laws 2009, is amended to read:
  ' 743.610.  { + (1) As used in this section:
  ' (a) 'Covered person' means an individual who was a
certificate holder under a group health insurance policy:
  ' (A) On the day before a qualifying event; and
  ' (B) During the three-month period ending on the date of the
qualifying event.
  ' (b) 'Qualified beneficiary' means:
  ' (A) A spouse or dependent child of a covered person who, on
the day before a qualifying event, was insured under the covered
person's group health insurance policy; or
  ' (B) A child born to or adopted by a covered person during the
period of the continuation of coverage under this section who
would have been insured under the covered person's policy if the
child had been born or adopted on the day before the qualifying
event.
  ' (c) 'Qualifying event' means the loss of membership in a
group health insurance policy caused by:
  ' (A) Voluntary or involuntary termination of the employment of
a covered person;
  ' (B) A reduction in hours worked by a covered person;
  ' (C) A covered person becoming eligible for Medicare;
  ' (D) A qualified beneficiary losing dependent child status
under a covered person's group health insurance policy;
  ' (E) Termination of membership in the group covered by the
group health insurance policy; or
  ' (F) The death of a covered person. + }
  '  { - (1) - }  { +  (2) + } A group health insurance policy
providing coverage for hospital or medical expenses, other than
coverage limited to expenses from accidents or specific diseases,
must contain a provision that   { - certificate holders whose
coverage under the policy otherwise would terminate because of
termination of employment or membership may continue coverage
under the policy for themselves and their eligible dependents as
provided in this section - }  { +  a covered person and any
qualified beneficiary may continue coverage under the policy as
provided in this section + }.
  '  { - (2) Continuation of coverage is available only to a
certificate holder who has been insured continuously under the
policy or similar predecessor policy during the three-month
period ending on the date of the termination of employment or
membership. - }
  ' (3) Continuation of coverage is not available to a
  { - certificate holder - }  { +  covered person or qualified
beneficiary + } who is eligible for:
  ' (a)   { - Federal - }  Medicare   { - coverage - } ; or
  ' (b) Coverage for hospital or medical expenses under any other
program   { - which was not covering the certificate holder
immediately before the certificate holder's termination of
employment or membership - }  { +  that was not covering the
covered person or qualified beneficiary on the day before a
qualifying event + }.
  ' (4) The continued coverage need not include benefits for
dental, vision care or prescription drug expense, or any other
benefits under the policy   { - additional to - }  { +  other
than + } hospital and medical expense benefits.
  ' (5)   { - A certificate holder who has terminated employment
or membership and who wishes to continue coverage must request
continuation in writing: - }   { + A covered person or qualified
beneficiary who wishes to continue coverage must provide the
insurer with a written request for continuation no later than 10
days after the later of the date of a qualifying event or the
date the insurer provides the notice required by subsection (10)
of this section. + }
  '  { - (a) Not later than 10 days after the later of the date
on which employment or membership terminated and the date on
which the employer or group policyholder gave the certificate
holder notice of the right to continue coverage; and - }
  '  { - (b) Not more than 31 days after the date of termination
of employment or membership. - }
  ' (6) A   { - certificate holder - }  { +  covered person or
qualified beneficiary + } who requests continuation of coverage
shall pay the premium on a monthly basis and in advance  { - , as
provided in this subsection. The certificate holder shall pay the
premium - }  to the insurer or to the employer or policyholder,
whichever the group policy provides. The required premium payment
may not exceed the group premium rate for the insurance being
continued under the group policy as of the date the premium
payment is due.   { - The certificate holder must pay the first
premium not later than 31 days after the date on which the
certificate holder's coverage under the policy otherwise would
end. - }
  ' (7) Continuation of coverage as provided under this section
ends on the earliest of the following dates:
  '  { - (a) Nine months after the date on which the certificate
holder's coverage under the policy otherwise would have ended
because of termination of employment or membership. - }
  '  { - (b) The end of the period for which the certificate
holder last made timely premium payment, if the certificate
holder fails to make timely payment of a required premium
payment. - }
  '  { - (c) The premium payment due date coinciding with or next
following the date the certificate holder becomes eligible for
federal Medicare coverage. - }
  '  { - (d) The date on which the policy is terminated or the
certificate holder's employer terminates participation under the
policy. However, if the employer replaces the coverage which is
terminating for the certificate holder with similar coverage
under another group policy: - }
  '  { - (A) The certificate holder may obtain coverage under the
replacement group policy for the balance of the period that the
certificate holder would have remained covered under the replaced
group policy under this section; - }
  '  { - (B) The replacement group policy must provide, at a
minimum, the applicable level of benefits of the replaced policy
reduced by any benefits still payable under that policy; and - }
  '  { - (C) The replaced policy must continue to provide
benefits to the certificate holder to the extent of that policy's

accrued liabilities and extensions of benefits as if the
replacement had not occurred. - }
  '  { +  (a) Nine months after the date of the qualifying event
that was the basis for the continuation of coverage.
  ' (b) The end of the period for which the last timely premium
payment for the coverage is received by the insurer.
  ' (c) The premium payment due date coinciding with or next
following the date that continuation of coverage ceases to be
available in accordance with subsection (3) of this section.
  ' (d) The date that the policy is terminated. However, if the
policyholder replaces the terminated policy with similar coverage
under another group health insurance policy:
  ' (A) The covered person and qualified beneficiaries may obtain
coverage under the replacement policy for the balance of the
period that the covered person or qualified beneficiary would
have remained covered under the terminated policy in accordance
with this section; and
  ' (B) The terminated policy must continue to provide benefits
to the covered person and qualified beneficiaries to the extent
of that policy's accrued liabilities and extensions of benefits
as if the replacement had not occurred. + }
  '  { - (8) The group health insurance policy must contain a
provision that: - }
  '  { - (a) The surviving spouse of a certificate holder, if
any, who is not eligible for continuation of coverage under ORS
743.600 may continue coverage under the policy, at the death of
the certificate holder, with respect to the spouse and any
dependent children whose coverage under the policy otherwise
would terminate because of the death, in the same manner that a
certificate holder may exercise the right under this section. - }

  '  { - (b) The spouse of a certificate holder, if any, who is
not eligible for continuation of coverage under ORS 743.600 may
continue coverage under the policy, upon dissolution of marriage
with the certificate holder, with respect to the spouse and any
children whose coverage under the policy otherwise would
terminate because of the dissolution of marriage, in the same
manner that a certificate holder may exercise the right under
this section. - }
  '  { - (c) A spouse who requests continuation of coverage under
this subsection must pay the premium for the spouse and any
dependent children, on a monthly basis and in advance, as
provided in this paragraph. The spouse shall pay the premium to
the insurer or to the employer or policyholder, whichever the
group policy provides. The required premium payment under this
subsection may not exceed the group premium rate, for the
insurance being continued under the group policy, as of the date
the premium payment is due. - }
  '  { +  (8) A qualified beneficiary who is not eligible for
continuation of coverage under ORS 743.600 may continue coverage
under this section upon the dissolution of marriage with or the
death of the covered person in the same manner that a covered
person may exercise the right to continue coverage under this
section. + }
  ' (9)   { - A certificate holder who has terminated employment
by reason of layoff may not be subject upon any rehire that
occurs within nine months of the time of the layoff to any
waiting period prerequisite to - }   { + A covered person rehired
by an employer no later than nine months after the layoff of the
covered person by the employer may not be subjected to a waiting
period for + } coverage under the employer's group health
insurance policy if the
  { - certificate holder - }  { +  covered person + } was
eligible for coverage at the time of the   { - termination
and - }  { +  layoff, + } regardless of whether the

 { - certificate holder - }  { +  covered person + } continued
coverage during the layoff.
  '  { +  (10) If an insurer terminates the group health
insurance coverage of a covered person or qualified beneficiary
without providing replacement coverage that meets the criteria in
subsection (7)(d) of this section, the insurer shall provide
written notice to the covered person and any qualified
beneficiary no later than 10 days after the insurer is notified
of the qualifying event under subsection (5) of this section. The
notice shall include at least the following information:
  ' (a) Contact information for the insurer;
  ' (b) Forms necessary to request continuation of coverage and
instructions for completing the forms;
  ' (c) Information sufficient to determine premium rates for
continuation of coverage and instructions for paying premiums;
  ' (d) A clear statement of who is eligible to continue
coverage;
  ' (e) Enrollment information relating to other coverage issued
by the insurer that is held by the employer or group and for
which the covered person or a qualified beneficiary may be
eligible;
  ' (f) An explanation of the process to appeal a denial of a
claim under the continuation of coverage;
  ' (g) Information, in a form approved by the Director of the
Department of Consumer and Business Services, about how to
contact the consumer advocacy unit of the Insurance Division of
the Department of Consumer and Business Services; and
  ' (h) Other information required by the director. + }
  '  { - (10) - }  { +  (11) + } This section applies only to
employers who are not required to make available continuation of
health insurance benefits under Titles X and XXII of the
Consolidated Omnibus Budget Reconciliation Act of 1985, as
amended, P.L. 99-272, April 7, 1986.
  '  { +  SECTION 6d. + } Section 2, chapter 73, Oregon Laws
2009, is amended to read:
  '  { +  Sec. 2. + } (1) Notwithstanding the limitations of ORS
743.610, the Director of the Department of Consumer and Business
Services by rule may extend the period of time during which
coverage is available to a   { - certificate holder - }  { +
covered person or qualified beneficiary + } and may open a new
period of time during which a
  { - certificate holder - }  { +  covered person or qualified
beneficiary + } may request continuation of   { - health benefit
coverage under the state continuation of benefits program - }
 { +  coverage as + } described in ORS 743.610 if:
  ' (a) The establishment of the extension   { - and - }
 { + or + } new request period is in response to and consistent
with federal legislation relating to the continuation of
 { - health benefit - }  coverage; and
  ' (b) The director finds that the rule is necessary to take
advantage of a benefit provided to insurers, employers or
employees by the federal legislation relating to the continuation
of   { - health benefit - }  coverage.
  ' (2) The rules adopted by the director under subsection (1) of
this section may include but need not be limited to:
  ' (a) Changes to the maximum period of coverage;
  ' (b) Adoption of notice requirements for insurers, plan
administrators, employers, group policyholders   { - and
certificate holders - }  { + , covered persons and qualified
beneficiaries + };
  ' (c) Criteria to determine if a   { - certificate holder - }
 { +  covered person or qualified beneficiary + } is eligible for
a benefit;
  ' (d) Procedures to allow an additional opportunity   { - to
request continuation coverage under ORS 743.610 (5) to a
certificate holder whose employment was involuntarily terminated
between September 1, 2008, and the effective date of this 2009
Act - }  { +  for the covered person or qualified beneficiary to
request continuation of coverage under ORS 743.610 if the
employment of the covered person was involuntarily terminated
between September 1, 2008, and May 31, 2010 + };
  ' (e) Any necessary extension of the time by which the
  { - certificate holder - }  { +  covered person or qualified
beneficiary + } must pay the first premium as required under ORS
743.610; and
  ' (f) Any necessary extension of the time by which the
  { - certificate holder - }  { +  covered person or qualified
beneficiary + } must request or elect continuation  { + of + }
coverage.'.
  On page 5, line 3, after 'including' insert a colon and delete
the rest of the line and lines 4 through 6 and insert:
  ' (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.'.
  On page 8, lines 7 through 10, restore the bracketed material
and delete the boldfaced material.
  On page 17, line 41, after the comma delete the rest of the
line and delete lines 42 through 45.
  On page 18, delete lines 1 through 6 and insert 'a carrier may
not rescind the coverage of an enrollee in a small employer
health benefit plan unless:
  ' (a) The enrollee or a person seeking coverage on behalf of
the enrollee:
  ' (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 plan;
  ' (b) The carrier provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
the enrollee; and
  ' (c) The carrier provides notice of the rescission to the
department in the form, manner and time frame prescribed by the
department by rule.
  ' (9) Notwithstanding any provision of subsection (6) of this
section to the contrary, a carrier may not rescind a small
employer health benefit plan unless:
  ' (a) The small employer or a representative of the small
employer:
  ' (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 plan;
  ' (b) The carrier provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
each plan enrollee who would be affected by the rescission of
coverage; and
  ' (c) The carrier provides notice of the rescission to the
department in the form, manner and time frame prescribed by the
department by rule.'.
  In line 7, delete '(9)' and insert '(10)'.
  In line 15, delete '(10)' and insert '(11)'.
  On page 19, line 29, delete '(11)' and insert '(12)'.
  In line 37, delete '(12)(a)' and insert '(13)(a)'.
  On page 20, line 9, delete '(13)' and insert '(14)'.
  In line 13, delete '(14)' and insert '(15)'.
  In line 15, delete '(15)' and insert '(16)'.
  In line 18, delete '(16)' and insert '(17)'.
  In line 21, delete '(17)' and insert '(18)' and delete '
dollar'.
  In line 22, before 'essential' insert 'dollar amount of the'.
  In line 24, delete '(18)' and insert '(19)'.
  On page 26, line 7, after the comma delete the rest of the line
and lines 8 through 15 and insert 'a carrier may not rescind the
coverage of an enrollee under the plan unless:
  ' (a) The enrollee:
  ' (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 plan;
  ' (b) The carrier provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
the enrollee; and
  ' (c) The carrier provides notice of the rescission to the
department in the form, manner and time frame prescribed by the
department by rule.
  ' (9) Notwithstanding any provision of subsection (6) of this
section to the contrary, a carrier may not rescind a plan unless:
  ' (a) The plan sponsor or a representative of the plan sponsor:
  ' (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 plan;
  ' (b) The carrier provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
each plan enrollee who would be affected by the rescission of
coverage; and
  ' (c) The carrier provides notice of the rescission to the
department in the form, manner and time frame prescribed by the
department by rule.'.
  In line 16, delete '(9)' and insert '(10)'.
  In line 23, delete '(10)' and insert '(11)' and delete '
dollar' and after 'the' insert 'dollar amount of the'.
  In line 26, delete '(11)' and insert '(12)'.
  On page 29, line 29, delete '(3)' and insert '(4)'.
  On page 31, line 36, delete 'one or more individual' and insert
'all'.
  On page 32, line 17, delete '(3)' and insert '(4)'.
  In line 30, delete 'dollar' and after 'the' insert ' dollar
amount of the'.
  On page 33, delete line 30 and insert:
  ' (a) Denial of eligibility for or termination of enrollment in
a health benefit plan;'.
  On page 34, line 12, delete 'internal appeal' and insert '
expedited response' and delete '(2)(e)' and insert ' (2)(d)'.
  In line 14, after 'A' insert 'written'.
  On page 38, delete lines 36 through 39 and insert:
  ' (b) An explanation of the procedures described in subsection
(2) of this section for making coverage determinations and
resolving grievances. The explanation must be culturally and
linguistically appropriate, as prescribed by the department by
rule, and must include:
  ' (A) The procedures for requesting an expedited response to an
internal appeal under subsection (2)(d) of this section or for
requesting an expedited external review of an adverse benefit
determination;'.
  On page 39, line 43, delete 'Responding to grievances in a
manner' and insert 'An expedited response to a request for an
internal appeal'.
  On page 40, line 44, delete 'and internal appeals' and insert
'described in ORS 743.801 (4)(a)'.
  On page 41, line 3, delete 'and internal appeal'.
  In line 7, delete 'grievance' and insert 'appeal'.
  On page 46, line 13, after the second 'condition' insert a
colon and begin a new paragraph and insert '(A)'.
  In line 16, after 'would' delete the rest of the line and
insert ':
  ' (i) Place the health of a person, or an unborn child in the'.
  In line 17, delete the period and insert ';
  ' (ii) Result in serious impairment to bodily functions; or
  ' (iii) Result in serious dysfunction of any bodily organ or
part; or
  ' (B) With respect to a pregnant woman who is having
contractions, for which there is inadequate time to effect a safe
transfer to another hospital before delivery or for which a
transfer may pose a threat to the health or safety of the woman
or the unborn child.'.
  On page 47, line 36, after 'health' delete the rest of the
line.
  In line 37, delete 'surgical expense benefits' and insert '
benefit plans, as defined in ORS 743.730,'.
  On page 48, after line 16, insert:
  ' (5) This section does not prohibit an insurer from denying or
limiting coverage based on a preexisting condition of a child who
is 19 years of age or older.'.
  In line 17, delete '(5)' and insert '(6)'.
  Delete lines 18 through 21 and insert:
  ' (a) 'Child' means an individual who is under 26 years of
age.'.
  On page 50, after line 43, insert:
  '  { +  SECTION 42a. + } ORS 743A.141 is amended to read:
  ' 743A.141. (1) As used in this section, 'hearing aid' means
any nondisposable, wearable instrument or device designed to aid
or compensate for impaired human hearing and any necessary ear
mold, part, attachments or accessory for the instrument or
device, except batteries and cords.
  ' (2) A health benefit plan, as defined in ORS 743.730, shall
provide payment, coverage or reimbursement for one hearing aid
per hearing impaired ear if:
  ' (a) Prescribed, fitted and dispensed by a licensed
audiologist with the approval of a licensed physician; and
  ' (b) Necessary for the treatment of hearing loss in an
enrollee in the plan who is:
  ' (A)   { - Under - }  18 years of age { +  or younger + }; or
  ' (B)   { - 18 years of age or older, eligible as a dependent
under the plan - }  { +  19 to 25 years of age + } and enrolled
in  { + a secondary school or + } an accredited educational
institution.
  ' (3)(a) The maximum benefit amount required by this section is
$4,000 every 48 months, but a health benefit plan may offer a
benefit that is more favorable to the enrollee. The benefit
amount shall be adjusted on January 1 of each year to reflect the
increase since January 1, 2010, in the U.S. City Average Consumer
Price Index for All Urban Consumers for medical care as published
by the Bureau of Labor Statistics of the United States Department
of Labor.
  ' (b) A health benefit plan may not impose any financial or
contractual penalty upon an audiologist if an enrollee elects to
purchase a hearing aid priced higher than the benefit amount by
paying the difference between the benefit amount and the price of
the hearing aid.
  ' (4) A health benefit plan may subject the payment, coverage
or reimbursement required under this section to provisions of the
plan that apply to other durable medical equipment benefits
covered by the plan, including but not limited to provisions
relating to deductibles, coinsurance and prior authorization.
  ' (5) This section is exempt from ORS 743A.001.'.
  On page 51, line 19, delete 'and 4' and insert ', 4 and 4a'.
  On page 52, line 9, delete 'and 4' and insert ', 4 and 4a'.
  In line 37, delete '(10)' and insert '(11)'.
  In line 39, after '47.' insert '(1)' and delete the comma and
insert 'and'.
  In line 40, after '5' insert ', 6, 7'.
  After line 42, insert:
  ' (2) Section 4a of this 2011 Act applies to health benefit
plans issued or renewed on or after the effective date of this
2011 Act.
  ' (3) The amendments to ORS 743.610 by sections 6b and 6c of
this 2011 Act apply to group health insurance policies issued or
renewed before, on or after the effective date of this 2011 Act.
  '  { +  SECTION 48. + }  { + (1) Section 5, chapter 73, Oregon
Laws 2009, is repealed.
  ' (2) Section 2, chapter 73, Oregon Laws 2009, as amended by
section 6d of this 2011 Act, is repealed on January 2, 2012. + }
  '  { +  SECTION 49. + }  { + If Senate Bill 91 becomes law,
section 5, chapter ___, Oregon Laws 2011 (Enrolled Senate Bill
91) (amending ORS 743.730), is repealed and ORS 743.730, as
amended by section 7 of this 2011 Act, 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 section 2, chapter ___, Oregon Laws 2011
(Enrolled Senate Bill 91). + }
  '  { - (6) - }  { +  (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. + }
  '  { - (7) - }  { +  (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.
  '  { - (8) - }  { +  (10) + } 'Dependent' means the spouse or
child of an eligible employee, subject to applicable terms of the
health benefit plan covering the employee.
  '  { - (9) - }   { + (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.
  '  { - (10) - }   { + (12) + } 'Employee' means any individual
employed by an employer.
  '  { - (11) - }   { + (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 Oregon Health Insurance
Exchange established pursuant to section 17, chapter 595, Oregon
Laws 2009. + }
  '  { - (12) - }   { + (15) + } 'Exclusion period' means a
period during which specified treatments or services are excluded
from coverage.
  '  { - (13) - }   { + (16) + }   { -  ' Financially impaired'
means a carrier that - }  { +  ' 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.
  '  { - (14)(a) - }   { + (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.
  '  { - (15) - }   { + (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).
  '  { - (16) - }   { + (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.
  '  { - (17)(a) - }   { + (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.
  '  { - (18) - }   { + (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.
  '  { - (19) - }   { + (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.
  '  { - (20) - }   { + (23) + } 'Initial enrollment period'
means a period of at least 30 days following commencement of the
first eligibility period for an individual.
  '  { - (21) - }   { + (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. + }
  '  { - (22) - }   { + (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.
  '  { - (23) - }   { + (27) + } 'Oregon Medical Insurance Pool'
means the pool created under ORS 735.610.
  '  { - (24) - }   { + (28) + } '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.
  '  { - (25) - }   { + (29) + } '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.
  '  { - (26) - }   { + (30) + } 'Rating period' means the
12-month calendar period for which premium rates established by a
carrier are in effect, as determined by the carrier.
  '  { - (27) - }   { + (31) + } 'Representative' does not
include an insurance producer or an employee or authorized
representative of an insurance producer or carrier.
  '  { +  (32) '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 section 2, chapter
___, Oregon Laws 2011 (Enrolled Senate Bill 91). + }
  '  { - (28)(a) - }   { + (33) + } '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 50. + } If Senate Bill 91 becomes law, section
6, chapter ___, Oregon Laws 2011 (Enrolled Senate Bill 91), is
amended to read:
  '  { +  Sec. 6. + } Sections 2, 3 and 4 { + , chapter ___,
Oregon Laws 2011 (Enrolled Senate Bill 91), + }   { - of this
2011 Act - }  and the amendments to ORS 743.730 by   { - section
5 of this 2011 Act - }   { + section 49 of this 2011 Act + }
become operative on January 2, 2014.'.
  In line 43, delete '48' and insert '51'.
                         ----------