Amend: OAR 836-053-1404
Many health care providers and insurers are transitioning using classification
codes found in the "Diagnostic and Statistical Manual of Mental Disorders,
DSM-IV-TR, Fourth Edition" (DSM-IV) to the coding in the "Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition" (DSM-5). Until
all users have transitioned entirely to the DSM-5, it is necessary to include
applicable diagnostic codes from both versions in defining mental or nervous
condition for purposes of the mandatory requirements of Oregon’s mental
health parity statute. These temporary rules add appropriate diagnostic codes
from the DSM-5 to the rule.
Adopted: November 14, 2014
Effective: November 14, 2014 through May 12, 2015
Adopt: OAR 836-053-0100 and 836-053-0105
These rules implement the provisions of enrolled House Bill 4104 (2014 Legislative Session). The rules compliment rules of the Workers’ Compensation Division intended to facilitate better management and payment for interim medical benefits resulting from a work related injury or disease. These rules prohibit a carrier from imposing a waiver or exclusion in a health benefit plan for coverage of a service otherwise provided solely on the basis that the service is provided for a work-related injury or disease. The rules also establish an expedited preauthorization process for approving interim medical services. The rules also specify how payment is accomplished if a workers’ compensation claim is approved or denied. Finally the rules clarify when a claim for interim medical benefits is deemed a “clean claim” for purposes of requirements in the Insurance Code that require prompt payment of claims.
As specified in House Bill 4104, these requirements apply to health benefit plan contracts entered into or renewed on or after January 1, 2015.
Adopted: October 15, 2014
Effective: January 1, 2015
Adopt: OAR 836-010-0013 and 836-053-0066
Amend: OAR 836-053-0431 and 836-053-0465
These permanent rules replace temporary rules ID 6-2014 (Temp), 7-2014 (Temp),
and 8-2014 (temp), which established a special enrollment period, set forth
the filing and rating requirements and plan guidance for transitional plans
in 2015, and implemented the provisions of chapter 80, Oregon Laws 2014.
Adopted: October 6, 2014
Effective: October 6, 2014
Amend: OAR 836-042-0045
This rule adopts revisions to the revised 2008 edition of the Statistical Plan
for Workers’ Compensation and Employers Liability Insurance (Statistical
Plan), as filed by the National Council on Compensation Insurance (NCCI). The
primary revision to the Statistical Plan is to update the Pension Tables in
the plan using updated data for life expectancies and remarriage rates. The
revisions also include a number of reporting clarifications and maintenance
updates to enhance the rules.
Failure to adopt NCCI’s proposed revisions will cause Oregon’s governing
statistical plan for workers’ compensation and employer’s liability
insurance to differ from the statistical plan used in other states. The statistical
plan information is used in determining annual advisory loss costs. Lack of
uniformity in the statistical plan used across states can result in an inability
to combine Oregon-specific data with countrywide data to generate stable, credible
advisory loss costs. The lack of uniformity may also lead to inconsistencies
and errors in reporting by insurers who write workers’ compensation in
several states, including Oregon.
Adopted: October 1, 2014
Effective: October 1, 2014
This rule allows an insurer, with the consent of the claimant, to pay claims
by means of a prepaid card, direct deposit system, automated teller machine
card or debit card or other means of electronic transfer.
This rule will take effect upon adoption.
Adopted: August 15, 2014
Effective: August 15, 2014
Amend: OAR 836-053-0431
The federal Affordable Care Act (ACA) and Chapter 681, Oregon Laws 2013, (Enrolled
House Bill 2240) require that insurers that issue individual health benefit
plans offer coverage to persons 65 or older who are not enrolled in Medicare
and, outside of the Oregon Health Insurance Exchange, without regard to a person’s
legal status. Permanent changes to the existing rule are necessary to ensure
that all persons entitled to coverage can obtain coverage. These amendments
to OAR 836-053-0431 clarify that carriers that issue individual health benefit
plans must offer and provide individual health benefit plan coverage to applicants
who are 65 or older unless such persons are actually enrolled in Medicare; and
to applicants who are applying for coverage outside of the Oregon Health Insurance
Exchange without regard to the legal status of a person.
The rule also makes non substantive technical corrections and adjusts some
provisions in the rule to be consistent with other temporary provisions to the
same rule currently in effect.
This rule replaces changes made by amendments included in a temporary rule
that expires on July 31, 2014.
Adopted: July 30, 2014
Effective: July 30, 2014
Amend: OAR 836-071-0267
Currently, this rule allows an insurance producer to impose an incidental charge
for the actual cost of obtaining a motor vehicle report from the Motor Vehicle
Division of the Oregon Department of Transportation or from the comparable agency,
but limits the charge to not more than $4. The Motor Vehicle Division of the
Oregon Department of Transportation currently charges $9.68 for electronically
obtained reports. The changes in the proposed rule eliminate the $4 cap and
simply allow the producer to pass on to the consumer the actual cost imposed
by the Motor Vehicle Division for obtaining the report.
The amendments to these rules will take effect upon adoption.
Adopted: July 21, 2014
Effective: July 21, 2014
Adopt: OAR 836-200-0401, 836-200-0406, 836-200-0411, 836-200-0416, 836-200-0421
These rules implement new registration requirements imposed on pharmacy benefit managers in legislation passed by the 2013 Legislative Assembly. Beginning January 1, 2014, individuals or business entities that contract with pharmacies on behalf of an insurer, a third-party administrator or the Oregon Prescription Drug Program (established in ORS 414.312) to process claims, pay pharmacies or negotiate rebates for prescription drugs or medical supplies, must register annually with the Department of Consumer and Business Services. These permanent rules replace temporary rules that established the initial procedures for registration and renewal of registration necessary to allow pharmacy benefit managers to comply with the requirements of the new law.
The rule numbers have changed from the proposed rule because the original numbers were no longer available.
Adopted: July 21, 2014
Effective: July 21, 2014
Adopt: OAR 836-010-0150
This rule requires entities regulated by the Department of Consumer and Business
Services to treat same-sex marriages validly performed the same as any marriage
of heterosexual couples validly performed. The rule is necessary to comply with
the recent federal court decisions by the United States Supreme Court and Oregon
District Court that held prohibitions on same gender marriages unconstitutional
under the U.S. Constitution.
This permanent rule will apply on and after the date the rules are adopted.
Adopted: July 17, 2014
Effective: July 17, 2014
Adopt: OAR 836-007-0001
This rule clarifies when and how the director may exercise the discretionary authority to seek restitution or other equitable relief on behalf of a consumer who has suffered damages as a result of an insurer’s violation of the Insurance Code, applicable federal law or the insurer’s breach of an insurance contract or policy that the insurer has with the consumer. The rule defines “consumer,” “actual damages” and “equitable relief” and specifies when the director will seek relief. The rule specifically states that the director will not seek relief on behalf of a consumer who is entitled to an exclusive remedy under the workers compensation laws of this state and specifies that the director may reduce actual damages upon a showing that the consumer has failed to reasonably mitigate damages.
This permanent rule will apply on and after the date the rules are adopted. The department adopted temporary rules effective December 27, 2013 and this permanent rule replaces the temporary rules.
Adopted: June 20, 2014
Effective: June 20, 2014
Amend: OAR 836-052-0142
Some individuals on Medicare rely on individual health plans as their
secondary coverage, rather than Medicare Supplement (Medigap) insurance,
for services not covered by Medicare parts A, B or D. For at least
some of these individuals the commercial individual health plan (IHP)
may have been equal to or superior to what they could have through
Medigap (e.g., at the time there may have been superior pharmacy coverage
through the IHP). In other instances, individuals might not realize
the advantage of migrating to Medigap coverage when they became Medicare
eligible and the insurer or agent did not guide them to switch to
Generally, the only time a person has a right to purchase Medigap
coverage on a guaranteed issue basis is upon gaining eligibility for
Medicare. For most persons this occurs only once at age 65. For persons
determined to be disabled prior to age 65, the first opportunity is
at the time of their disability determination with accompanying Medicare
eligibility; for these persons a second opportunity is presented at
age 65. If a person does not choose a Medigap policy at the time of
disability determination or turning 65, the person may be able to
purchase Medigap in the future on an underwritten basis, but the opportunity
is lost to ever opt in on a guaranteed issue basis.
This permanent rule replaces a temporary rule issued in December
2013 that requires guaranteed issue for individual health plans ending
according to the deadlines established under the Affordable Care Act
(ACA) for termination of noncompliant plans. Since December, the ACA
deadlines have been adjusted on two occasions and insurers have the
ability to choose the dates of plan termination within guidelines,
resulting in the extension of the previously established termination
dates in most cases to a date after the expiration of the emergency
rule. The result of the termination when it occurs is to end IHP coverage
for persons who relied on this coverage as a substitute for Medigap.
This permanent rule extends the period of guaranteed issue to coincide
with the termination of IHP under the ACA. This will protect the affected
The amendments in this rule require guaranteed issue of Medigap for
individuals who relied on IHP to supplement Medicare and who have
no control over the impending termination of the IHP as required by
the ACA. Continuing this protection for Oregon consumers is consistent
with the principle of protecting persons who involuntarily lose other
Adopted: May 19, 2014
Effective: May 19, 2014