Adopt: OAR 836-010-0637 & 836-052-0680
Amend: OAR 836-052-0531, 836-052-0566, 836-052-0636, 836-052-0676,
Recently long term care insurance has experienced extremely
high rate increases and other actions that have harmed consumers, in some cases,
resulting in the loss of a policy at a time the insured is most likely to need
the insurance afforded under a policy. These rules adopt provisions to protect
the consumer while still complying with federal requirements for long term care
These rules incorporate portions of the August 2014 update to the NAIC Long
Term Care Insurance Model Regulation #641. In addition, new policy options are
established for Long Term Care Partnership Policies while still complying with
Adopted: June 10, 2015
Effective: January 1, 2016
Adopt: OAR 836-053-1205
This new permanent rule adopts requirements for payers
to accept a uniform prescription drug prior authorization form. This requirement
was established by the 2013 Legislative Assembly in Senate Bill 382. Acceptance
of a uniform form by all payers in Oregon is expected to streamline and simplify
requests for prior approval for prescription drugs prescribed by providers.
The rule applies to payers as defined in ORS 743.061 which includes health insurers,
third party administrators, prepaid managed care health services organizations,
any person or public body that either individually or jointly establishes a
self-insurance plan, program, or contract, including but not limited to persons
and public bodies that are otherwise exempt from the Insurance Code under ORS
731.036, health care clearinghouses or other entities that process or facilitate
the processing of health care financial and administrative transactions from
a nonstandard format to a standard format, and any other person identified by
the department that processes health care financial and administrative transactions
between a health care provider and an entity described in this subsection.
The rule does not require payers to reject a request for prior authorization
for a prescription drug if the provider submits a form other than the uniform
form, but it does require a payer to accept the form whenever it is used by
a provider to submit a request.
The requirement to accept this uniform prior authorization form applies to
payers on and after July 1, 2015 as established in Senate Bill 382.
Adopted: May 27, 2015
Effective: May 27, 2015
Adopt: OAR 836-053-1407 and 836-053-1408
Amend: OAR 836-053-1404
Many health care providers and insurers are transitioning from 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 rules add appropriate diagnostic codes from the DSM-5 to the rule and clarify allowable exceptions and exclusions to the mental health parity statute.
This permanent rule will apply on and after the date the rules are adopted.
Adopted: May 12, 2015
Effective: May 12, 2015
Adopt: OAR 836-010-0026
This new rule, OAR 836-010-0026 defines discretionary
clause and prohibits an insurer from including a discretionary clause in an
insurance policy, contract, or agreement that would grant deference to the insurer
in proceedings subsequent to the insurer’s decision, denial, or interpretation
of terms, coverage, or eligibility for benefits.
This rule is applicable on and after March 12, 2015 to any new or renewal of
an insurance policy, contract, or agreement in Oregon.
For forms approved prior to March 12, 2015, insurers do not have to refile to correct the language, but insurers will have to comply with the rule as of the effective date. For any filings on or after March 12, 2015, the form language must comply with the rule. This rule applies to all lines of business.
Adopted: March 12, 2015
Effective: March 12, 2015
Amend: OAR 836-011-0000
This rulemaking prescribes, for reporting year 2014,
the required forms for the annual and supplemental financial statements required
of insurers, multiple employer welfare arrangements and health care service
contractors under ORS 731.574, as well as the necessary instructions for completing
Adopted: March 10, 2015
Effective: March 10, 2015
Adopt: OAR 836-051-0235
Amend: OAR 836-051-0210, 836-051-0220 and 836-051-0230
These permanent rules recognize a new annuity mortality table (2012 IAR Table) for use in determining reserve liabilities for annuities. The National Association of Insurance Commissioners (NAIC) adopted the revisions to NAIC Model Rule (Regulation) #821 in December 2012. Adoption of this table will require insurers to use the new table as the reserve mortality standard for individual annuity or pure endowment contracts issued after January 1, 2015. The 2012 IAR Table is a generational mortality table developed by the Society of Actuaries that incorporates projections for future mortality improvements. For affected contracts, reserves will ore accurately reflect anticipated mortality improvements for years beyond contract issue. Generally, the new table will result in higher reserves than current requirements.
Adopted: December 12, 2014
Effective: January 1, 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