836-053-0211 - Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan

836-053-0211. Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan

(1) As used in this rule, an "enrollee" includes an employee covered under a group health benefit plan and a dependent of an employee covered under a group health benefit plan.

(2) A carrier issuing a group health plan may not:

(a) Modify health insurance with respect to an employee or any eligible dependent of an employee by means of a rider, endorsement or otherwise, for the purpose of restricting or excluding coverage for certain diseases or medical conditions otherwise covered by the health benefit plan;

(b) Decline to offer coverage to any eligible member of a group;

(c) Delay enrollment for an otherwise eligible member of the group or dependent for reasons related to actual or expected health status, race, color, national origin, sex, sexual orientation as defined in ORS 174.100, age or disability; or

(d) Use a health statement when offering a group health benefit plan.

(3) Unless otherwise required by law. a modification to an existing group health benefit plan that is required by ORS 743.730 to 743.754 must be implemented for each policyholder on the next renewal date. As used in this rule, "the next renewal date" means the first renewal date of the policy issued to the policyholder that occurs on or after January 1, 2014.

(4) A carrier must enroll a person who is eligible in a small group health benefit plan during the plan's open enrollment period and when a person is eligible or becomes eligible as a result of the occurrence of an event described in this section, if:

(a) The person applies for coverage within at least 30 calendar days after:

(A) An event described in section 603 of the Employee Retirement Income Security Act of 1974, as amended;

(B) An event described in 45 CFR 146.117(a)(3) if the person is eligible for special enrollment under 45 CFR 146.117(a)(2), except for an event described in 45 CFR 146.117(a)(3)(D) a carrier must enroll a person who applies for coverage within 30 days, or later if allowed by the carrier, after the first denial of a claim due to the operation of a lifetime limit on all benefits; or

(C) Gaining a dependent, including a spouse, or becoming a dependent through marriage, birth, adoption or placement for adoption if the person is eligible for special enrollment under 45 CFR 146.117(b)(2); or

(b) The person applies for coverage within 60 calendar days after:

(A) Loss of eligibility for coverage under a Medicaid plan under title XIX of the Social Security Act or a state child health plan under title XXI of the Social Security Act; or

(B) An event described in 45 CFR 155.725(j)(2)(iii).

(5) The following effective dates apply to coverage for enrollment under section (4) of this rule:

(a) For section (4)(a)(A), coverage must be effective by the applicable date described in 45 CFR 155.420(b)(1).

(b) For section (4)(a)(B) coverage must be effective no later than the first day of the first calendar month following the date the plan or issuer receives the request for special enrollment.

(c) For section (4)(a)(C) coverage must be effective:

(A) In the case of marriage, no later than the first day of the first calendar month following the date the carrier receives the request for special enrollment.

(B) In the case of birth, on the date of birth.

(C) In the case of adoption or placement for adoption, no later than the date of adoption or placement for adoption.

(e) For section (4)(b)(A) coverage must be effective by the applicable date described in 45 CFR 155.420(b)(1).

(f) For section (8)(b)(B) coverage must be effective no later than the first day of the first calendar month following the date the plan or issuer receives the request for special enrollment.

(6) At or before enrollment, a carrier must provide notice to an enrollee that complies with the requirements of 45 CFR 146.117(c).

(7) An enrollee under section (4) of this rule may not be considered a late enrollee.

(8) Violation of this rule is an unfair trade practice under ORS 746.240.

(ID 12-2013, f. 12-31-13, cert. ef. 1-1-14)

Stat. Auth.: ORS 731.244 & 743.731

Stats. Implemented: Sec. 7, ch. 681, OL 2013, ORS 743.522, 743.730-743.754 & 746.240

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