Or. Admin. Code § 409-025-0110 - General Reporting Requirements

(1) Determination of "mandatory reporter":

(a) For carriers and licensed third-party administrators, the Authority shall identify mandatory reporters using information collected by DCBS including, but not limited to, data from the Health Insurance Member Enrollment Report.

(A) The Authority shall aggregate the most recent four quarters of data.

(B) The Authority shall calculate the mean total lives for each carrier and licensed third-party administrator. Mean total lives shall be calculated by using the total covered lives in the following lines of business for each carrier and licensed third-party administrator:

(i) Large group;

(ii) Small group;

(iii) Individual market;

(iv) Medicare Advantage; and

(v) Self-insured.

(C) All carriers and licensed third-party administrators with calculated mean total lives of 5,000 or higher shall be mandatory reporters.

(b) All PBMs shall be mandatory reporters.

(c) All CCOs shall be mandatory reporters.

(d) All reporting entities with Dual Eligible Special Needs Plans in Oregon shall be mandatory reporters.

(e) All insurers providing coverage funded under Part D of Medicare shall be mandatory reporters.

(f) All insurers offering a health benefits plan in Oregon's health insurance exchange shall be mandatory reporters.

(g) All insurers providing group health insurance plans to PEBB and OEBB members shall be mandatory reporters.

(2) If an organization believes a determination by the Authority of its mandatory status to be in error, the organization must contact the Authority to contest the determination as described in the notice no later than 90 days prior to the first scheduled date of submission of production files.

(3) Any carrier or licensed third-party administrator who has been identified as a mandatory reporter and believes their entity has fewer than 5,000 mean total lives due to ERISA self-insured shall notify the Authority by filing a request for waiver under OAR 409-025-0140.

(4) An organization may elect to participate as a voluntary reporter by notifying the Authority in writing.

(5) Mandatory and voluntary reporters shall submit data files for all required lines of business. They may submit data files for the voluntary lines of business and may not submit data files for any excluded lines of business.

(a) Required lines of business include:

(A) Medicare Advantage Part C and Medicare Part D;

(B) Medicaid;

(C) Individual;

(D) Small employer health insurance;

(E) Large group;

(F) Associations and trusts;

(G) PEBB and OEBB group health insurance plans;

(H) Self-insured plans not subject to ERISA; and

(I) Dental insurance.

(b) Voluntary lines of business include self-insured plans subject to ERISA.

(c) Excluded lines of business include:

(A) Accident policy;

(B) Disability policy;

(C) Hospital indemnity policy;

(D) Long-term care insurance;

(E) Medicare supplemental insurance;

(F) Specific disease policy;

(G) Stop-loss plans;

(H) Student health policy;

(I) Supplemental insurance that pays deductibles, copays or coinsurance;

(J) Vision-only insurance; and

(K) Workers compensation.

(d) A mandatory reporter that contracts with another entity remains responsible for reporting all required lines of business. If the mandatory reporter elects to have the data reported by a contracted entity, the mandatory reporter shall notify the Authority and provide contact information for the contracted entity.

(6) Mandatory and voluntary reporters shall comply with data file layout, format, and coding requirements in OAR 409-025-0120.

(7) Mandatory and voluntary reporters shall comply with data submission requirements in OAR 409-025-0130.

(8) A mandatory reporter who plans to withhold data must submit a waiver of reporting in compliance with OAR 409-025-0140. If the mandatory reporter believes that the data are prohibited from disclosure under state or federal statutes, regulations or rules, then the waiver request must state the data prohibited from disclosure and the statute, regulation or rule that requires withholding the data.

(9) The Authority shall provide written notification by July 1 of each year to all mandatory reporter's subject to the reporting requirements of OAR 409-025-0100 to 409-025-0150 for the following calendar year.

(10) New mandatory reporters submitting for the first time, or mandatory reporters that did not submit data in the previous year, shall submit test files before production files are due. The mandatory reporters shall submit test files no later than 60 days before the first scheduled date of submission of production files.

Notes

Or. Admin. Code § 409-025-0110

OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10; OHP 4-2012, f. 5-23-12, cert. ef. 6-1-12; OHP 5-2012(Temp), f. 6-23-12, cert. ef. 6-1-12 thru 11-15-12; OHP 6-2012; f. 6-26-12, cert. ef. 7-9-12; OHP 1-2016, f. & cert. ef. 1/5/2016; OHP 10-2016, f. 6-22-16, cert. ef. 1/1/2017; OHP 2-2017, f. 6-23-17, cert. ef. 1/1/2018; OHP 7-2018, amend filed 06/29/2018, effective 1/1/2019; OHP 2-2019, amend filed 05/30/2019, effective 1/1/2020; OHP 8-2022, amend filed 12/01/2022, effective 12/1/2022

Statutory/Other Authority: ORS 442.466

Statutes/Other Implemented: ORS 442.464 & 442.466