Or. Admin. Code § 836-053-1030 - Written Information to Enrollees
(1) Each insurer must furnish written
information to policyholders that is required by ORS
743.804, including but not
limited to information relating to enrollee rights and responsibilities,
including the right to appeal adverse benefit determinations, services, access
thereto and related charges and scheduling, and access to external review, as
provided in this rule. An insurer:
(a) Must
furnish the information regarding an individual health insurance policy to each
policyholder; and
(b) Must furnish
the information regarding a group health insurance policy to the group
policyholder for distribution to enrollees of the group policy.
(2)
(a) The written information described in
section (1) of this rule must be included either in the policy or in other
evidence of coverage that is delivered to the individual policyholder by the
insurer, or in the case of a group health insurance policy, that is delivered
by the insurer to the group policyholder for distribution to
enrollees.
(b) As used in ORS
743.804(2)(g),
"continued coverage under the health benefit plan" means coverage of an ongoing
course of treatment previously approved by the insurer.
(c) The information required under subsection
(a) of this section must include all of the following:
(A) A description of the external review
process, including when external review is available and how to request
external review. The description must include the phone number of the Division
of Financial Regulation.
(B) A
disclosure that when filing a request for an external review the enrollee will
be required to authorize the release of any records, including medical records
of the covered person that may be required to be reviewed for the purpose of
reaching a decision on the external review.
(C) A disclosure that the enrollee is
financially responsible for benefits paid to or on behalf of an enrollee
pursuant to ORS 743.804(2)(g)
if the insurer's adverse benefit determination is upheld on appeal.
(D) A disclosure that the enrollee may
request and receive from the insurer the information the insurer is required to
disclose under ORS 743.804(5).
(3) The information
required by ORS 743.804 must include the
following in relation to referrals for specialty care, behavioral health
services, hospital services and other services, in addition to other relevant
information regarding referrals:
(a) If
applicable, how gate keeping or access controls apply to referrals and whether
and how the controls differ for specialty care, behavioral health services and
hospital services; and
(b) Any
limitation on referrals if a plan has a defined network of participating
providers and if referrals for specialty care may be limited to a portion of
the network, such as to those specialists who contract with an enrollee's
primary care group.
(4)
The information required by ORS
743.804 must include the
information required by ORS
743A.012, relating to coverage
of emergency medical conditions and obtaining emergency services, including a
statement of the prudent layperson standard for an emergency medical condition,
as that term is defined in ORS
743A.012. An insurer may meet
the requirement of providing information in ORS
743A.012 by providing adequate
disclosure in the information required by ORS
743.804(1) and
this rule. An insurer may use the following statement regarding the use of the
emergency telephone number 9-1-1, or other wording that appropriately discloses
its use:
"If you or a member of your family needs immediate assistance for a medical emergency, call 9-1-1 or go directly to an emergency room."
(5) The information
required by ORS 743.804(1)(b) and
(4) must include information regarding the
use of the insurer's grievance process, including the assistance available to
enrollees in filing written grievances in accordance with OAR
836-053-1090 and the utilization
review appeal procedures required by ORS
743.807(2)(c).
The information must be contained in a separate section and captioned in a
manner that clearly indicates that the section addresses grievances and
appeals.
(6) The information
required by ORS 743.804(1)(b) and
(4) must include a notice that states the
right of an enrollee to file a complaint with or seek assistance from the
director of the Department of Consumer and Business Services. An insurer may
use the following statement or other appropriate wording for this purpose:
"You have the right to file a complaint or seek other assistance from the Division of Financial Regulation.
Assistance is available:
By calling 503-947-7984 or the toll-free message line at 888-877-4894;
By electronic mail at: DFR.InsuranceHelp@dcbs.oregon.gov;
By writing to the Division of Financial Regulation, Consumer Advocacy at:
PO Box 14480; Salem, OR 97309-0405; or
Through the Internet at dfr.oregon.gov/help."
(7) The information required by ORS
743.804(1) for
an insurance policy providing managed health care must include a description of
the procedures by which enrollees, purchasers and providers may participate in
the development and implementation of insurer policy and operation.
(8) The portion of the information required
by ORS 743.804 that describes how an
insurer makes decisions regarding coverage and payment for treatment or
services must include a notice to enrollees that they may request an additional
written summary of information that the insurer may consider in its utilization
review of a particular condition to the extent the insurer maintains such
criteria. The notice to enrollees must include the name and telephone number of
the administrative section of the insurer that handles enrollee requests for
information.
(9) If a plan has a
defined network of participating providers, the information required by ORS
743.804 must include a list of
all participating primary care providers, direct access providers and all
specialty care providers. For the purposes of this section, a primary care
provider or direct access provider is a participating provider under the terms
of the plan who an enrollee may designate as the primary care provider for the
enrollee or from whom an enrollee may obtain services without referral. The
list of providers must include for each provider the provider's name,
professional designation, category of practice and the city in which the
practice of the provider is located.
(10) If a plan includes risk-sharing
arrangements with physicians or other providers, the information required by
ORS 743.804 must contain a statement
to that effect, including a brief description of risk-sharing in general and
must notify enrollees that additional information is available upon request.
For the purpose of this requirement, a risk-sharing arrangement does not
include a fee-for-service arrangement or a discounted fee-for-service
arrangement. An insurer may use the following statement or other appropriate
wording to describe risk-sharing:
"This plan includes "risk-sharing" arrangements with physicians who provide services to the members of this plan. Under a risk-sharing arrangement, the providers that are responsible for delivering health care services are subject to some financial risk or reward for the services they deliver. An example of a risk-sharing arrangement is a contract between an insurer and a group of heart surgeons in which the surgeons agree to provide all of the heart operations needed by plan members and the insurer agrees to pay a fixed monthly amount for those services."
(11) If the insurer of a plan uses a
mandatory closed formulary, the information required by ORS
743.804 for that plan must
prominently disclose and explain the formulary provision. The disclosure and
explanation must be in boldfaced type or otherwise emphasized.
(12) An insurer that issues a health benefit
plan must include a notice with the information required by ORS
743.804 that discloses that
additional information is available to enrollees upon request. The notice must
include the name and telephone number of the insurer's administrative section
that handles enrollee requests for information. The notice must also include
the contact described in section (6) of this rule and a statement that the
following additional information may be available from the Department of
Consumer and Business Services:
(a) An annual
summary of grievances and appeals;
(b) An annual summary of utilization review
policies;
(c) An annual summary of
quality assessment activities;
(d)
The results of all publicly available accreditation surveys;
(e) An annual summary of the insurer's health
promotion and disease prevention activities;
(f) An annual summary of scope of network and
accessibility of services.
Notes
Statutory/Other Authority: ORS 731.244 & ORS 743.857
Statutes/Other Implemented: ORS 743.699, ORS 743.804 & ORS 743.807
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