Or. Admin. Code § 836-053-0825

Current through Register Vol. 63, No. 11, November 1, 2024

Section 836-053-0825 - Rescission of a Group Health Benefit Plan

(1) For purposes of ORS 743B.013 and ORS 743B.105, "representative" means a person who, with specific authority from the employer or plan sponsor to do so, binds the employer or plan sponsor to a contract for health benefit plan coverage.

(2) The notice required by ORS 743B.013(6), ORS 743B.105(8) and ORS 743B.310(3) to each plan enrollee affected by the rescission must be in writing and include all of the following:

(a) Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact underlying the rescission.

(b) An explanation of why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact.

(c) A statement explaining an enrollee's right to file a grievance or request a review of the decision to rescind coverage.

(d) A description of the health carrier's applicable grievance procedures, including any time limits applicable to those procedures.

(e) A statement explaining that complaints relating to the notice of rescission required under ORS 743B.013(6), ORS 743B.105(8) and ORS 743B.310(3) may be made with the Department of Consumer and Business Services by writing to the department at PO Box 14480, Salem, OR 97309-0405; by calling 503-947-7984 or toll-free 888-877-4894; online at dfr.oregon.gov; or by electronic mail to DFR.InsuranceHelp@dcbs.oregon.gov. The statement shall also explain that complaints to the Department of Consumer and Business Services do not constitute grievances under the health benefit plan and may not preserve an enrollee's rights under the plan.

(f) The toll-free customer service number of the insurer.

(g) The effective date of the rescission and the date back to which the coverage will be rescinded.

(3) Subject to ORS 743.023(3), a health carrier may provide the required notice for small employer group health insurance either by first class mail or electronically.

(4)

(a) On or before June 30 of each calendar year, an insurer must submit an electronic notice for the preceding calendar year in the format prescribed by the director of the Department of Consumer and Business Services and in accordance with instructions set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services at dfr.oregon.gov. The notice required by ORS 743B.013(6)(c), ORS 743B.105(8)(c) and ORS 743B.310(4) must include information related to group health benefit plan rescissions including but not limited to the total number of:

(A) Fully rescinded group health benefit plans;

(B) Partially rescinded group health benefit plans;

(C) Group health benefit plans in force on December 31 of the report year;

(D) Enrollees affected by a fully rescinded group health benefit plan; and

(E) Enrollees affected by a partially rescinded group health benefit plan.

(b) The notice required under this section may be combined with the notice required under OAR 836-053-0830 and OAR 836-053-0835.

(5) An insurer may not rescind coverage for fraud if a representative fails to accurately comply with the requirement to provide reasonable assurance that pediatric dental coverage is separately provided.

Or. Admin. Code § 836-053-0825

ID 23-2011, f. & cert. ef. 12-19-11; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 4-2016, f. & cert. ef. 4/8/2016; ID 33-2023, minor correction filed 07/20/2023, effective 7/20/2023

Statutory/Other Authority: ORS 743.018, ORS 743.019, ORS 743.020 & ORS 743B.310

Statutes/Other Implemented: ORS 743.018, ORS 743.019, ORS 743.020, ORS 743B.310, ORS 742.003, ORS 742.005, ORS 742.007, ORS 743.022, ORS 743B.005, ORS 743B.013 & ORS 743B.105