Or. Admin. R. 836-082-0055

Current through Register Vol. 63, No. 8, August 1, 2024

Section 836-082-0055 - Continuance of Group Health Insurance Coverage in Situations Involving Replacement

(1) This rule:

(a) Indicates the insurer responsible for liability when one insurer's group health policy or contract providing coverage for hospital or medical services or expenses replaces a policy or contract of similar benefits of another insurer;

(b) Indicates which policy or contract provides coverage for a policyholder when an insurer replaces a group health insurance policy or contract with a policy or contract of similar benefits.

(2) An insurer of a prior policy or contract is liable as follows:

(a) If the insurer of the prior policy or contract is not the insurer of the succeeding policy, the insurer of the prior policy or contract shall remain liable as provided in ORS 743.529 with respect to an individual who is hospitalized on the date of termination of a prior policy or contract, and otherwise only to the extent of its accrued liabilities and extensions of benefits;

(b) If the insurer for the prior policy or contract and the succeeding policy or contract is the same, the insurer shall remain liable under the prior policy or contract only to the extent of its accrued liabilities and extensions of benefits.

(3) Except as ORS 743.529 otherwise applies to an individual who is hospitalized on the date of termination of the prior policy, if an individual was validly covered under the prior plan on the date of discontinuance and is a member of the class or classes of individuals eligible for coverage under the succeeding plan, the individual shall be eligible for coverage under the succeeding plan without regard to actively-at-work or nonconfinement provisions. Any reference under this section to an individual who was or was not totally disabled is a reference to the individual's status immediately prior to the date the succeeding plan's coverage becomes effective. The following provisions govern such coverage:

(a) Except as provided for preexisting conditions in section (5) of this rule, the minimum level of benefits to be provided by the succeeding plan shall be the applicable level of benefits of the succeeding plan reduced by any benefits payable by the prior plan;

(b) Such coverage must be provided under the succeeding plan until the date on which the individual's coverage would terminate in accordance with the succeeding plan provisions applicable to individual termination of coverage, such as termination of employment or eligibility as a dependent.

(4) Section (3) of this rule does not apply with respect to an individual who is excluded under the succeeding policy because the individual is otherwise covered under another policy with similar benefits.

(5) In the case of a pre-existing conditions limitation included in the succeeding plan, the level of benefits applicable to pre-existing conditions of persons become covered by the succeeding plan in accordance with section (3) of this rule during the period of time this limitation applies under the succeeding plan may be either:

(a) The benefits of the succeeding plan determined without application of the pre-existing conditions limitation, reduced by any benefits actually paid or payable by the prior plan; or

(b) The benefits of the prior plan reduced by any benefits actually paid or payable by the prior plan.

(6) The insurer of the succeeding plan, in applying any deductibles or waiting periods in its plan, shall give credit for the satisfaction or partial satisfaction of the same or similar provisions under a prior plan providing similar benefits, whether the prior plan is its own or was issued by another insurer. In the case of deductible provisions, the credit shall apply for the same or overlapping benefit periods and shall be given for expenses actually incurred and applied against the deductible provisions of the prior plan during the calendar year in which the succeeding plan becomes effective. However, the credit shall apply or be given only to the extent the expenses are recognized under the terms of the succeeding plan and are subject to a similar deductible provision.

(7) In any situation in which a determination of the prior insurer's benefit is required, it shall be the responsibility of the claimant to furnish evidence of the terms of the prior plan and of claim payments by the prior insurer.

Or. Admin. R. 836-082-0055

ID 13-1990, f. 6-12-90, cert. ef. 7-1-90

Stat. Auth.: ORS 731, ORS 742 & ORS 746

Stats. Implemented: ORS 742.005(3) - ORS 742.005(4) & ORS 746.0015(1)