2021 Oregon Revised Statutes
Chapter 743B - Health Benefit Plans: Individual and Group
Section 743B.020 - Eligible employees and small employers; rules.


(a) An employee is an eligible employee as defined in ORS 743B.005; and
(b) An employer is a small employer as defined in ORS 743B.005.
(2) The method adopted by the department under subsection (1) of this section must be consistent with corresponding federal requirements for the Small Business Health Options Program as defined in ORS 741.300. [2015 c.515 §3a]
Note: 743B.020 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.

Structure 2021 Oregon Revised Statutes

2021 Oregon Revised Statutes

Volume : 18 - Financial Institutions, Insurance

Chapter 743B - Health Benefit Plans: Individual and Group

Section 743B.001 - Definitions.

Section 743B.003 - Purposes.

Section 743B.005 - Definitions.

Section 743B.010 - Issuance of group health benefit plan to affiliated group of employers; determination of number of employees for purpose of determining eligibility as small employer.

Section 743B.011 - Group health benefit plans subject to provisions of specified laws; exemptions.

Section 743B.012 - Requirement to offer all health benefit plans to small employers; offering of plan by carriers; exceptions.

Section 743B.013 - Requirements for small employer health benefit plans.

Section 743B.020 - Eligible employees and small employers; rules.

Section 743B.100 - Department’s authority to regulate market.

Section 743B.103 - Use of health-related information.

Section 743B.104 - Coverage in group health benefit plans; consideration of prospective enrollee health status restricted; effect of discontinuing offer of plans; exceptions; coverage by multiple employer welfare arrangements.

Section 743B.105 - Requirements for group health benefit plans other than small employer plans.

Section 743B.109 - Short term health insurance policies; rules.

Section 743B.125 - Individual health benefit plans; waiting or exclusion periods; preexisting condition exclusions; guaranteed issue and renewal.

Section 743B.126 - Carrier marketing of individual health benefit plans; rules; duties of carrier regarding applications; effect of discontinuing offer of plans.

Section 743B.128 - Exceptions to requirement to actively market all plans.

Section 743B.129 - Shortening period of exclusion following discontinued offering; rules.

Section 743B.130 - Requirement to offer bronze and silver plans; rules.

Section 743B.200 - Requirements for insurers offering managed health insurance; quality assessment.

Section 743B.202 - Requirements for insurers offering managed health or preferred provider organization insurance; rules; opportunity to participate.

Section 743B.220 - Requirements for insurers that require designation of participating primary care physician; exceptions.

Section 743B.222 - Designation of women’s health care provider as primary care provider; direct access to women’s health care provider.

Section 743B.225 - Continuity of care.

Section 743B.227 - Referrals to specialists.

Section 743B.250 - Required notices to applicants and enrollees; grievances, internal appeals and external reviews.

Section 743B.252 - External review; rules.

Section 743B.253 - Director to contract with independent review organizations to provide external review; rules.

Section 743B.254 - Required statements regarding external reviews.

Section 743B.255 - Enrollee application for external review; when enrollee deemed to have exhausted internal appeal.

Section 743B.256 - Duties of independent review organizations; expedited reviews.

Section 743B.257 - Civil penalty for failure to comply by insurer that agreed to be bound by decision.

Section 743B.258 - Private right of action.

Section 743B.260 - Claims and appeals of adverse benefit determinations under disability income insurance policies; rules.

Section 743B.280 - Definitions for ORS 743B.280 to 743B.285.

Section 743B.281 - Estimate of costs for in-network procedure or service.

Section 743B.282 - Estimate of costs for out-of-network procedure or service.

Section 743B.283 - Submission of methodology used to determine insurer’s allowable charges.

Section 743B.284 - Alternative mechanism for disclosure of costs and charges.

Section 743B.285 - Rules.

Section 743B.287 - Balance billing prohibited for health care facility services.

Section 743B.290 - Hospital payment of copayment or deductible for insured patient.

Section 743B.300 - Disclosure of differences in replacement health insurance policies; nonduplication for persons 65 and older; rules.

Section 743B.310 - Rescinding coverage; permissible bases; notice; rules.

Section 743B.320 - Minimum grace period; notice upon termination of policy; effect of failure to notify.

Section 743B.323 - Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium; rules.

Section 743B.324 - Rules for certain notice requirements.

Section 743B.330 - Notice to policyholder required for cancellation or nonrenewal of health benefit plan; effect of failure to give notice.

Section 743B.340 - When group health insurance policies to continue in effect upon payment of premium by insured individual.

Section 743B.341 - Continuation of benefits after termination of group health insurance policy; rules.

Section 743B.342 - Continuation of benefits after injury or illness covered by workers’ compensation.

Section 743B.343 - Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older.

Section 743B.344 - Procedure for obtaining continuation of coverage under ORS 743B.343.

Section 743B.345 - Premium for continuation of coverage under ORS 743B.344; termination of right to continuation.

Section 743B.347 - Continuation of coverage under group policy upon termination of membership in group health insurance policy; applicability of waiting period to rehired employee.

Section 743B.400 - Decisions regarding health care facility length of stay, level of care and follow-up care.

Section 743B.403 - Insurer prohibited practices; patient communication and referral.

Section 743B.405 - Medical services contract provisions; nonprovider party prohibitions; future contracts.

Section 743B.406 - Vision care providers.

Section 743B.407 - Naturopathic physicians.

Section 743B.420 - Prior authorization requirements.

Section 743B.422 - Utilization review requirements for medical services contracts to which insurer not party; right to appeal.

Section 743B.423 - Utilization review requirements for insurers offering health benefit plan.

Section 743B.424 - Applicability.

Section 743B.425 - Prior authorization prohibited for first 60 days of treatment for opioid or opiate withdrawal and for post-exposure prophylactic antiretroviral drugs; exceptions.

Section 743B.427 - Nonquantitative treatment limitations on coverage of behavioral health conditions.

Section 743B.450 - Prompt payment of claims; limits on use of electronic payment methods; rules.

Section 743B.451 - Refund of paid claims.

Section 743B.452 - Interest on unpaid claims.

Section 743B.453 - Underpayment of claims.

Section 743B.454 - Claims submitted during credentialing period.

Section 743B.458 - Performance-based incentive payments for primary care.

Section 743B.460 - Conditions for restricting payments to only in-network providers.

Section 743B.462 - Direct payments to providers.

Section 743B.470 - Medicaid not considered in coverage eligibility determination; claims for services paid for by medical assistance; prohibited ground for denial of enrollment of child; insurer duties.

Section 743B.475 - Guidelines for coordination of benefits; rules.

Section 743B.500 - Selling and leasing of provider panels by contracting entity; definitions.

Section 743B.501 - Registration of contracting entity.

Section 743B.502 - Third party contracts for leasing of provider panels; requirements.

Section 743B.503 - Additional requirements for third party contracts.

Section 743B.505 - Provider networks; rules.

Section 743B.555 - Confidential communications.

Section 743B.601 - Synchronization of prescription drug refills.

Section 743B.602 - Step therapy.

Section 743B.800 - Risk adjustment procedures; rules.

Section 743B.810 - Enrollees covered by workers’ compensation.