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Section 743B.001 - Definitions. - (1) "Adverse benefit determination" means an insurer’s denial, reduction or...
Section 743B.003 - Purposes. - (1) To promote the availability of health insurance coverage to...
Section 743B.005 - Definitions. - (1) "Actuarial certification" means a written statement by a member...
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. - (2) Subsequent to the issuance of a health benefit plan...
Section 743B.011 - Group health benefit plans subject to provisions of specified laws; exemptions. - (a) Any portion of the premium or benefits is paid...
Section 743B.012 - Requirement to offer all health benefit plans to small employers; offering of plan by carriers; exceptions. - (2) A carrier shall issue to a small employer any...
Section 743B.013 - Requirements for small employer health benefit plans. - (a) Other than a grandfathered health plan, must cover essential...
Section 743B.020 - Eligible employees and small employers; rules. - (a) An employee is an eligible employee as defined in...
Section 743B.100 - Department’s authority to regulate market. - (a) Registration by each carrier with the department of the...
Section 743B.103 - Use of health-related information. - (a) Require an applicant to provide health-related information as a...
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. - (2) A carrier that elects to discontinue offering all of...
Section 743B.105 - Requirements for group health benefit plans other than small employer plans. - (1) A carrier offering a group health benefit plan may...
Section 743B.109 - Short term health insurance policies; rules. - (a) The policy is not subject to certain federal requirements...
Section 743B.125 - Individual health benefit plans; waiting or exclusion periods; preexisting condition exclusions; guaranteed issue and renewal. - (2) With respect to individual coverage under a grandfathered health...
Section 743B.126 - Carrier marketing of individual health benefit plans; rules; duties of carrier regarding applications; effect of discontinuing offer of plans. - (2) Except as provided in subsection (3) of this section,...
Section 743B.128 - Exceptions to requirement to actively market all plans. - (1) A health benefit plan sold only to a bona...
Section 743B.129 - Shortening period of exclusion following discontinued offering; rules. - (2) The department shall adopt rules establishing standards for shortening...
Section 743B.130 - Requirement to offer bronze and silver plans; rules. - (2) The department shall prescribe by rule, in accordance with...
Section 743B.200 - Requirements for insurers offering managed health insurance; quality assessment. - (1) Have a quality assessment program that enables the insurer...
Section 743B.202 - Requirements for insurers offering managed health or preferred provider organization insurance; rules; opportunity to participate. - (1) File an annual summary with the Department of Consumer...
Section 743B.220 - Requirements for insurers that require designation of participating primary care physician; exceptions. - (a) Permit the enrollee to change participating primary care physicians...
Section 743B.222 - Designation of women’s health care provider as primary care provider; direct access to women’s health care provider. - (2) Every health insurance policy that covers hospital, medical or...
Section 743B.225 - Continuity of care. - (2) An insurer offering managed health insurance or preferred provider...
Section 743B.227 - Referrals to specialists. - (a) The plan must establish and implement a procedure for...
Section 743B.250 - Required notices to applicants and enrollees; grievances, internal appeals and external reviews. - (1) Provide to all enrollees directly or in the case...
Section 743B.252 - External review; rules. - (a) Whether a course or plan of treatment is medically...
Section 743B.253 - Director to contract with independent review organizations to provide external review; rules. - (2) The director shall seek public comment when the director...
Section 743B.254 - Required statements regarding external reviews. - (1) A statement of the right of an enrollee to...
Section 743B.255 - Enrollee application for external review; when enrollee deemed to have exhausted internal appeal. - (2) An enrollee is eligible for external review only if...
Section 743B.256 - Duties of independent review organizations; expedited reviews. - (a) Decide whether the dispute pertains to an adverse benefit...
Section 743B.257 - Civil penalty for failure to comply by insurer that agreed to be bound by decision. - (2) A decision of an independent review organization is admissible...
Section 743B.258 - Private right of action. - (2) The Legislative Assembly intends that there is no private...
Section 743B.260 - Claims and appeals of adverse benefit determinations under disability income insurance policies; rules. - (a) "Adverse benefit determination" means a denial, reduction, termination of...
Section 743B.280 - Definitions for ORS 743B.280 to 743B.285. - (1) "In-network" means performed by a provider or provider group...
Section 743B.281 - Estimate of costs for in-network procedure or service. - (a) The type of procedure or service; (b) The name...
Section 743B.282 - Estimate of costs for out-of-network procedure or service. - (a) The type of procedure or service; (b) The name...
Section 743B.283 - Submission of methodology used to determine insurer’s allowable charges. - (1) Upon request by the director, the methodology used to...
Section 743B.284 - Alternative mechanism for disclosure of costs and charges. - Note: See note under 743B.280.
Section 743B.285 - Rules. - Note: See note under 743B.280.
Section 743B.287 - Balance billing prohibited for health care facility services. - (a) "Emergency services" has the meaning given that term in...
Section 743B.290 - Hospital payment of copayment or deductible for insured patient. - Note: 743B.290 was added to and made a part of...
Section 743B.300 - Disclosure of differences in replacement health insurance policies; nonduplication for persons 65 and older; rules. - (2) The provisions of this section do not apply to...
Section 743B.310 - Rescinding coverage; permissible bases; notice; rules. - (2) An insurer may not rescind coverage of an individual...
Section 743B.320 - Minimum grace period; notice upon termination of policy; effect of failure to notify. - (2) An insurer of a group health insurance policy providing...
Section 743B.323 - Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium; rules. - (2) The notice described in subsection (1) of this section...
Section 743B.324 - Rules for certain notice requirements. - Note: 743B.324 was enacted into law by the Legislative Assembly...
Section 743B.330 - Notice to policyholder required for cancellation or nonrenewal of health benefit plan; effect of failure to give notice. - (2) An insurer shall notify a policyholder in writing if...
Section 743B.340 - When group health insurance policies to continue in effect upon payment of premium by insured individual. - (a) A provision that, when the premium for the policy...
Section 743B.341 - Continuation of benefits after termination of group health insurance policy; rules. - (2) The Director of the Department of Consumer and Business...
Section 743B.342 - Continuation of benefits after injury or illness covered by workers’ compensation. - (1) The employee takes full-time employment with another employer; or...
Section 743B.343 - Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older. - (a) The surviving spouse of a certificate holder may continue...
Section 743B.344 - Procedure for obtaining continuation of coverage under ORS 743B.343. - (a) The person designated as the plan administrator by the...
Section 743B.345 - Premium for continuation of coverage under ORS 743B.344; termination of right to continuation. - (1) The monthly premium for the continuation shall not be...
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. - (a) "Covered person" means an individual who was a certificate...
Section 743B.400 - Decisions regarding health care facility length of stay, level of care and follow-up care. - (2) An insurer may not terminate or restrict the practice...
Section 743B.403 - Insurer prohibited practices; patient communication and referral. - (1) Providing information to or communicating with a patient in...
Section 743B.405 - Medical services contract provisions; nonprovider party prohibitions; future contracts. - (a) In the event of alleged improper medical treatment of...
Section 743B.406 - Vision care providers. - (a) "Contractual discount" means a percentage reduction, required under a...
Section 743B.407 - Naturopathic physicians. - (2) To be credentialed by an insurer as a primary...
Section 743B.420 - Prior authorization requirements. - (1) Prior authorization determinations relating to benefit coverage and medical...
Section 743B.422 - Utilization review requirements for medical services contracts to which insurer not party; right to appeal. - (1) The criteria used in the review process and the...
Section 743B.423 - Utilization review requirements for insurers offering health benefit plan. - (2) All utilization review activities conducted pursuant to subsection (1)...
Section 743B.424 - Applicability. - Note: See note under 743B.405.
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. - (a) Require prior authorization: (A) During the first 60 days...
Section 743B.427 - Nonquantitative treatment limitations on coverage of behavioral health conditions. - (a) "Behavioral health benefits" means insurance coverage of mental health...
Section 743B.450 - Prompt payment of claims; limits on use of electronic payment methods; rules. - (2) A contract between an insurer and a provider may...
Section 743B.451 - Refund of paid claims. - (2) Except in the case of fraud or abuse of...
Section 743B.452 - Interest on unpaid claims. - (a) The date on which the insurer received the claim;...
Section 743B.453 - Underpayment of claims. - (a) Request additional payment from a health insurer to satisfy...
Section 743B.454 - Claims submitted during credentialing period. - (a) "Complete application" means a provider’s application to a health...
Section 743B.458 - Performance-based incentive payments for primary care. - Note: 743B.458 was added to and made a part of...
Section 743B.460 - Conditions for restricting payments to only in-network providers. - (2) Benefits paid by an insurer to a provider under...
Section 743B.462 - Direct payments to providers. - (a) "Health benefit plan" has the meaning given that term...
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. - (a) "Health insurer" or "insurer" means an employee benefit plan,...
Section 743B.475 - Guidelines for coordination of benefits; rules. - (1) The procedures by which persons insured under the policies...
Section 743B.500 - Selling and leasing of provider panels by contracting entity; definitions. - (1)(a) "Contracting entity" means any person that contracts directly with...
Section 743B.501 - Registration of contracting entity. - (a) The official name of the entity and any secondary,...
Section 743B.502 - Third party contracts for leasing of provider panels; requirements. - (a) The third party contract is specifically authorized by the...
Section 743B.503 - Additional requirements for third party contracts. - (2)(a) A third party shall inform the contracting entity and...
Section 743B.505 - Provider networks; rules. - (a) Contract with or employ a network of providers that...
Section 743B.555 - Confidential communications. - (a) "Carrier" has the meaning given that term in ORS...
Section 743B.601 - Synchronization of prescription drug refills. - (a) "Health plan" means: (A) A "health benefit plan" as...
Section 743B.602 - Step therapy. - (a) "Beneficiary" means an individual receiving health care that is...
Section 743B.800 - Risk adjustment procedures; rules. - (2) The Department of Consumer and Business Services may establish...
Section 743B.810 - Enrollees covered by workers’ compensation. - (a) The injured worker is covered by workers’ compensation insurance...