The Director of the Department of Consumer and Business Services shall appoint a Health Insurance Reform Advisory Committee. This committee shall consist of at least one insurance producer, one representative of a health maintenance organization, one representative of a health care service contractor, one representative of a domestic insurer, one representative of a labor organization and one representative of consumer interests and shall have representation from the broad range of interests involved in the small employer and individual market and shall include members with the technical expertise necessary to carry out the following duties:
(1)(a) Subject to approval by the director, the committee shall recommend the form and level of coverages under the basic health benefit plans pursuant to ORS 743.736 to be made available by small employer carriers and the portability health benefit plans to be made available pursuant to ORS 743.760 or 743.761. The committee shall take into consideration the levels of health benefit plans provided in Oregon and the appropriate medical and economic factors and shall establish benefit levels, cost sharing, exclusions and limitations. The health benefit plans described in this section may include cost containment features including, but not limited to:
(A) Preferred provider provisions;
(B) Utilization review of health care services including review of medical necessity of hospital and physician services;
(C) Case management benefit alternatives;
(D) Other managed care provisions;
(E) Selective contracting with hospitals, physicians and other health care providers; and
(F) Reasonable benefit differentials applicable to participating and nonparticipating providers.
(b) The committee shall submit the basic and portability health benefit plans and other recommendations to the director within the time period established by the director. The health benefit plans and other recommendations shall be deemed approved unless expressly disapproved by the director within 30 days after the date the director receives the plans.
(2) In order to ensure the broadest availability of small employer and individual health benefit plans, the committee shall recommend for approval by the director market conduct and other requirements for carriers and insurance producers, including requirements developed as a result of a request by the director, relating to the following:
(a) Registration by each carrier with the Department of Consumer and Business Services of its intention to be a small employer carrier under ORS 743.733 to 743.737 or a carrier offering individual health benefit plans, or both.
(b) Publication by the Department of Consumer and Business Services or the committee of a list of all small employer carriers and carriers offering individual health benefit plans, including a potential requirement applicable to insurance producers and carriers that no health benefit plan be sold to a small employer or individual by a carrier not so identified as a small employer carrier or carrier offering individual health benefit plans.
(c) To the extent deemed necessary by the committee to ensure the fair distribution of high-risk individuals and groups among carriers, periodic reports by carriers and insurance producers concerning small employer, portability and individual health benefit plans issued, provided that reporting requirements shall be limited to information concerning case characteristics and numbers of health benefit plans in various categories marketed or issued, or both, to small employers and individuals.
(d) Methods concerning periodic demonstration by small employer carriers, carriers offering individual health benefit plans and insurance producers that the small employer and individual carriers are marketing or issuing, or both, health benefit plans to small employers or individuals in fulfillment of the purposes of ORS 743.730 to 743.773.
(3) Subject to the approval of the Director of the Department of Consumer and Business Services, the committee shall develop a standard health statement to be used for all late enrollees and by all carriers offering individual policies of health insurance.
(4) Subject to the approval of the director, the committee shall develop a list of the specified services for small employer and portability plans for which carriers may impose an exclusion period, the duration of the allowable exclusion period for each specified service and the manner in which credit will be given for exclusion periods imposed pursuant to prior health insurance coverage. [1991 c.916 §12; 1993 c.18 §164; 1995 c.603 §§10,38; 1999 c.987 §11; 2003 c.364 §114]
Section: Previous 743.738 743.739 743.740 743.741 743.742 743.743 743.744 743.745 743.746 743.747 743.748 743.749 743.750 743.751 743.752 NextLast modified: August 7, 2008