The following requirements apply to all group health benefit plans covering two or more certificate holders:
(1) A preexisting conditions provision in a group health benefit plan shall apply only to a condition for which medical advice, diagnosis, care or treatment was recommended or received during the six-month period immediately preceding the enrollment date of an enrollee or late enrollee. As used in this section, the enrollment date of an enrollee shall be the earlier of the effective date of coverage or the first day of any required group eligibility waiting period and the enrollment date of a late enrollee shall be the effective date of coverage.
(2) A preexisting conditions provision in a group health benefit plan shall terminate its effect as follows:
(a) For an enrollee not later than the first of the following dates:
(A) Six months following the enrollee’s effective date of coverage; or
(B) Twelve months following the start of any required group eligibility waiting period.
(b) For a late enrollee, not later than 12 months following the late enrollee’s effective date of coverage.
(3) In applying a preexisting conditions provision to an enrollee or late enrollee, except as provided in this subsection, all group benefit plans shall reduce the duration of the provision by an amount equal to the enrollee’s or late enrollee’s aggregate periods of creditable coverage if the most recent period of creditable coverage is ongoing or ended within 63 days of the enrollment date in the new group health benefit plan. The crediting of prior coverage in accordance with this subsection shall be applied without regard to the specific benefits covered during the prior period. This subsection does not preclude, within a group health benefit plan, application of:
(a) An affiliation period that does not exceed two months for an enrollee or three months for a late enrollee; or
(b) An exclusion period for specified covered services applicable to all individuals enrolling for the first time in the group health benefit plan.
(4) Late enrollees may be excluded from coverage for up to 12 months or may be subjected to a preexisting conditions provision for up to 12 months. If both an exclusion from coverage period and a preexisting conditions provision are applicable to a late enrollee, the combined period shall not exceed 12 months.
(5) All group health benefit plans shall contain special enrollment periods during which eligible employees and dependents may enroll for coverage, as provided in 42 U.S.C. 300gg as amended and in effect on July 1, 1997.
(6) Each group health benefit plan shall be renewable with respect to all eligible enrollees at the option of the policyholder except:
(a) For nonpayment of the required premiums by the policyholder.
(b) For fraud or misrepresentation of the policyholder or, with respect to coverage of individual enrollees, the enrollees or their representatives.
(c) When the number of enrollees covered under the plan is less than the number or percentage of enrollees required by participation requirements under the plan.
(d) For noncompliance with the carrier’s employer contribution requirements under the health benefit plan.
(e) When the carrier discontinues offering or renewing, or offering and renewing, all of its group health benefit plans in this state or in a specified service area within this state. In order to discontinue plans under this paragraph, the carrier:
(A) Must give notice of the decision to the Director of the Department of Consumer and Business Services and to all policyholders covered by the plans;
(B) May not cancel coverage under the plans for 180 days after the date of the notice required under subparagraph (A) of this paragraph if coverage is discontinued in the entire state or, except as provided in subparagraph (C) of this paragraph, in a specified service area;
(C) May not cancel coverage under the plans for 90 days after the date of the notice required under subparagraph (A) of this paragraph if coverage is discontinued in a specified service area because of an inability to reach an agreement with the health care providers or organization of health care providers to provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and renewing, all health benefit plans issued by the carrier in the group market in this state or in the specified service area.
(f) When the carrier discontinues offering and renewing a group health benefit plan in a specified service area within this state because of an inability to reach an agreement with the health care providers or organization of health care providers to provide services under the plan within the service area. In order to discontinue a plan under this paragraph, the carrier:
(A) Must give notice of the decision to the director and to all policyholders covered by the plan;
(B) May not cancel coverage under the plan for 90 days after the date of the notice required under subparagraph (A) of this paragraph; and
(C) Must offer in writing to each policyholder covered by the plan, all other group health benefit plans that the carrier offers in the specified service area. The carrier shall offer the plans at least 90 days prior to discontinuation.
(g) When the carrier discontinues offering or renewing, or offering and renewing, a health benefit plan for all groups in this state or in a specified service area within this state, other than a plan discontinued under paragraph (f) of this subsection. With respect to plans that are being discontinued, the carrier must:
(A) Offer in writing to each policyholder covered by the plan, one or more health benefit plans that the carrier offers in the specified service area.
(B) Offer the plans at least 90 days prior to discontinuation.
(C) Act uniformly without regard to the claims experience of the affected policyholders or the health status of any current or prospective enrollee.
(h) When the director orders the carrier to discontinue coverage in accordance with procedures specified or approved by the director upon finding that the continuation of the coverage would:
(A) Not be in the best interests of the enrollees; or
(B) Impair the carrier’s ability to meet contractual obligations.
(i) When, in the case of a group health benefit plan that delivers covered services through a specified network of health care providers, there is no longer any enrollee who lives, resides or works in the service area of the provider network.
(j) When, in the case of a health benefit plan that is offered in the group market only through one or more bona fide associations, the membership of an employer in the association ceases and the termination of coverage is not related to the health status of any enrollee.
(k) For misuse of a provider network provision. As used in this paragraph, “misuse of a provider network provision” means a disruptive, unruly or abusive action taken by an enrollee that threatens the physical health or well-being of health care staff and seriously impairs the ability of the carrier or its participating providers to provide services to an enrollee. An enrollee under this paragraph retains the rights of an enrollee under ORS 743.804.
(L) A carrier may modify a group health benefit plan at the time of coverage renewal. The modification is not a discontinuation of the plan under paragraphs (e) and (g) of this subsection.
(7) Notwithstanding any provision of subsection (6) of this section to the contrary, a group health benefit plan may be rescinded by a carrier for fraud, material misrepresentation or concealment by a policyholder and the coverage of an enrollee may be rescinded for fraud, material misrepresentation or concealment by the enrollee.
(8) A carrier that continues to offer coverage in the group market in this state is not required to offer coverage in all of the carrier’s group health benefit plans. If a carrier, however, elects to continue a plan that is closed to new policyholders instead of offering alternative coverage in its other group health benefit plans, the coverage for all existing policyholders in the closed plan is renewable in accordance with subsection (6) of this section.
(9) This section applies only to group health benefit plans that are not small employer health benefit plans. [1995 c.603 §17; 1995 c.603 §40; 1997 c.716 §§12,13; 1999 c.987 §13; 2001 c.943 §13; 2003 c.748 §6]
Section: Previous 743.747 743.748 743.749 743.750 743.751 743.752 743.753 743.754 743.755 743.756 743.757 743.758 743.759 743.760 743.761 NextLast modified: August 7, 2008