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Insurance Division

Rates and Forms Section

Health

Oregon Health Filing Tips

  • Advertisements: Any advertising that is attached to or mailed with an application must be submitted for prior approval. New product standards and filing requirements will be discussed in the October 2009 Industry Training.
  • Alcohol Exclusion: ORS 743A.164 requires that an individual health insurance policy, other than disability income, provide coverage for medical treatment of injuries or illnesses caused in whole or in part by the insured's use of alcohol or a controlled substance that is equivalent to coverage for other injuries or illnesses.
  • Applications: If revising, adding, or deleting language in an application or replacing an application, include a "red-lined" copy of the previously approved version of the form in the submission support materials. The application will need a new form number or addition of an edition date/version date to the previously approved form number. If a new or revised application is to be used with a previously approved form, please explain how the changes in the application may or may not affect the rating of the product previously approved.
  • Associations, Trusts, and Discretionary Groups - For Health ONLY: Due to the passage of House Bill 3321 (2007), out-of-state exempt associations, trusts, and discretionary groups are no longer allowed. Revised product standards and new Oregon Administrative Rules (OAR) are available on the Oregon Insurance Web site for submission and assignment of an OID entity number. All associations, trusts, discretionary groups and MEWAs must be reviewed and approved by the OID.
  • Blanket Health: The same coverage must be provided to everyone who is eligible for coverage under the group policy. Optional coverage added via endorsement or rider is at the option of the group policyholder (rather than the individual insured) and provides the same coverage for everyone. A pre-existing condition exclusion is not allowed because everyone under the policy must receive the same coverage.
  • Changes to Business Operations / Modification and Discontinuance of Health Benefit Plans: These should be filed under H21.Health - Other. Do not use these TOI/Sub-TOI codes for any other type of filing or the submission will be disapproved without review. Filing checklist #440-2896 is used with these submissions. The proposed action will determine what notification requirements apply, and if withdrawing from Oregon, whether a 5-year ban would be applicable. Please include affected policy forms and when/if they were approved.
  • Cover Letter: For SERFF filings, attach the Cover Letter in the Supporting Documentation tab. Please list the form name and number for each form being submitted with the filing - the number and edition date must be listed exactly as they appear on the filed documents. If not using a cover letter on a SERFF submission, please provide this form information in the Filing Description portion of the General Information tab.
  • See Guidelines for Filing Life & Health Policies, Riders, etc regarding making changes to the base contract:
    An endorsement, rider, or amendment changes previously approved policy provisions or benefits, and is issued separately from the original policy forms:

    Endorsements and/or amendments (changes):

    • Must be filed and approved prior to delivery
    • When filed in a separate document, must contain a unique form number in the bottom left hand corner
    • The OID limits the number of changes to the base policy forms
    • Only one allowed per health insurance policy

    The Analyst may require a company to file an entirely new version of the base policy if there are significant changes made by the endorsement or amendment.

    • Definitions:
      • Rider - means an optional benefit available for purchase (e.g. prescriptions, vision, dental, etc.)
      • Endorsement or Amendment - these are used to change specific contract provisions. These terms may be used interchangeably.
    • Filing in Pieces: Insert pages are not allowed. The policy form or certificate form must have the same form number in the bottom left hand corner of each page throughout the entire form/document. Any changes to the base contract/policy require that the policy be re-filed with a new form number (such as adding an edition date) for all pages (see Filing Revisions).
    • Variability: Items may be included as variable by bracketing the variable language in the policy form. All options (choices) and/or ranges (minimum to maximum benefit amounts) must be either shown in the policy form, or submitted in a separate document called a Statement of Variability (SOV) that explains in detail each variable item. Regardless of the method used, the form must have brackets around the variable data. Blank lines are not permitted. Also, fixed and maximum charges cannot be filed as variable.
    • Filing Revisions: A "red-lined" version showing where changes have been made is required to be included when revising any previously approved forms.
      • When revising, adding, or deleting language in a form, the form must be re-filed with a new form number or with the addition of a revision date/edition date to the previously approved form number.
  • Health Form Numbering: Individual Health Insurance statute ORS 743.405(7) states the form number must appear on the first page of the policy form. Insert pages are not allowed. The policy form number or certificate form number must have the same form number in the bottom left hand corner of each page throughout the entire form/document.

    Any changes to the base contract/policy require the policy to be re-filed with a new form number (such as adding an edition date) for all pages (see Filing Revisions). If variability is filed via a Statement of Variability, then it needs to be submitted as a form for approval, with its own unique form number in the bottom left hand corner on each page of the document. This could be as simple as using the policy form number followed by -SOV.

  • LEGISLATION:
    • HB 2009: Health care reform: HB 2009 makes a variety of reforms to Oregon's health care system to contain costs and improve quality. The bill includes a focus on preventive care and evidence-based medicine, development of a "health insurance exchange" to allow comparison shopping for insurance plans, stronger standards for review of insurance rates, and streamlining administrative functions by consolidating the state's health care functions into one agency. Details are available on the Division web site.
    • HB 2116: Assessments to expand health coverage: A new, 1 percent assessment on health insurance premiums and a hospital tax will generate revenues to help provide health care coverage for 80,000 children and 35,000 low-income adults. Insurance companies may increase health insurance premiums by 1 percent, effective Oct. 1, 2009.
    • HB 2433: Health care premium subsidies: This law ensures that Oregonians who were laid off during the economic downturn can take full advantage of health care premium assistance available through the federal economic stimulus package. The bill expands the state continuation plan from six months to nine months, gives Oregonians who lost their job before the stimulus package was announced a second opportunity to elect to continue coverage, and establishes notification requirements for insurers. This law became effective on April 28, 2009.
    • SB 507: Preferred provider applications: Currently, health insurers are not required to approve or deny a provider's application to become a "credentialed provider" within a designated period of time or reimburse the provider for services provided during the credentialing period. This bill requires health insurers to approve or deny a provider's application to become a credentialed provider within 90 days of receipt. Health insurers must pay providers for claims during the 90-day "credentialing period" at least at the non-participating provider rates, with certain exceptions. This bill applies to requests to enter into medical service contracts submitted by a provider on or after the effective date. The bill declares an emergency and became effective upon passage.
    • SB 508: Insurer/provider payment reconciliation: Requires health insurers to request a refund from health care providers within 24 months of the date of payment, with certain exceptions, and to allow six months for payment of a refund. The bill also requires providers to request an additional payment for a claim from insurers within 24 months after the date the claim was denied, with certain exceptions, and to allow insurers six months to make the additional payment.
    • SB 679: Healthy lifestyles dividends: Authorizes insurers to pay cash rewards (dividends) to members who participate in approved programs to promote healthy behaviors.
    • SB 862: Community-based health care initiatives: Improves access to health care for those without insurance by establishing a limited number of community-based health care programs that are exempt from the Insurance Code. The bill declares an emergency and became effective June 23, 2009.
  • Limited Benefit Plans: When coverage in the base policy/contract is based on an event (rather than expenses), such as hospital confinement, and the benefit is a fixed dollar amount (rather than a percentage of expenses), then ALL benefits, including those in optional riders, must be flat dollar amounts. Benefits based on expenses (percentages) cannot be combined with benefits based on an event (fixed dollar amounts). Please see the September 15, 2008 Industry Training Power Point Presentation on the Oregon Insurance Division Web site for more information and details.
  • Long Term Care (LTC) has a 10-year look-back limit on medical questions.
  • Long Term Care Provider Facilities: LTC must include all four (4) types of required Treatment Facilities (Nursing Home, Assisted Living, Home Care, and Adult Foster Care) from ORS 743.656(1)(b).
  • Long Term Care Changes - 2007 (Enrolled SB 191):
    • These new changes mirror those adopted by the NAIC in 2007. New rules are located in OAR 836-052-0500 through 836-052-0786 and include several exhibits.
    • Watch for newly revised LTC product standards on the Insurance Division Web site and in SERFF.
  • Mandated Coverage Provisions, Benefits, and Providers: Due to the passage of several House and Senate Bills in the 2007 Oregon legislative session, and the 2009 Oregon legislative session, the Benefits and Provider Mandates chart has been revised and is now available on the Oregon Insurance Division's Web site. Click on the link titled Mandated Health Insurance Provisions/Benefits to view the nine (9) new mandates from the 2009 session.
    1. HB 2506: Requires health plans to cover services of professional counselors and marriage and family therapists if certain other services are covered by the plan
    2. HB 2589: Requires hearing aid coverage for those under age 18.
    3. HB 2794: Requires coverage of the human papillomavirus (HPV) vaccine for females between ages 11 and 26. HPV is the main cause of cervical cancer in women.
    4. HB 3496: Exempts mandate (enteral formula) from sunset provision
    5. SB 9: Removes sunset on required coverage of inborn errors of metabolism.
    6. SB 24: Mandates coverage of medically necessary, evidence-based telemedicine services (provided by video conference).
    7. SB 316: Requires health benefit plans to cover routine costs of care in qualifying clinical trials subject to co-pays and other cost-sharing.
    8. SB 734: Requires certain health insurers to cover quit-smoking and other tobacco use cessation programs.
    9. SB 381: Requires health benefit plans to cover medically necessary treatments for traumatic brain injury.
  • Medicare Changes and Rules - 2009/2010: The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and the Genetic Information Nondiscriminatory Act of 2008 (GINA), will be included in the Insurance Division Rates & Forms Industry Training on October 26, 2009.
    • New plans will be submitted for compliance with Federal law regarding Medicare Supplement plans.
    • Detailed plan changes and filing instructions will be on line by July 1, 2010. Please see the Oregon Insurance filing instructions on our web site.
  • Rate filings: Tell us the form number to which the rate change applies.
    • Must include a fully completed Appendix A with any rate filings, showing the 10 year expected experience projection for individual and small (under 50) groups.
    • An actuarial memorandum is not required for large (51 and above) group filings, except for certain association filings, Medicare Supplements and Long Term Care for which all rates must be filed and approved.
    • Must include complete actuarial support documentation whenever rates are part of a filing submission.
    • Premiums must be reasonable in relationship to benefits.
  • Terrorism Exclusions: No terrorism exclusion language allowed.