2015 Oregon Revised Statutes
Volume : 16 - Financial Institutions, Insurance
Chapter 735 - Alternative Insurance
Section 735.727 - Annual report to Legislative Assembly.

A community-based health care initiative approved by the Oregon Health Authority must report to the Legislative Assembly no later than October 1 of each year. The report must contain at a minimum the following information:

(1) The financial status of the community-based health care improvement program, including the dues, the costs per enrollee per month, the total amount of claims paid, the total amount of dues collected and the administrative expenses;

(2) A description of the set of health care services covered by the program and an analysis of service utilization;

(3) The number of qualified employers, qualified employees and dependents enrolled;

(4) The number and scope of practice of participating health care providers;

(5) Recommendations for improving the program and establishing programs in other geographical regions of the state; and

(6) Any other information requested by the authority or the Legislative Assembly. [2009 c.470 §4; 2015 c.318 §45]

Note: See note under 735.721.

OREGON REINSURANCE PROGRAM

Note: Sections 1, 2, 4, 4a and 42 (2), chapter 698, Oregon Laws 2013, provide:

Sec. 1. The Oregon Reinsurance Program is established in the Oregon Health Authority. The program shall be administered by the Oregon Medical Insurance Pool Board, created in ORS 735.610, for the purposes of stabilizing the rates and premiums for individual health benefit plans and providing greater financial certainty to consumers of health insurance in this state by providing state reinsurance payments to insurers from assessments described in section 2 of this 2013 Act. [2013 c.698 §1]

Sec. 2. (1) As used in this section, section 1, chapter 698, Oregon Laws 2013, and ORS 735.610:

(a) "Health benefit plan" has the meaning given that term in ORS 743.730 [renumbered 743B.005].

(b) "Insurer" means an insurer described in ORS 735.605 (4)(a), (b) or (d).

(c) "National attachment point" means the attachment point set forth in the United States Department of Health and Human Services’ annual notice of benefit and payment parameters, in accordance with 45 C.F.R. 153.230.

(d) "National coinsurance rate" means the reinsurance rate set forth in the United States Department of Health and Human Services’ annual notice of benefit and payment parameters, in accordance with 45 C.F.R. 153.230.

(e) "National reinsurance cap" means the reinsurance cap set forth in the United States Department of Health and Human Services’ annual notice of benefit and payment parameters, in accordance with 45 C.F.R. 153.230.

(f) "Program" means the Oregon Reinsurance Program established in section 1, chapter 698, Oregon Laws 2013.

(g) "Reinsurance eligible health benefit plan" means a health benefit plan providing individual coverage that:

(A) Is delivered or issued for delivery in this state;

(B) Is not a grandfathered health plan as defined in ORS 743.730; and

(C) Meets the criteria prescribed by the Oregon Medical Insurance Pool Board under subsection (2) of this section.

(h) "Reinsurance eligible individual" means an individual:

(A) Who applied for coverage in a reinsurance eligible health benefit plan during the initial open enrollment period specified in 42 U.S.C. 18031(c)(6), including any extension of the initial open enrollment period approved by the United States Department of Health and Human Services for Oregon residents;

(B) Who, as a result of the application made during the initial open enrollment period, is enrolled in the coverage; and

(C) Who was:

(i) On December 31, 2013, enrolled in the Oregon Medical Insurance Pool created in ORS 735.610;

(ii) On June 30, 2013, enrolled in the Temporary High Risk Pool Program established in section 1, chapter 47, Oregon Laws 2010;

(iii) On December 31, 2013, insured under a portability health benefit plan as defined in ORS 743.760; or

(iv) On December 31, 2013, reinsured under the reinsurance program for children’s coverage described in ORS 735.614 (1)(b).

(i) "State attachment point" means the threshold dollar amount for claims costs incurred by a reinsurance eligible health benefit plan for an insured individual’s covered benefits in a benefit year, after which threshold the claims costs for the benefits are eligible for state reinsurance payments.

(j) "State coinsurance rate" means the rate at which the Oregon Medical Insurance Pool Board will reimburse a reinsurance eligible health benefit plan for claims costs incurred for an insured individual’s covered benefits in a benefit year after the state attachment point and before the state reinsurance cap.

(k) "State reinsurance cap" means the threshold dollar amount for claims costs incurred by a reinsurance eligible health benefit plan for an insured individual’s covered benefits, after which threshold the claims costs for the benefits are no longer eligible for state reinsurance payments.

(2) The board shall prescribe by rule the criteria for a health benefit plan to qualify for reinsurance payments under the program. The criteria must be consistent with requirements for:

(a) Premium rates under 42 U.S.C. 300gg;

(b) Guaranteed availability under 42 U.S.C. 300gg-1;

(c) Guaranteed renewability under 42 U.S.C. 300gg-2;

(d) Coverage of essential health benefits under 42 U.S.C. 18022; and

(e) Using a single risk pool under 42 U.S.C. 18032(c).

(3) An issuer of a reinsurance eligible health benefit plan becomes eligible for a reinsurance payment when the claims costs for a reinsurance eligible individual’s covered benefits in a calendar year exceed the state attachment point. The amount of the payment shall be the product of the state coinsurance rate and the issuer’s claims costs for the reinsurance eligible individual’s claims costs that exceed the state attachment point, up to the state reinsurance cap, as follows:

(a) For 2014:

(A) The state attachment point is $30,000.

(B) The state reinsurance cap is $300,000.

(C) Except as provided in paragraph (b) of this subsection, the state coinsurance rate is:

(i) For claims costs above the national attachment point and up to and including the national reinsurance cap:

(I) If the national coinsurance rate is at or above 90 percent of the claims costs, zero percent; or

(II) If the national coinsurance rate is below 90 percent of the claims costs, the difference between 90 percent of the claims costs and the national coinsurance rate but no more than 10 percent; and

(ii) Ninety percent for claims costs:

(I) From the state attachment point up to and including the national attachment point; and

(II) From the national reinsurance cap up to and including the state reinsurance cap.

(b) The board may lower the state coinsurance rate if the reinsurance claims incurred exceed the total amount of the assessments collected under subsection (4) of this section.

(c) The board shall adopt by rule a state attachment point, state reinsurance cap and state coinsurance rate for calendar years 2015 and 2016 that complement the federal reinsurance program requirements, so that the reinsurance claims do not exceed the total amount of the assessments collected under subsection (4) of this section. After the rules required under this paragraph are adopted for a calendar year, the board may not:

(A) Change the state attachment point or the state reinsurance cap adopted for that calendar year; or

(B) Increase the state coinsurance rate adopted for that calendar year.

(4) The board shall impose an assessment on all insurers at a rate that is expected to produce an amount of funds sufficient to pay administrative expenses and to make reinsurance payments that are due to issuers of reinsurance eligible health benefit plans in a calendar year or to make payments to the Oregon Health Authority for the costs of the program described in ORS 735.612 (2) that is administered by the authority, but not greater than the rate that would be expected to produce funds totaling the lesser of:

(a) An amount per month multiplied by the number of insureds and certificate holders in this state who are insured or reinsured; or

(b) The total assessment set forth in subsection (5) of this section.

(5) The amount per month and total assessment on all insurers are as follows:

(a) For calendar year 2014, the amount per month is $4 and the total assessment is $72 million.

(b) For calendar year 2015, the amount per month is $3.50 and the total assessment is $63 million.

(c) For calendar year 2016, the amount per month is $2.20 and the total assessment is $40 million.

(6) In determining the number of insureds and certificate holders in this state who are insured or reinsured, the board shall exclude individuals with the following types of coverage:

(a) The medical assistance program under ORS chapter 414;

(b) Medicare;

(c) Disability income insurance;

(d) Hospital-only insurance;

(e) Dental-only insurance;

(f) Vision-only insurance;

(g) Accident-only insurance;

(h) Automobile insurance;

(i) Specific disease insurance;

(j) Medical supplemental plans;

(k) TRICARE;

(L) Prescription drug only plans;

(m) Long term care insurance; and

(n) Federal Employees Health Benefits Program.

(7) If the board collects assessments that exceed the amount necessary to pay administrative expenses, to make all of the reinsurance payments that are due to issuers of reinsurance eligible health benefit plans in calendar years 2014, 2015 and 2016, or to make payments to the Oregon Health Authority for the costs of the program described in ORS 735.612 (2) that is administered by the authority, the board shall refund the excess, on a pro rata basis, to insurers who are subject to the assessment imposed by subsection (4) of this section.

(8) The board may not impose an assessment under subsection (4) of this section for calendar years beginning with 2017.

(9) All moneys received or collected by the board under this section shall be paid into the Oregon Medical Insurance Pool Account established in ORS 735.612.

(10) The board, in consultation with the Department of Consumer and Business Services, may adopt rules necessary to carry out the provisions of this section including, but not limited to, rules prescribing:

(a) The eligibility requirements for participation in the program by an issuer of a reinsurance eligible health benefit plan;

(b) The form and manner of issuing notices of assessment amounts;

(c) The amount, manner and frequency of the payment and collection of assessments;

(d) The amount, manner and frequency of reinsurance payments; and

(e) Reporting requirements for insurers subject to the assessment and for issuers of reinsurance eligible health benefit plans. [2013 c.698 §2; 2013 c.722 §32; 2014 c.80 §2]

Sec. 4. (1) As used in this section:

(a) "Health benefit plan" has the meaning given that term in ORS 743.730 [renumbered 743B.005].

(b) "Oregon Medical Insurance Pool Board" means the board created in ORS 735.610.

(c) "Oregon Reinsurance Program" means the program created in section 1 of this 2013 Act.

(d) "Reinsurance eligible individual" has the meaning given that term in section 2 of this 2013 Act.

(2) An insurer that offers a health benefit plan must report to the Oregon Medical Insurance Pool Board, in the form and manner prescribed by the board by rule, information about reinsurance eligible individuals insured by the health benefit plan, as necessary for the board to calculate reinsurance payments under the Oregon Reinsurance Program. [2013 c.698 §4]

Sec. 4a. In a rate filing under ORS 743.018, an insurer must identify the impact of:

(1) State reinsurance payments under section 2 of this 2013 Act and federal reinsurance payments on projected claims costs and in the development of rates; and

(2) Assessments imposed under section 2 of this 2013 Act on rates. [2013 c.698 §4a]

Sec. 42. (2) Sections 1, 2, 4 and 4a, chapter 698, Oregon Laws 2013, and ORS 735.600, 735.605, 735.610, 735.612, 735.615, 735.616, 735.620, 735.625, 735.630, 735.635, 735.645 and 735.650 are repealed July 1, 2017.

[2013 c.698 §42(2); 2013 c.640 §20(2)]