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Enrolled Senate Bill 738 requires a health insurance policy that covers dental health services to cover services provided by an expanded practice dental hygienist if the same services are covered when provided by a licensed dentist and the expanded practice dental hygienist has entered into a provider contract with the insurer. Section 12 of SB 738 (ORS 680.210) requires the Department of Consumer and Business Services (DCBS) to adopt rules requiring health insurers to report to DCBS on the reimbursement of services to expanded practice dental hygienists and requires DCBS to provide the information to the Oregon Board of Dentistry (OBD).

This new rule establishes those reporting requirements and also defines "expanded practice dental hygienist" and "health insurer" for purposes of the reporting requirement. The first report is due on or before August 1, 2012.

These rules were developed in response to numerous complaints received by the Department of Consumer and Business Services regarding open enrollment periods and unexpected rate increases with respect to Medicare supplement policies. To address these complaints, the rules:

Clarify that for a person who receives "retroactive" eligibility for Medicare as a result of an appeal of an initial denial for eligibility, the six month open enrollment period begins after the person is notified of their enrollment in Medicare, not on the date the person’s enrollment has been backdated to.

Adopt a "birthday rule" for Medicare supplement policies to allow an individual the opportunity to change Medicare supplement plans (as long as the new policy has the same or lesser benefits) with guaranteed issue and nondiscrimination in rating once per year for a period of thirty days beginning on the individual’s birthday.

This rulemaking prescribes, for reporting year 2011, the required forms for the annual and supplemental financial statements required of insurers, multiple employer welfare arrangements and health care service contractors under ORS 731.574, as well as the necessary instructions for completing the forms.

The proposed amendments to the rule also add information about how to inspect the instructions and forms necessary to complete the annual financial statements.

This rulemaking is necessary to implement the requirements of House Bill 2095 (2011 Session) by which the State of Oregon becomes a member of the Interstate Insurance Product Regulatory Commission (IIPRC) on January 1, 2012.

This rulemaking revises the department's rules to reflect Oregon's new status as a member of the IIPRC. The rules remove obsolete references adopted under previous legislation to life insurance, annuities or disability insurance products that the director need not separately consider or review if the form was already approved by the Interstate Insurance Product Regulation Commission.  This rulemaking reflect Oregon's new status as a member of the Compact. The rules remove the obsolete references to those earlier approved products and clarify that rates and forms approved by the IIPRC are not subject to the department's rate and form review process.

The rules will take effect on and apply to products filed after January 1, 2012, the date Oregon becomes a member of the IIPRC.

The amendments to these rules reflect changes to the National Association of Insurance Commissioners (NAIC) Model Regulation #815. The rules generally specify which mortality table is recognized for use in determining minimum reserve liabilities. Adoption of these amendments to the rules would allow a company to substitute the 2001 CSO Preferred Mortality Tables in place of the 2001 CSO Smoker or Nonsmoker Mortality Tables for policies issued prior to January 1, 2007.  The conditions for use of the preferred tables are also set out in the rules and the use does require the consent of the director of the Department of Consumer and Business Services.

These changes are necessary to maintain Oregon's accreditation.

This rule adopts by reference uniform standards for administrative simplification of health care claims transactions developed and recommended by the Oregon Health Authority under Section 2, chapter 130, Oregon Laws 2011 (replacing Section 1192, Chapter 595, Oregon Laws 2009. The standards adopted by this rulemaking pertain to health care claims and encounter transactions and are set forth in the "Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X222 Health Care Claim: Professional (837)," "The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X223 Health Care Claim: Institutional (837)" and "The Oregon Companion Guide for the Implementation of the EDI Transaction: ASC X12/005010X224 Health Care Claim: Dental (837)."

These rules also establish a waiver for plans that are certified by the Council for Affordable Quality Healthcare's (CAQH) Committee on Operating Rules for Information Exchange (CORE).  Because the Oregon Companion Guides have been developed in alignment with CORE and CORE is now recognized by federal agencies as the national standard, meeting either the CORE or the Companion Guide standard will allow for standardization.

The rules also clarify that "health care entity" does not include a pharmacy or a pharmacy benefits manager, thus exempting these entities from the requirements of the rules.

This rule provides the Insurance Division with an additional tool to determine whether a property and casualty insurer falls within a risk based capital (RBC) company action level. Current rules define a company action level as an RBC ratio of 200 percent. This rule requires the Division to take action if a company's RBC falls between 200 and 300 percent and its combined ratio is above 120 percent. This additional tool assists in determining whether an insurer is maintaining adequate capital and surplus to meet statutory requirements and policyholder obligations.

The changes to the rules also correct and update internal references.