ORS 743B.125 Individual Health Benefit Plans; Waiting Or Exclusion Periods; Preexisting Condition Exclusions; Guaranteed Issue and Renewal

• Library: Oregon Statutes
• Edition: 2023
• Currency: Current through legislation effective January 1, 2024
• Year: 2023
• Citation: ORS 743B.125

(1) With respect to coverage under an individual health benefit plan, a carrier may not impose a preexisting condition exclusion or an individual coverage waiting period.

(2) With respect to individual coverage under a grandfathered health plan, a carrier:

(a) May impose an exclusion period for specified covered services applicable to all individuals enrolling for the first time in the individual health benefit plan.

(b) May not impose a preexisting condition exclusion unless the exclusion complies with the following requirements:

(A) The exclusion applies only to a condition for which medical advice, diagnosis, care or treatment was recommended or received during the six-month period immediately preceding the individual's effective date of coverage.

(B) The exclusion expires no later than six months after the individual's effective date of coverage.

(c) May not impose a waiting period.

(3) An individual health benefit plan other than a grandfathered health plan must cover, at a minimum, all essential health benefits.

(4)

(a) A carrier shall issue any individual health benefit plan offered by the carrier, other than a grandfathered health plan, to any individual who applies for the health benefit plan, if:

(A) The individual resides in the geographic area where the plan is offered;

(B) The individual agrees to make the required premium payments; and

(C) Issuance of the health benefit plan is not otherwise prohibited by law.

(b) The Department of Consumer and Business Services may allow a carrier to cap the number of individuals enrolled in an individual health benefit plan offered by the carrier if the department finds that issuing the health benefit plan to more individuals than are currently enrolled in the plan would have a material adverse effect upon the carrier's ability to fulfill the carrier's contractual obligations or result in the financial impairment of the carrier.

(c) Except as otherwise provided in this section and ORS 743.022, a carrier offering an individual health benefit plan may not impose different terms or conditions on the coverage provided or the premium charged based on the actual or expected health status of an enrollee or prospective enrollee.

(5) A carrier shall renew an individual health benefit plan, including a health benefit plan issued through a bona fide association, unless:

(a) The policyholder fails to pay the required premiums.

(b) The policyholder or a representative of the policyholder engages in fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms of the policy.