Oregon medical-plan questions focus on what Oregon requires of health insurers. Topics include the definition of health insurance, coverage of newborns, adopted children and dependents to age 26, renewal and market-withdrawal rules for individual health benefit plans, and the underwriting rules on sexual orientation and HIV. The general material (indemnity vs. managed care, HMOs and PPOs, cost sharing, HDHPs, the ACA) is in the national Medical Plans guide.

What counts as health insurance in Oregon

• Health insurance covers bodily injury, disablement or death by accident; sickness and childbirth expenses; prevention; and dental and optometric care. It expressly excludes workers' compensation (ORS 731.162).
• Blanket health insurance is issued to an organization and covers a defined group, such as common-carrier passengers, students of a school or college, a sports team or camp, or volunteer firefighters (ORS 743.536).
• A short term health insurance policy lasts 3 months or less, renewals included (ORS 743B.005(25)).
• A small employer had an average of 1 to 50 full-time-equivalent employees in the preceding calendar year (ORS 743B.005(26)).

Children and dependents (ORS 743A.090)

Newborns

• A plan that covers family members must cover a newborn from the moment of birth.
• If extra premium is required, the plan may require notice of the birth and payment within 31 days to continue the child's coverage.

Adopted children

• Covered on placement for adoption, whether or not the adoption is final.

Age limit

• A "child" is anyone under 26.

Disabled children 26 and older

• Coverage can continue if a physician certifies an ongoing disability that prevents self-sustaining employment.
• The child must have been covered under the parent's insurance for at least 2 years right before aging out.
• A dependency or income condition must also be met.

Individual health benefit plans (ORS 743B.125)

• No annual or lifetime dollar limits on essential health benefits.
• Carriers must renew except for:
  • Nonpayment.
  • Fraud or intentional material misrepresentation.
  • Market withdrawal.
  • Other listed reasons.
• A carrier leaving the individual market must give notice and may not cancel coverage for 180 days after the notice.
• Grace periods, right to return and other policy provisions are in the Oregon Individual Accident and Health Provisions guide.

Underwriting limits (OAR 836-050)

Sexual orientation (836-050-0240)

• An insurer may not ask about it, investigate it, or use it to decide insurability.

HIV questions (836-050-0245)

• Allowed only if questions about other high-risk conditions are asked and handled the same way.
• They must be factual, such as "have you been diagnosed or treated for."

Symptom questions (836-050-0245)

• Questions about symptoms such as chronic cough or weight loss must be limited to a period of no more than 10 years.

HIV testing (836-050-0250)

• Requires the applicant's signed informed consent on a Director-approved form.
• The consent is valid for 6 months.

Domestic violence (ORS 746.015)

• Being a victim of domestic or sexual violence can't be used to deny, cancel, nonrenew or surcharge coverage.

Selling to people 65 and older (ORS 743B.300)

• When an applicant 65 or older is replacing or supplementing existing health coverage, the producer must offer to compare the existing policy with the coverage being offered.
• Medicare supplement rules are in the Oregon Senior and Special Needs guide.

Who regulates

• Health insurers and producers are regulated by the Division of Financial Regulation under the Director of DCBS.
• Claim-handling deadlines are the same as other lines. Acknowledge within 30 days, investigate within 45 days, and decide within 30 days of proof of loss (OAR 836-080-0225 to 0235).
• The Oregon Life and Health Insurance Guaranty Association covers basic hospital, medical and surgical or major medical benefits up to $500,000 per life (ORS 734.810).

Common exam traps

• Dependents to 26. Disabled adult children need 2 years of prior coverage under the parent's plan.
• Newborns are covered from birth. The 31-day window is for notice and premium.
• Short-term in Oregon means 3 months or less, including renewals.
• Sexual orientation can't be asked about. HIV questions must match how other high-risk conditions are handled.
• Workers' compensation isn't health insurance under ORS 731.162.