(a) Establishing minimum benefit standards;
(b) Requiring the ratio of benefits to premiums to be not less than a specified percentage in order to be considered reasonable, and requiring the periodic filing of data that will demonstrate the insurer’s compliance;
(c) Establishing requirements intended to discourage duplication or overlapping of coverage and replacement, without regard to the advantage to policyholders, of existing policies by new policies; and
(d) Establishing requirements for carriers offering health benefit plans that spend less than 12 percent of total medical expenditures on payments for primary care to submit with each rate filing a plan to increase spending on payments for primary care as a percentage of total medical expenditures by at least one percent each plan year.
(2) As used in this section:
(a) "Primary care" means family medicine, general internal medicine, naturopathic medicine, obstetrics and gynecology, pediatrics or general psychiatry.
(b) "Total medical expenditures" means payments to reimburse the cost of physical and mental health care provided to enrollees, excluding prescription drugs, vision care and dental care, whether paid on a fee-for-service basis or as part of a capitated rate or other type of payment mechanism. [1979 c.857 §2; 1997 c.96 §1; 1999 c.987 §4a; 2017 c.489 §5]
Note: The amendments to 743.010 by section 15, chapter 489, Oregon Laws 2017, become operative January 1, 2023. See section 20, chapter 489, Oregon Laws 2017. The text that is operative on and after January 1, 2023, is set forth for the user’s convenience.
(1) In addition to all other powers of the Director of the Department of Consumer and Business Services with respect thereto, the director may issue rules with respect to policy forms and health benefit plan forms described in ORS 742.005 (6)(a) and (b):
(a) Establishing minimum benefit standards;
(b) Requiring the ratio of benefits to premiums to be not less than a specified percentage in order to be considered reasonable, and requiring the periodic filing of data that will demonstrate the insurer’s compliance;
(c) Establishing requirements intended to discourage duplication or overlapping of coverage and replacement, without regard to the advantage to policyholders, of existing policies by new policies; and
(d) Establishing requirements for carriers offering health benefit plans to spend at least 12 percent of total medical expenditures on payments for primary care.
(2) As used in this section:
(a) "Primary care" means family medicine, general internal medicine, naturopathic medicine, obstetrics and gynecology, pediatrics or general psychiatry.
(b) "Total medical expenditures" means payments to reimburse the cost of physical and mental health care provided to enrollees, excluding prescription drugs, vision care and dental care, whether paid on a fee-for-service basis or as part of a capitated rate or other type of payment mechanism.