Coverage of COVID-19 Immunizations
February 17, 2021
On February 4, 2021, Commissioner Stolfi issued Bulletin No. DFR 2021-1, which clarifies the Division of Financial Regulation’s expectations around the coverage of COVID-19 vaccinations. In accordance with Oregon’s COVID-19 public health declaration and the CARES Act, the division confirms that coverage of the COVID-19 vaccine:
- Must be provided by all health benefit plans
- Cannot be restricted to in-network providers
- Cannot have any cost-sharing requirements
- Must be provided without requiring any prior authorization or any other form of utilization review
- May not impose any other limitation that would prevent an enrollee from receiving the vaccine at no out-of-pocket cost
The bulletin is retroactive to January 27, 2021. Although this bulletin is directed towards insurance carriers, employers based in Oregon should familiarize themselves with this guidance as individuals begin to access COVID-19 immunizations.
Bulletin No. DFR 2021-1 »
COVID-19 Temporary Paid Leave Program
February 02, 2021
The Oregon legislature recently established the COVID-19 Temporary Paid Leave Program to provide coverage to individuals that are not eligible for FFCRA leave. The leave is provided if the employee is unable to work due to the need to quarantine or self-isolate because of COVID-19. Up to 10 days of leave will be provided through the program, and it is only available if the employee’s employer does not provide COVID-19-related paid time off.
In order to be eligible under the program, employees must meet all the following requirements:
- They work in Oregon and are required to file an Oregon personal income tax return.
- They are directed to quarantine by a local or tribal public health authority or healthcare provider because of exposure to someone infected or have COVID-19-related symptoms and are seeking a medical diagnosis.
- They are not able to work (including telework) because they need to quarantine or isolate.
- They do not expect to earn more than $60,000 individually or $120,000 jointly in 2020.
- Their employer does not provide COVID-19-related paid sick leave or they have exhausted their available COVID-19-related paid sick leave.
- They are not applying for unemployment insurance benefits for the time off due to quarantine or isolation.
- They are not applying for workers’ compensation benefits for the time off due to quarantine or isolation or experiencing COVID-19 symptoms.
- They are not seeking or using benefits from similar COVID-19 quarantine relief programs in Oregon or another state.
- They are not applying for or receiving other forms of paid leave from their employer during their quarantine or isolation, such as banked sick leave or vacation leave.
- They are not laid off or furloughed by their employer.
- They must have notified their employer that you need to quarantine or isolate.
- They can claim only one quarantine period.
- They are not self-employed.
- They are not part of the gig economy (Lyft, Uber, DoorDash, GrubHub, Instacart, etc.)
- They are not being paid off the record (this means their employer is not reporting their income to the state and often employers who pay off the record pay in cash).
Employees will apply with the state to receive the benefit. Approved applicants will receive a check in the mail, and the money is taxable.
Employers with Oregon employees that are not offering any paid time off for employees who have the need for COVID-related leave should be mindful of this program.
COVID-19 Temporary Paid Leave Program »
Employee Flier »
April 14, 2020
On March 25, 2020, the Department of Consumer and Business Services and Oregon Health Authority issued telehealth guidance in relation to the ongoing COVID-19 outbreak, recognizing the need for Oregonians to be able to access health care services without visiting their provider in person. The guidance requires health plans to:
- Cover telehealth services delivered by in-network providers to replace in-person visits whenever possible and medically or clinically appropriate
- Examine reimbursement rates for telehealth services to ensure they are adequate to enable providers to increase capacity to serve patients with appropriate telehealth delivery methods
- Ensure cost-sharing requirements for services delivered via telehealth are no greater than if the service was delivered through in-person settings
- Clearly communicate to their members and provider networks about options to receive health care services via appropriate telehealth delivery modes as well as how to bill for such services
- Examine their provider networks to ensure robust telehealth services are available and consider contracting with more providers to help bolster telehealth capacity during the current outbreak
- Use telehealth service delivery methods to ensure patients maintain access to behavioral health services
- Eliminate barriers to providing medically and clinically appropriate care using appropriate telehealth delivery models
While insurers will have to comply with this guidance, employers should familiarize themselves with the additional telehealth benefits provided.
Telehealth Guidance »
March 31, 2020
The Oregon Division of Financial Regulation recently issued a number of bulletins addressing the COVID-19 crisis. Two of those bulletins with particular application to employee benefits are as follows:
- Telehealth Guidance: The state recently shared guidance indicating that health plans are expected to provide increased access to health care services through telehealth delivery platforms and to encourage patients to use telehealth delivery options to limit the amount of in-person health care services they seek. The guidance requires insurers to eliminate barriers to providing medically appropriate care through telehealth. One such way that insurers must do this is by ensuring that cost sharing requirements for services delivered via telehealth are no greater than if the services are delivered in-person.
- Grace Period for All Insurers: On March 25, 2020, the Department of Consumer and Business Services issued a temporary emergency order requiring all insurance companies to extend grace periods for premium payments, postpone policy cancellations and nonrenewals, and extend deadlines for reporting claims.
Although these directives are aimed at insurers, employers should familiarize themselves with the guidance should they or their employees need to avail themselves of the services.
Telehealth Guidance »
Grace Period Order »
Oregon Insurers Will Provide Coronavirus Coverage
March 17, 2020
The Division of Financial Regulations has indicated that the state has reached an agreement with several health insurance companies on their coverage for COVID-19 testing and treatment. Specifically, a number of insurers have agreed to cover COVID-19 testing, office visits, urgent care and emergency room visits without cost sharing. Additionally, the insurers have agreed to offer any future immunization without cost sharing. The state’s guidance also provides an FAQ that provides additional information on treatment. Employers can provide this guidance to their plan participants that may need to receive testing.
Coronavirus Information About Insurance and Scams »
Newborn Nurse Visiting Services Required
October 29, 2019
On July 15, 2019, Gov. Brown signed SB 526 into law. Effective September 29, 2019, the law requires health benefit policies issued in Oregon to reimburse the cost of newborn nurse visiting services. The coverage must be provided without any cost-sharing, coinsurance, or deductibles to families with newborns up to six months old.
Although insurers must offer these nurse services in health benefit plans, an eligible enrollee is not required to receive the services as a condition of coverage. Additionally, the carrier is responsible for notifying an enrollee about the services whenever an enrollee adds a newborn to coverage. Carriers may use in-network providers or may contract with local public health authorities to provide such services.
The measures are primarily directed towards insurers. However, Oregon employers should be aware of the new coverage requirements, particularly if planning to offer an HDHP option with an HSA program. An HDHP cannot provide for cost sharing, with the exception of preventive care, before the deductible is satisfied. Accordingly, it may be advisable for employers to talk to counsel about the impact of the new state mandate on HDHP/HSA arrangements
SB 526 »
Lawmakers Pass Paid Leave Law
July 23, 2019
On July 11, 2019, Oregon lawmakers passed HB 2005, establishing a paid family and medical leave act that will provide partial or full compensation to covered individuals that take family, medical, or safe leave. The bill is now awaiting Gov. Brown’s signature, and she has indicated that she will sign the measure. Oregon would then become the eighth state to pass a paid family leave law and the law would go into effect in January 2023.
Under the act, workers will receive up to twelve weeks of paid time off to recuperate from their own serious illness, to care for new adopted and foster children, or to address a domestic violence situation. The leave is generally funded by a new payroll tax with a 60/40 payment obligation for employees and employers, respectively. Employees will incur a new payroll tax not to exceed 1% of employee wages, up to a maximum of $132,900 in wages. Employers with 25 or more employees will be taxed to cover the remaining 40% of the obligation. Employers with fewer than 25 employees are exempt from paying the tax.
To be eligible for the leave, an employee must have earned at least $1,000 in wages during the previous year. While on leave, many workers will receive full wage replacement. This paid leave is in addition to paid sick leave, workers’ compensation benefits, and any PTO or vacation benefits provided by the employer, but the wage replacement offered under this act must be taken concurrently with Oregon Family Leave Act and federal Family and Medical Leave Act.
Employers should review the act and develop a plan for compliance. We will continue to monitor the Oregon Bureau of Labor and Industries as corresponding regulations assisting with compliance obligations.
HB 2005 »
HHS Approves Oregon’s Section 1332 Waiver
October 31, 2017
On Oct. 19, 2017, HHS and Treasury approved Oregon’s application for a state innovation waiver under Section 1332 of the ACA. As background, the ACA allows states to apply for a waiver from certain ACA requirements, as long as the state meets certain requirements (including the requirement to show that the state’s own innovative concepts and strategies will result in more individuals receiving coverage).
Oregon’s application sought to implement the Oregon Reinsurance Program (ORP) for 2018 and beyond. Its purpose is to stabilize premiums and increase coverage in the individual market. The ORP is a state-operated reinsurance program that will reimburse insurers for a percentage of an individual’s claims up to an attachment point and a cap. Because the ORP will lower premiums, the second-lowest-cost silver plan premium is reduced, which means the federal government will spend less on premium tax credits (PTCs) for individuals in Oregon. As a result, Oregon will receive pass-through funding based on the amount of PTCs that would have been provided to individuals absent the waiver. This does not mean the individual mandate is no longer applicable in Oregon, or that individuals cannot continue to receive PTCs in Oregon. Rather, the federal government will send additional funds to Oregon to help fund the ORP.
The HHS approval is effective for Jan. 1, 2018, through Dec. 31, 2022. The HHS approval contains no new employer obligations, but employers should understand its impact on the individual market.
HHS Approval Letter »
Clarifications to Paid Sick Time Law
August 08, 2017
In June 2015, Gov. Brown signed SB 454 into law, which made Oregon the fourth state to require paid sick leave for employees beginning Jan. 1, 2016. However, since the law’s inception, there has been some confusion around certain aspects of implementation. Thus, in an effort to address ambiguity, Gov. Brown signed SB 299 into law on June 29, 2017, which makes clarifications and amendments to the paid sick time law.
As background, employers located in Oregon with 10 or more employees (six if located in a city with a population exceeding 500,000 [i.e., Portland]) must provide up to 40 hours of paid sick leave each year. Employers with fewer than 10 employees (six employees if located in a city with population exceeding 500,000) are required to give 40 hours of unpaid protected sick leave to eligible workers. Paid sick leave begins to accrue at a rate of one hour for every 30 hours of actual work. Employees begin accruing sick leave immediately upon hire, although they cannot use the leave time until 91 calendar days after date of hire.
Although not exhaustive, the following are some of the most notable amendments to the state paid sick leave law:
- Employers may now cap employees’ sick leave bank to 80 hours maximum, and may also limit employees’ accrual to up to only 40 hours of sick time per year.
- Employers with a current PTO policy that is equivalent or more generous than the minimum requirements must make sure to comply with the state leave requirements for the first 40 hours provided each year, but would not need to comply beyond the first 40 hours provided under the PTO policy.
- Seasonal farm stands or temporary construction trailers used for office purposes that are located in the Portland area are exempt from the lower employee count (i.e., those located in Portland with six or more employees).
- When determining the number of employees employed by an employer, certain individuals need not be included in the employee count. These individuals include directors of a corporation, members of an LLC, partners of an LLP and sole proprietors if these individuals have a substantial ownership interest in the business (i.e., more than 15 percent or a percentage equal to or greater than the average of other owners). These individuals’ family members (spouses, children, parents) may also be excluded.
- If an employee is paid hourly, weekly, monthly or on a piece-rate basis or commission basis, employers must pay any leave time used at the same rate of the employee’s hourly, weekly or monthly wage or the state minimum wage (whichever is greater).
FAQs intended to assist employers with compliance are now available online. The new amendments are effective as of Jan. 1, 2018. Employers located in Oregon should review their leave policies and ensure they are in line with the new and existing requirements under the state’s paid sick leave law.
Sick Time Law FAQs »
SB 299 »
OR State Updates - 2015 Jan 20 No.01
October 20, 2015
On Oct. 14, 2015, the Oregon Insurance Division informally announced their intent to adopt a temporary rule on the definition of small employer in response to the passage of the federal PACE Act (HR 1624). Legislation passed (HB 2466) during the 2015 Oregon Legislative session amended the state’s definition of small employer to match the federal definition of 1-100 employees. However, the state legislation granted rulemaking authority to the Oregon Insurance Division in the event that the federal departments of HHS, DOL or the Treasury issued guidance or otherwise changed the definition.
As a result of the change in the federal definition under the PACE Act (allowing the states to decide their own small group sizes) the Oregon Insurance Division announced their intent to amend the definition of ‘small employer’ as defined in Oregon statutes. This means there will be no change to the current definition in Oregon. As a result, on Jan. 1, 2016, “small employer” will continue to be defined as an employer that employs 1 to 50 employees. Therefore there is no need for expanded transitional health benefit plans (previously authorized by HB 2466) and the temporary rule regarding transitional health plans will be rescinded (ID 10-2015).
On Oct. 16, 2015, the temporary rule was posted to the Insurance Division webpage. The Oregon Insurance Department expects to issue permanent rules after consideration by the Healthcare Reform Rulemaking Advisory Committee. The temporary rule is effective immediately.
Guidance on Definition of Small Employer »
Temporary Rule »
Revised Counting Methodology »