The individual market includes individuals and families who do not have access to employer-sponsored group coverage. Approximately 220,000 Oregonians, or 5.4 percent of the population, currently purchase health insurance in the individual market, either through healthcare.gov or directly through an insurer. In the individual health insurance market, the division must review both the content of insurance contracts and the rates charged for the coverage provided. The division's review of insurance contracts ensures that mandated benefits are covered and consumer protection standards are met. Provisions of the Oregon Insurance Code or federal law applicable to the individual market include:
*Guaranteed issue. No one can be denied individual health insurance coverage because of pre-existing conditions.
Guaranteed renewability. All individual health insurance policies are guaranteed renewable as long as premium payments are made. A general exception from the guaranteed renewability requirement exists for a company that chooses to withdraw from a particular geographic area or from the entire state or that discontinues a particular health plan.
*Rating rules. Premium rates cannot be based on an individual's health or claims experience, and insurance companies may not consider an individual's health status in setting premium rates. With the exception of age, tobacco use, and geographic region, insurers are prohibited from using individual characteristics when setting premiums and cannot increase rates for an individual more than once per year.
*Mandated benefits. All individual health insurance policies must include essential health benefits and certain mandated health benefits. Under the Affordable Care Act, insurers must provide preventive benefits, some of which are similar to benefits mandated under Oregon law. Under federal law, however, insurers may not impose cost sharing (co-pays, deductibles, etc.) on preventive benefits. Oregon law does not limit cost sharing on Oregon-mandated coverage. This means that unless an Oregon mandate is also a preventive benefit under federal law, an insurer will be able to continue to impose cost sharing on the coverage.
*Requirement does not apply to grandfathered plans.