Division 053

OAR Chapter 836

Division 053 Exhibits, appendixes, forms, attachments

836-053-0009
Exhibit 1: SB 91 Oregon Standard Plans

836-053-0012
Exhibit 1: Base benchmark health benefit plan
Exhibit 2: Pediatric dental benefits
Exhibit 3: Pediatric vision benefits

836-053-0013
Exhibit 1: 2025 Bronze plan cost-sharing matrix (draft)
Exhibit 2: 2025 Silver plan cost-sharing matrix (draft)

836-053-0015
Exhibit A: Revised Counting Methodology for Determining Small or Large Group
Exhibit B: Second Revised Counting Methodology for Determining Small or Large Group

836-053-0465
Exhibit 1

836-053-0471
Exhibit 1
Exhibit 2
Exhibit 3

836-053-0510
Oregon Standard Health Statement - Form 440-3087
Word | PDF | Spanish

836-053-0610
Oregon Confidential Communication Request Form

836-053-0863
State Continuation Notice Word

836-053-1205
Uniform Prior Authorization Prescription Request - Form 440-4992

836-053-1510(2)
Primary Care Reporting Template
Primary Care Spending Reporting Template Guidelines
Primary Care Spending Report list of codes for 2019 Report

836-053-1605
Appendix A: Non-anesthesia reimbursement base rate