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Form 440-4872 - Standards For Filing Individual And Small Group Health Benefit Plan Rates - Oregon Department Of Consumer And Business Service

Department of Consumer & Business Services

Oregon Insurance Division – 5

P.O. Box 14480

350 Winter St. NE

Salem, OR 97309-0405

Phone (503) 947-7983

Standards for Filing Individual and Small Group Health Benefit Plan Rates

This checklist must be submitted with your filing in compliance with OAR 836-010-0011(2). These standards are summaries, and review

of the entire statute or rule may be necessary. Complete each item to confirm that diligent consideration has been given to each and is

certified by the signature on the certification of compliance form. “Not applicable” can be used only if the item does not apply to the

rates being filed. Not including required information may cause this filing to be considered incomplete and returned without review.

These standards are subject to change as HHS releases more information.

Insurer Name:

Date:

TOI (type of insurance):

Sub-TOI:

H15I – Individual Health - Hospital/Surgical/Medical Expense

H15I.001- Hospital/Surgical/Medical Expense

H16G – Group Health Major Medical

H16G.001A – Any size group – PPO

H16G.001B – Any size group – POS

H16G.001C – Any size group – Other

H16G.003A – Small Group only - PPO

H16G.003B – Small Group only – PPO Basic

H16G.003D – Small Group only – POS

H16G.003E – Small Group only – POS Basic

H16G.003G – Small Group only – Other

H16I – Individual Health – Major Medical

H16I.005A – Individual – PPO

H16I.005B – Individual – POS

H16I.005C – Individual – Other

Product Type:

HMO

PPO

EPO

POS

HSA

HDHP

FFS

Other

440-4872 (4/4/13 INS)

Form 440-4872 - Standards For Filing Individual And Small Group Health Benefit Plan Rates - Oregon Department Of Consumer And Business Service