Around the PIA Western Alliance States – Week of May 25, 2026

Oregon — DFR health insurance rate review process to begin in June: The Oregon Division of Financial Regulation (DFR) will begin its annual health insurance rate review process in June for the 2027 plan year, with state regulators warning that federal decisions could have a significant effect on what Oregonians pay for coverage next year.

Insurance companies submitting proposed 2027 rates are expected to cite several emerging federal factors in their filings.

“The loss of the federal Affordable Care Act (ACA) subsidies, impact of tariffs, and changing federal guidance have left more Oregonians vulnerable to health care costs generally,” said Oregon Insurance Commissioner TK Keen. “Oregonians who buy their own coverage or work for small businesses deserve to know about the rate filing process, what’s driving rates to increase or decrease, and how to share their perspective. This level of transparency and accountability is unprecedented for a rate review process, and one we take seriously as a regulator.”

The transparent, actuarial-driven process includes publication of planned rates and public hearings on the rate filings for the individual and small group markets. Each year, health insurance companies submit planned rates, which the division then reviews under strict actuarial standards to ensure the rates are sound and insurers remain solvent.

The division analyzes the rates to determine whether they are actuarially sound, a process that is a months-long review. Part of the analysis includes reviewing the rates to ensure they are not excessive, inadequate, or unfairly discriminatory, as well as whether the planned administrative expenses are reasonable. DFR does not create or establish rates but rather reviews the rate proposals of insurance companies and ensures that all statutory factors are considered.

Oregon also operates a reinsurance program that operates to offset costs in the individual market and reduces rates by 6 percent to 8 percent each year. That program, using a combination of federal and state funds, is particularly effective at offsetting high-dollar claims in the individual market. DFR is pursuing a renewal of this reinsurance program with support from Oregon Gov. Tina Kotek.

Who this process affects

This rate review process applies to Oregonians who purchase health coverage through the health insurance marketplace or directly from an insurance company, and to employees of small businesses with fewer than 50 employees.

As of December 2025, per DFR’s quarterly enrollment reports, the Oregon individual market covered 148,376 people (3.4 percent of Oregonians), while the small group market covered 137,485 people (3.2 percent). In total, these markets cover 285,861 people (roughly 6.6 percent). It does not affect people covered through Medicare, Medicaid/Oregon Health Plan, or large employer or self-insured plans.

DFR’s role in the process

Rate review is a technical, actuarially driven process designed to ensure that the rates insurance companies file are supported by relevant data. DFR’s review team examines each insurer filing in detail, scrutinizing projected medical costs, administrative expenses, utilization trends, and reserve adequacy. The question DFR is answering is not simply whether rates are high or low, but whether they accurately reflect the cost of providing coverage to Oregonians while keeping insurers financially stable.

DFR has authority under Oregon law to require insurers to justify every component of a rate request. If the division finds that projections are inflated or administrative costs are unreasonable, it will reduce rates accordingly. An insurer’s financial position and market stability are also key considerations that are analyzed throughout the process.

DFR has created a website to inform consumers of the process and provide key documents and a space for public comment.

What’s likely to drive rate requests this year

Historically, insurance companies have cited several factors for explaining the rates they are charging that centered on medical and pharmaceutical costs, utilization, and the existence of federal subsidies. For plan year 2027, Congress not extending the enhanced federal ACA subsidies, the impact of tariffs, and decreased enrollment numbers (shrinking the risk pool) are likely to be factors reflected in insurance companies’ filings. DFR’s actuaries will independently evaluate each of these justifications, rather than accepting them as submitted.

Anticipated key dates

·       June 3: Rate filings due from health insurance companies

·       July 13: First public hearing (virtual)

·       July 31: Second public hearing (virtual, if needed)

·       Early August: DFR issues preliminary rate decisions

·       Early September: DFR issues final approval of rates

The June 3 filing date and July 13 public hearing date are set. The remaining dates may change based upon additional federal guidance. Last year, rates were delayed and not finalized until October due to delays from the federal government.

Public hearings and comments

DFR holds public hearings where insurance companies present their rate requests and respond to questions from DFR staff. The division encourages the public to attend and participate in this process. DFR accepts and reviews all public comments before final decisions are made. A link will be provided on www.oregonhealthrates.org for public comment closer to the hearing.

The most useful public input describes specific experiences with coverage, claims, network access, or plan changes. This type of input is context that helps DFR understand how rate decisions affect Oregonians and supplements the actuarial record.

The division will record the hearings and place them on the DFR rate review-specific website shortly after their conclusion.

DFR has a comprehensive overview of the rate review process, which can be found here — https://bit.ly/49IsDf1

Washington — Kuderer appointed to the Council of State Governments’ Executive Committee: The Council of State Governments (CSG) has appointed Washington state Insurance Commissioner Patty Kuderer to its Executive Committee. The appointment took effect immediately, and Kuderer’s term ends Dec. 31, 2026.

Kuderer, who regularly attended CSG-sponsored conferences during her nine-year tenure as a state legislator, said she was honored by the selection.

“I know the CSG plays a vital role in facilitating collaboration, cooperation, and respect among the different branches of government,” she said. “That’s an important mission, especially in today’s political world, and I’m excited to be a part of it.”

CSG, founded in 1933, is a national nonpartisan organization championing excellence in all three branches of state government. It fosters collaboration and community between elected and appointed officials in state governments across the country and the six U.S. territories.

As a member of the CSG Executive Committee, Kuderer will vote on official CSG policy statements along with the governance of the organization and its budget.

Kuderer previously served on the CSG West Executive Committee and Housing Committee, and the CSG Shared State Legislation Committee. Kuderer is also a 2022 alum of CSG’s Henry Toll Fellowship, a distinguished leadership development program for state government officials.

Washington — Notice of Federal and State Legal Protections for American Indian/Alaska Native Enrollees and Indian Health Care Providers: In August 2024, the Office of the Insurance Commissioner published a guidance document to strengthen issuers’ compliance with federal and state protections for American Indian/Alaska Native (AI/AN) enrollees and Indian health care providers, by consolidating applicable state and federal statutes and rules in one document.

Since the release of the guidance document, OIC has received several complaints regarding issuers’ failure to comply with or correctly interpret the protections referenced in the document. As a result, the purpose of this GovDelivery is to highlight the state and federal laws relevant to the complaints we’ve received and strengthen issuer compliance.

Issues raised in complaints: 

Refusal to reimburse Indian health providers (IHP) because they are “out-of-network”

Improper application of enrollee cost-sharing 

Failure to reimburse at required rates 

Delayed reimbursement because IHP did not comply with issuer credentialing requirements. 

Relevant provisions:

Right to recovery

Pursuant to 25 U.S.C. § 1621e(a), an Indian health care provider shall have the right to recover from an issuer the reasonable charges billed by the Indian health care provider in providing health services through the Indian health care provider or, if higher, the highest amount the issuer would pay for care and services that are furnished by providers other than governmental entities, to any individual to the same extent that such individual, or any nongovernmental provider of such services, would be eligible to receive reimbursement for such charges or expenses if— (a) such services had been provided by a nongovernmental provider; and (b) such individual had been required to pay such charges or expenses and did pay such charges or expenses.

Right of Recovery Supersedes Issuer Contracts. No state law or issuer contract provision entered into or renewed after November 23, 1988, shall prevent or hinder the right of recovery.

Qualified Health Plans (QHPs) – Cost Sharing. 

For services or items furnished directly by an Indian health care provider or through referral under contract health services, QHPs shall not reduce the payment to an Indian health care provider by the amount of any cost-sharing that would be due from the AI/AN but for the requirement under 42 U.S.C. § 18071(d)(2) that no cost sharing under the plan shall be imposed under the plan for such item or service.

Limited Cost Sharing. 

AI/AN people of any income can be enrolled in a QHP limited cost sharing plan, and such individuals shall have no cost sharing for essential health benefits received from an Indian health care provider or through referral under contract health services (currently referred to as “purchase and referred care”) as defined in 25 U.S.C. § 1603(5).The issuer of the plan may not reduce the payment to an Indian health care provider for such services or items. In Washington, these plans are referred to as “Cost-Sharing Reduction (CSR) Tier 3 plan variations.”

Credentialing

“Issuers are not responsible for credentialing providers and facilities that are part of the Indian health system.” Health professionals employed by an Indian health care provider are not required to have a Washington state license if they have a license in another state and are performing the services described in the contract or compact of the Tribal health program under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.).

Licensure of Indian Health Care Provider Facilities. 

A Federal health care program [e.g., Medicare, Medicaid, Children’s Health Insurance Program, Veterans Administration, Qualified Health Plans] must accept an entity that is operated by the Indian Health Service, an Indian Tribe, Tribal organization, or urban Indian organization as a provider eligible for reimbursement of health care services furnished to an AI/AN on the same basis as any other qualified provider under the program if the entity meets generally applicable state or other requirements for participation as a provider of health care services under the program.

Claims Format 

All issuers are prohibited from denying a claim for benefits submitted by an Indian health care provider based on the format in which the claim is submitted if such format complies with the format required for submission of claims under title XVIII of the Social Security Act [42 U.S.C. 1395 et. seq.] or recognized under section 1175 of such Act [42 U.S.C. § 1320d-4].

Payer of Last Resort 

Health programs operated by the Indian Health Service, Indian Tribes, Tribal organizations, and Urban Indian organizations (as those terms are defined in § 4 of the Indian Health Care Improvement Act (25 U.S.C. § 1603)) shall be the payer of last resort for services provided by such Service, Tribes, or organizations to individuals eligible for services through such programs, notwithstanding any federal, state, or local law to the contrary. Therefore, all alternate resources that are available and accessible such as Medicare, Medicaid, SCHIP, private insurance, etc. are used before Indian health care provider’s funds can be expended.

For more information regarding issuer obligations under state and federal law, please see Federal and State Legal Protections for American Indian/Alaska Native Enrollees and Indian Health Care Providers — https://bit.ly/3RJuXMn

Washington — Captive insurer regulatory updates (R 2025-14): We adopted the captive insurer regulatory updates rule R 2025-14 on May 19, 2026. The rule takes effect on June 19, 2026. The rule implements House Bill 1842, which allows public utility districts to form, own, or use captive insurers. The rule also gives captive insurers more clarity and flexibility in their audited financial statement submissions and reporting requirements.

For more information, including the adopted rule (CR-103) and the concise explanatory statement, please visit the rule's webpage.