Around the PIA Western Alliance States – Week of September 9, 2024

Oregon — Oregon Division of Financial Regulation issues final health rates for 2025; five insurance companies now statewide in individual market: The Oregon Division of Financial Regulation (DFR) has finalized the rate decisions for 2025 health insurance for the individual and small group markets. The division reviews and approves rates for these markets through a detailed and transparent public process before they can be charged to policyholders.

This transparent process includes actuarial analysis provided to the public, public hearings, and a public comment period. Annually, insurance companies submit rate filings for the upcoming plan year. These filings are rigorously reviewed by division actuaries during a monthslong public review process. That process is now final and Oregonians will see an average rate increase of 8.3 percent in the individual market and a 12.2 percent increase in the small group markets.

The final rates in the individual market came in 1 percent lower than the original rate requests from companies and the small group market came in one-tenth of 1 percent lower than originally requested. The lowered rate averages were driven by an actuarial review by the division that found several components of the company rate filings to be above division actuarial parameters. DFR has the authority to review and revise rates to ensure they are “reasonable and not excessive, inadequate or unfairly discriminatory,” under ORS 743.018 (4).

“We work hard to find any way we can to save Oregonians money throughout this process,” said Andrew R. Stolfi, Oregon insurance commissioner and director of the Department of Consumer and Business Services. “The health insurance market is competitive with five carriers offering plans in every Oregon county 2025, which gives Oregonians more options to shop for plans to fit their budget.”

Moda became the fifth company to offer health insurance in every county in Oregon after expanding into Benton, Linn, and Lincoln counties. Moda joins BridgeSpan, PacificSource, Providence, and Regence as health insurance companies who provide coverage in all parts of Oregon. It will be the first time that five insurers have offered plans in every county.

In the small group market, which serves small businesses with one to 50 employees, eight insurance companies submitted health insurance rates with a weighted final average increase of 12.2 percent. The average increase range is now 5.7 percent to 16.3 percent, for a weighted average increase of 12.2 percent. The increase was due in large part to medical costs and inflation.

DFR’s review also showed that the Oregon Reinsurance Program continues to help stabilize the health insurance market and keep rates lower. This program works to offset risk experienced by insurers, ultimately lowering premiums. Reinsurance lowered rates by at least 6 percent for the seventh straight year. In fact, this year it saved consumers 8.4 percent.

See the attached chart for the full list of rate change requests — https://dfr.oregon.gov/healthrates/Documents/2025-rate-and-county-coverage.pdf

The division has created a Consumer Guide to 2025 Health Insurance Rate Filings to explain how rates were arrived at and the adjustments made. This guide provides comprehensive detail as to the key components of the 2025 rates and an explanation to adjustments made by the division.

The division has also created a general Consumer Guide to Health Insurance Rate Review to help explain how rates are determined each year.

Oregon — Oregon Division of Financial Regulation protects consumers, recovers more than $5.6 million in first half of 2024: The Oregon Division of Financial Regulation (DFR), through its consumer advocacy, compliance, and enforcement teams, recovered $5,675,543 for Oregonians in the first half of 2024. DFR's consumer advocates and compliance teams have recovered $5,195,749, while the enforcement team has ordered $479,794 in restitution.

DFR consumer advocates help Oregonians in a variety of ways, depending on the issue. They handle complaints and questions from Oregon consumers who are experiencing difficulties with insurance, mortgages, banking products, securities, student loans, and a variety of other financial services regulated by DFR. Advocates have extensive industry knowledge across many platforms and they analyze and resolve complex issues.

Through the first two quarters of 2024, advocates have received 2,827 complaints, with insurance cases topping the list with 1,733 complaints. Last year, DFR advocates handled 4,852 complaints, including 3,140 insurance cases (by far the largest area of work), and recovered more than $8.3 million. A list of 2024 complaints broken down by subject and quarter is below.

Here are a few examples of work DFR advocates have done this year:

    During the January 2024 ice storm, two seniors suffered damage to their home. Their power was out for a couple of days when a neighbor checked on them. They were suffering from signs of hypothermia due to the 18-degree temperature in their home. They were taken to the hospital and after returning home, they found a water pipe had burst, pouring water onto the floor and causing damage. They filed a claim with their insurer, which denied the coverage, stating that they were responsible for maintaining heat or taking precautions such as draining the water system. DFR's consumer advocates got the company to reverse its decision and the consumers were paid more than $19,000 for their claim.

    A person died within the two-year contestable period of their life insurance policy. The company denied the claim, stating that medical conditions were not disclosed on the application. After reviewing the phone recordings between the agent and the person, there were incomplete medical questions asked during the application process that did not match the questions on the physical application. Because the agent omitted pertinent medical questions, the advocate convinced the insurer to pay the death claim – $304,697, including interest.

    A consumer filed a complaint after the auto insurer wrote a low initial estimate ($1,123) off photos only. The insurer's estimator admitted the estimate was low, but planned to update it as the work was done. After receiving the complaint, our office requested the insurer send an on-site estimator, which resulted in a new estimate for $7,491.90, consistent with the shop's estimate for the known damage.

“These stories illustrate just some of the many issues that come into our office every day and the multitude of ways that our consumer advocates can help," said Andrew R. Stolfi, Oregon insurance commissioner and director of the Oregon Department of Consumer and Business Services. “Our staff work hard to help people sift through insurance and financial issues that are often extremely complex and we encourage the public to reach out to us with questions and concerns."

Oregon Governor Tina Kotek appreciates how the division helps people in need.

“My administration will always be on the side of Oregonians when they need help," said Gov. Kotek. “The team at Oregon's Division of Financial Regulation works hard every day solving complex cases and putting money back into the pockets of Oregonians."

On average, DFR receives more than 1,200 complaints per quarter. In addition to the nearly 5,000 complaints last year, advocates handled 4,393 in 2022. Consumers sometimes bring issues that are outside of DFR's regulatory authority. In those cases, the advocates refer them to the agency with jurisdiction over the matter.

The compliance teams have opened 86 cases so far in 2024 and recovered nearly $43,000 for Oregon consumers. The enforcement team has taken 49 actions so far this year and ordered nearly a half million dollars in restitution.

“Our team of people looks out for Oregonians. Our employees are extremely knowledgeable in a cross section of industry and believe strongly in what they do," said DFR Administrator TK Keen. “Their work has generated more than $20 million back to consumers in the past two and a half years and the number of complaints continues to rise each year.”

Washington — OIC Releases Second Prepublication Draft for R 2024-02, Rulemaking Related to Health Care Benefit Managers: We are releasing a second prepublication draft of the health care benefit manager rule (R 2024-02) for comments. The second prepublication draft addresses health care benefit manager and pharmacy benefit manager regulations including but not limited to implementation of E2SSB 5213 (Chapter 242, Laws of 2024).

Comments on the second prepublication draft are due by September 16, 2024. Please send them to rulescoordinator@oic.wa.gov. For more information, including the text of the second prepublication draft, please visit relating to health care benefit managers (R 2024-02) webpage.