77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session
Enrolled
House Bill 2240
Introduced and printed pursuant to House Rule 12.00. Presession
filed (at the request of Governor John A. Kitzhaber, M.D., for
Department of Consumer and Business Services)
CHAPTER ................
AN ACT
Relating to coverage of health care services; creating new
provisions; amending ORS 192.556, 410.080, 413.011, 413.032,
413.201, 414.041, 414.231, 414.826, 414.828, 414.839, 433.443,
731.036, 731.146, 735.625, 741.300, 743.018, 743.019, 743.405,
743.417, 743.420, 743.522, 743.524, 743.526, 743.528, 743.550,
743.552, 743.560, 743.610, 743.730, 743.731, 743.733, 743.734,
743.736, 743.737, 743.745, 743.748, 743.751, 743.752, 743.754,
743.757, 743.766, 743.767, 743.769, 743.777, 743.801, 743.804,
743.822, 743.894, 743A.090, 743A.168, 743A.192, 746.015 and
746.045 and section 1, chapter 867, Oregon Laws 2009; repealing
ORS 414.831, 414.841, 414.842, 414.844, 414.846, 414.848,
414.851, 414.852, 414.854, 414.856, 414.858, 414.861, 414.862,
414.864, 414.866, 414.868, 414.870, 414.872, 735.616, 735.700,
735.701, 735.702, 735.703, 735.705, 735.707, 735.709, 735.710,
735.712, 743.549, 743.760 and 743.761; and declaring an
emergency.
Be It Enacted by the People of the State of Oregon:
{ +
IMPLEMENTATION OF FEDERAL REQUIREMENTS + }
SECTION 1. { + Sections 2, 3, 4, 5, 6 and 7 of this 2013 Act
are added to and made a part of the Insurance Code. + }
SECTION 2. { + ' Essential health benefits' are the items and
services prescribed by the Department of Consumer and Business
Services by rule in accordance with federal law, including:
(1) Ambulatory patient services.
(2) Emergency services.
(3) Hospitalization.
(4) Maternity and newborn care.
(5) Mental health and substance use disorder services,
including behavioral health treatment.
(6) Prescription drugs.
(7) Rehabilitative and habilitative services and devices.
(8) Laboratory services.
(9) Preventive and wellness services and chronic disease
management.
(10) Pediatric services, including oral and vision care. + }
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SECTION 3. { + (1) As used in this section, 'health benefit
plan' means a health benefit plan, as defined in ORS 743.730,
that is offered in the individual or small group market.
(2) The Department of Consumer and Business Services may
establish by rule a procedure for adjusting risk between
insurers. If a procedure is established, the procedure may
include:
(a) An assessment imposed on an insurer if the actuarial risk
of the enrollees in the insurer's health benefit plans is less
than the average actuarial risk of all enrollees in all health
benefit plans in this state; and
(b) Payments to insurers if the actuarial risk of the enrollees
in the insurer's health benefit plans is greater than the average
actuarial risk of all enrollees in all health benefit plans in
this state.
(3) A procedure established under this section must be
consistent with 42 U.S.C. 18063 and regulations adopted by the
Secretary of the United States Department of Health and Human
Services to carry out 42 U.S.C. 18063. + }
SECTION 4. { + (1) As used in this section, 'student health
benefit plan' means a plan that is subject to rules adopted by
the United States Department of Health and Human Services under
42 U.S.C. 18118(c).
(2) Notwithstanding any other provision of law, the Department
of Consumer and Business Services shall by rule and in a manner
consistent with federal law, adopt requirements for student
health benefit plans. + }
SECTION 5. { + (1) The Department of Consumer and Business
Services may require an insurer to provide a written notice to an
insured to fully effectuate any law the department is responsible
for enforcing, including, but not limited to, laws regarding:
(a) Enrollment periods.
(b) The termination of coverage.
(c) The availability of coverage outside of an open enrollment
period.
(d) The rights of insureds.
(2) The department may prescribe by rule the form, manner and
contents of any required notices. Any requirements must be
designed to minimize the administrative burden on insurers,
including by allowing notices to be combined into one notice, as
appropriate. + }
SECTION 6. { + (1) Notwithstanding ORS 743.737 (8)(d) and
743.767 (3), at one time during the 2014 calendar year, insurers
may increase their rates by an amount that reflects:
(a) The health insurance providers fee imposed under section
9010 of the Patient Protection and Affordable Care Act (P.L.
111-148), as amended by section 10905 of the Patient Protection
and Affordable Care Act, and as amended by the Health Care and
Education Reconciliation Act of 2010 (P.L. 111-152); and
(b) A federal fee, tax or assessment imposed to pay for the
costs of a federal reinsurance program.
(2) To the extent the existing rate was approved by the
Department of Consumer and Business Services, the resulting rate,
including the additional amount reflecting the health insurance
providers fee and a federal fee, tax or assessment, shall be
considered an approved rate. + }
SECTION 7. { + 'Group health insurance' means that form of
health insurance covering groups of persons described in this
section, with or without one or more members of their families or
one or more of their dependents, or covering one or more members
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of the families or one or more dependents of such groups of
persons, and issued upon one of the following bases:
(1) Under a policy issued to an employer or trustees of a fund
established by an employer, who shall be deemed the policyholder,
insuring employees of such employer for the benefit of persons
other than the employer. As used in this subsection, ' employees'
includes:
(a) The officers, managers and employees of the employer;
(b) The individual proprietor or partners if the employer is an
individual proprietor or partnership;
(c) The officers, managers and employees of subsidiary or
affiliated corporations;
(d) The individual proprietors, partners and employees of
individuals and firms, if the business of the employer and such
individual or firm is under common control through stock
ownership, contract or otherwise;
(e) The trustees or their employees, or both, if their duties
are principally connected with such trusteeship;
(f) The leased workers of a client employer; and
(g) Elected or appointed officials if a policy issued to insure
employees of a public body provides that the term ' employees'
includes elected or appointed officials.
(2) Under a policy issued to an association, including a labor
union, that has an active existence for at least one year, that
has a constitution and bylaws and that has been organized and is
maintained in good faith primarily for purposes other than that
of obtaining insurance, which shall be deemed the policyholder,
insuring members, employees or employees of members of the
association for the benefit of persons other than the association
or its officers or trustees.
(3) Under a policy issued to the trustees of a fund established
by two or more employers in the same or related industry or by
one or more labor unions or by one or more employers and one or
more labor unions or by an association as described in subsection
(2) of this section, insuring employees of the employers or
members of the unions or of such association, or employees of
members of such association for the benefit of persons other than
the employers or the unions or such association. As used in this
subsection, 'employees' may include the officers, managers and
employees of the employer, and the individual proprietor or
partners if the employer is an individual proprietor or
partnership. The policy may provide that the term ' employees'
includes the trustees or their employees, or both, if their
duties are principally connected with such trusteeship.
(4) Under a policy issued to any person or organization to
which a policy of group life insurance may be issued or delivered
in this state, to insure any class or classes of individuals that
could be insured under such group life policy. + }
{ + NOTE: + } Section 8 was deleted by amendment. Subsequent
sections were not renumbered.
SECTION 9. ORS 731.146, as amended by section 6, chapter 752,
Oregon Laws 2007, is amended to read:
731.146. (1) 'Transact insurance' means one or more of the
following acts effected by mail or otherwise:
(a) Making or proposing to make an insurance contract.
(b) Taking or receiving any application for insurance.
(c) Receiving or collecting any premium, commission, membership
fee, assessment, due or other consideration for any insurance or
any part thereof.
(d) Issuing or delivering policies of insurance.
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(e) Directly or indirectly acting as an insurance producer for,
or otherwise representing or aiding on behalf of another, any
person in the solicitation, negotiation, procurement or
effectuation of insurance or renewals thereof, the dissemination
of information as to coverage or rates, the forwarding of
applications, the delivering of policies, the inspection of
risks, the fixing of rates, the investigation or adjustment of
claims or losses, the transaction of matters subsequent to
effectuation of the policy and arising out of it, or in any other
manner representing or assisting a person with respect to
insurance.
(f) Advertising locally or circularizing therein without regard
for the source of such circularization, whenever such advertising
or circularization is for the purpose of solicitation of
insurance business.
(g) Doing any other kind of business specifically recognized as
constituting the doing of an insurance business within the
meaning of the Insurance Code.
{ + (h) Offering individual or small group coverage under a
multistate health benefit plan, as defined in ORS 743.730. + }
{ - (h) - } { + (i) + } Doing or proposing to do any
insurance business in substance equivalent to any of paragraphs
(a) to { - (g) - } { + (h) + } of this subsection in a manner
designed to evade the provisions of the Insurance Code.
(2) Subsection (1) of this section does not include, apply to
or affect the following:
(a) Making investments within a state by an insurer not
admitted or authorized to do business within such state.
(b) Except as provided in ORS 743.015, doing or proposing to do
any insurance business arising out of a policy of group life
insurance { - or group health insurance, or both, - } or a
policy of blanket health insurance, if the master policy was
validly issued to cover a group organized primarily for purposes
other than the procurement of insurance and was delivered in and
pursuant to the laws of another state in which:
(A) The insurer was authorized to do an insurance business;
(B) The policyholder is domiciled or otherwise has a bona fide
situs; and
(C) With respect to a policy of blanket health insurance, the
policy was approved by the director of such state.
(c) Investigating, settling, or litigating claims under
policies lawfully written within a state, or liquidating assets
and liabilities, all resulting from the insurer's former
authorized operations within such state.
(d) Transactions within a state under a policy subsequent to
its issuance if the policy was lawfully solicited, written and
delivered outside the state and did not cover a subject of
insurance resident, located or to be performed in the state when
issued.
(e) The continuation and servicing of life or health insurance
policies remaining in force on residents of a state if the
insurer has withdrawn from such state and is not transacting new
insurance therein.
(3) If mail is used, an act shall be deemed to take place at
the point where the matter transmitted by mail is delivered and
takes effect.
SECTION 10. ORS 741.300 is amended to read:
741.300. As used in ORS 741.001 to 741.540:
(1) 'Essential health benefits' { - means the health care
services identified by the United States Secretary of Health and
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Human Services pursuant to 42 U.S.C. 18022 or approved by the
secretary pursuant to a waiver granted under 42 U.S.C. 18052 - }
{ + has the meaning given that term in section 2 of this 2013
Act + }.
(2) 'Health care service contractor' has the meaning given that
term in ORS 750.005.
(3) 'Health insurance' has the meaning given that term in ORS
731.162, excluding disability income insurance.
(4) 'Health insurance exchange' or 'exchange' means an American
Health Benefit Exchange as described in 42 U.S.C. 18031, 18032,
18033 and 18041 that is operated by the Oregon Health Insurance
Exchange Corporation.
(5) 'Health plan' means health insurance or health care
coverage offered by an insurer.
(6) 'Insurer' means an insurer as defined in ORS 731.106 that
offers health insurance, a health care service contractor or a
prepaid managed care health services organization.
(7) 'Insurance producer' has the meaning given that term in ORS
731.104.
(8) 'Prepaid managed care health services organization' has the
meaning given that term in ORS 414.736.
(9) 'State program' means a program providing medical
assistance, as defined in ORS 414.025, and any health plan
offered through the Public Employees' Benefit Board or the Oregon
Educators Benefit Board.
SECTION 11. ORS 743.018 is amended to read:
743.018. (1) Except for group life and health insurance, and
except as provided in ORS 743.015, every insurer shall file with
the Director of the Department of Consumer and Business Services
all schedules and tables of premium rates for life and health
insurance to be used on risks in this state, and shall file any
amendments to or corrections of such schedules and tables.
Premium rates are subject to approval, disapproval or withdrawal
of approval by the director as provided in ORS 742.003, 742.005
and 742.007.
(2) Except as provided in ORS 743.737 { - and 743.760 - }
and subsection (3) of this section, a rate filing by a carrier
for any of the following health benefit plans subject to ORS
743.730 to 743.773 shall be available for public inspection
immediately upon submission of the filing to the director:
(a) Health benefit plans for small employers.
{ - (b) Portability health benefit plans. - }
{ - (c) - } { + (b) + } Individual health benefit plans.
(3) The director may by rule:
(a) Specify all information a carrier must submit as part of a
rate filing under this section; and
(b) Identify the information submitted that will be exempt from
disclosure under this section because the information constitutes
a trade secret and would, if disclosed, harm competition.
(4) The director, after conducting an actuarial review of the
rate filing, may approve a proposed premium rate for a health
benefit plan for small employers or for an individual health
benefit plan if, in the director's discretion, the proposed rates
are:
(a) Actuarially sound;
(b) Reasonable and not excessive, inadequate or unfairly
discriminatory; and
(c) Based upon reasonable administrative expenses.
(5) In order to determine whether the proposed premium rates
for a health benefit plan for small employers or for an
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individual health benefit plan are reasonable and not excessive,
inadequate or unfairly discriminatory, the director may consider:
(a) The insurer's financial position, including but not limited
to profitability, surplus, reserves and investment savings.
(b) Historical and projected administrative costs and medical
and hospital expenses.
(c) Historical and projected loss ratio between the amounts
spent on medical services and earned premiums.
(d) Any anticipated change in the number of enrollees if the
proposed premium rate is approved.
(e) Changes to covered benefits or health benefit plan design.
(f) Changes in the insurer's health care cost containment and
quality improvement efforts since the insurer's last rate filing
for the same category of health benefit plan.
(g) Whether the proposed change in the premium rate is
necessary to maintain the insurer's solvency or to maintain rate
stability and prevent excessive rate increases in the future.
(h) Any public comments received under ORS 743.019 pertaining
to the standards set forth in subsection (4) of this section and
this subsection.
(6) With the written consent of the insurer, the director may
modify a schedule or table of premium rates filed in accordance
with subsection (1) of this section.
(7) The requirements of this section do not supersede other
provisions of law that require insurers, health care service
contractors or multiple employer welfare arrangements providing
health insurance to file schedules or tables of premium rates or
proposed premium rates with the director or to seek the
director's approval of rates or changes to rates.
SECTION 12. ORS 743.405 is amended to read:
743.405. An individual health insurance policy must meet the
following requirements:
(1) { + The policy must include a statement of + } the entire
money and other considerations { - therefor shall be expressed
therein - } { + due + }.
(2) { + The policy must state + }the time at which the
insurance takes effect and terminates { - shall be expressed
therein - } .
(3) { - It shall - } { + The policy may + } purport to
insure only one person, { - except that a policy may insure,
originally or by subsequent amendment, upon the application of an
adult member of a family who shall be deemed the policyholder,
any two or more eligible members of that family, including
husband, wife, dependent children or any children under a
specified age and any other person dependent upon the
policyholder - } { + unless an adult member of a family applies
for coverage of family members or other dependents + }.
(4) The policy may not be issued individually to an individual
in a group of persons { - as - } described in { - ORS
743.522 - } { + section 7 of this 2013 Act + } for the purpose
of separating the individual from health insurance benefits
offered or provided in connection with a group health benefit
plan.
(5) { + (a) + } Except as provided in ORS 743.498, the style,
arrangement and overall appearance of the policy may not give
undue prominence to any portion of the text, and every printed
portion of the text of the policy and of any indorsements or
attached papers shall be plainly printed in lightfaced type of a
style in general use, the size of which shall be uniform and not
less than { - 10 point with a lower case unspaced alphabet
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length not less than 120 point. Captions shall be printed in not
less than - } 12-point type.
{ + (b) + } As used in this subsection, 'text' includes all
printed matter except the name and address of the insurer, name
or title of the policy, the brief description if any, and
captions and subcaptions.
(6) { + The policy must state + } the exceptions and
reductions of indemnity { - must be set forth in the policy - }
. Except those required by ORS 743.411 to 743.477, exceptions and
reductions shall be printed at the insurer's option either
included with the applicable benefit provision or under an
appropriate caption such as EXCEPTIONS, or EXCEPTIONS AND
REDUCTIONS. However, if an exception or reduction specifically
applies only to a particular benefit of the policy, a statement
of the exception or reduction must be included with the
applicable benefit provision.
(7) Each form constituting the policy, including riders and
indorsements, must be identified by a form number in the lower
left-hand corner of the first page of the policy.
(8) The policy may not contain provisions purporting to make
any portion of the charter, rules, constitution or bylaws of the
insurer a part of the policy unless such portion is set forth in
full in the policy, except in the case of the incorporation of or
reference to a statement of rates or classification of risks, or
short rate table filed with the Director of the Department of
Consumer and Business Services.
SECTION 13. ORS 743.417 is amended to read:
743.417. (1) An individual health insurance policy shall
{ - contain a provision as follows: 'GRACE PERIOD: - } { +
specify + } a minimum grace period of { + at least + } 10 days
after the premium due date { - will be granted - } for the
payment of each premium falling due after the first premium,
during which grace period the policy shall continue in force.
{ - ' - }
(2) A policy that contains a cancellation provision may add the
following clause at the end of the provision { - set forth - }
{ + described + } in subsection (1) of this section: 'subject
to the right of the insurer to cancel in accordance with the
cancellation provision hereof. '
(3) A policy in which the insurer reserves the right to refuse
renewal shall have the following clause at the beginning of the
provision { - set forth - } { + described + } in subsection
(1) of this section: 'Unless not less than 30 days prior to the
premium due date the insurer has delivered to the insured or has
mailed to the last address of the insured as shown by the records
of the insurer written notice of its intention not to renew this
policy beyond the period for which the premium has been accepted.
The insurer shall state in the notice the reason for its refusal
to renew this policy. '
SECTION 13a. ORS 743.420 is amended to read:
743.420. (1) A health insurance policy { + , other than a
health benefit plan as defined in ORS 743.730, + } shall contain
a provision as follows: 'REINSTATEMENT: If any renewal premium is
not paid within the grace period, a subsequent acceptance of
premium by the insurer or by any insurance producer duly
authorized by the insurer to accept such premium, without
requiring in connection therewith an application for
reinstatement, shall reinstate the policy; provided, however,
that if the insurer or such insurance producer requires an
application for reinstatement and issues a conditional receipt
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for the premium tendered, the policy will be reinstated upon
approval of such application by the insurer or, lacking such
approval, upon the 45th day following the date of such
conditional receipt unless the insurer has previously notified
the insured in writing of its disapproval of such application.
The reinstated policy shall cover only loss resulting from such
accidental injury as may be sustained after the date of
reinstatement and loss due to such sickness as may begin more
than 10 days after such date. In all other respects the insured
and insurer shall have the same rights thereunder as they had
under the policy immediately before the due date of the defaulted
premium, subject to any provisions indorsed hereon or attached
hereto in connection with the reinstatement. Any premium accepted
in connection with a reinstatement shall be applied to a period
for which premium has not been previously paid, but not to any
period more than 60 days prior to the date of reinstatement. '
(2) The last sentence of the provision set forth in subsection
(1) of this section may be omitted from any policy which the
insured has the right to continue in force subject to its terms
by the timely payment of premiums until at least age 50 or, in
the case of a policy issued after age 44, for at least five years
from its date of issue.
SECTION 14. ORS 743.522 is amended to read:
743.522. { - (1) 'Group health insurance' means that form of
health insurance covering groups of persons described in this
section, with or without one or more members of their families or
one or more of their dependents, or covering one or more members
of the families or one or more dependents of such groups of
persons, and issued upon one of the following bases: - }
{ - (a) Under a policy issued to an employer or trustees of a
fund established by an employer, who shall be deemed the
policyholder, insuring employees of such employer for the benefit
of persons other than the employer. As used in this paragraph, '
employees' includes: - }
{ - (A) The officers, managers and employees of the
employer; - }
{ - (B) The individual proprietor or partners if the employer
is an individual proprietor or partnership; - }
{ - (C) The officers, managers and employees of subsidiary or
affiliated corporations; - }
{ - (D) The individual proprietors, partners and employees of
individuals and firms, if the business of the employer and such
individual or firm is under common control through stock
ownership, contract or otherwise; - }
{ - (E) The trustees or their employees, or both, if their
duties are principally connected with such trusteeship; - }
{ - (F) The leased workers of a client employer; and - }
{ - (G) Elected or appointed officials if a policy issued to
insure employees of a public body provides that the term '
employees' includes elected or appointed officials. - }
{ - (b) Under a policy issued to an association, including a
labor union, that has an active existence for at least one year,
that has a constitution and bylaws and that has been organized
and is maintained in good faith primarily for purposes other than
that of obtaining insurance, which shall be deemed the
policyholder, insuring members, employees or employees of members
of the association for the benefit of persons other than the
association or its officers or trustees. - }
{ - (c) Under a policy issued to the trustees of a fund
established by two or more employers in the same or related
Enrolled House Bill 2240 (HB 2240-B) Page 8
industry or by one or more labor unions or by one or more
employers and one or more labor unions or by an association as
described in paragraph (b) of this subsection, insuring employees
of the employers or members of the unions or of such association,
or employees of members of such association for the benefit of
persons other than the employers or the unions or such
association. As used in this paragraph, 'employees' may include
the officers, managers and employees of the employer, and the
individual proprietor or partners if the employer is an
individual proprietor or partnership. The policy may provide that
the term ' employees' includes the trustees or their employees,
or both, if their duties are principally connected with such
trusteeship. - }
{ - (d) Under a policy issued to any person or organization
to which a policy of group life insurance may be issued or
delivered in this state, to insure any class or classes of
individuals that could be insured under such group life
policy. - }
{ + (1) As used in this section and ORS 743.533:
(a) 'Client employer' means an employer to whom workers are
provided under contract and for a fee on a leased basis by a
worker leasing company licensed under ORS 656.850.
(b) 'Employee' may include a retired employee.
(c) 'Leased worker' means a worker provided by a worker leasing
company licensed under ORS 656.850. + }
(2) Group health insurance { + may be + } offered to a
resident of this state under a group health insurance policy
issued to a group other than one { + of the groups + } described
in { - subsection (1) of this section may be delivered - }
{ + section 7 of this 2013 Act + } if:
(a) The Director of the Department of Consumer and Business
Services finds that:
(A) The issuance of the policy is in the best interest of the
public;
(B) The issuance of the policy would result in economies of
acquisition or administration; and
(C) The benefits are reasonable in relation to the premiums
charged; and
(b) The premium for the policy is paid either from funds of a
policyholder, from funds contributed by a covered person or from
both.
{ - (3) As used in this section and ORS 743.533: - }
{ - (a) 'Client employer' means an employer to whom workers
are provided under contract and for a fee on a leased basis by a
worker leasing company licensed under ORS 656.850. - }
{ - (b) 'Employee' may include a retired employee. - }
{ - (c) 'Leased worker' means a worker provided by a worker
leasing company licensed under ORS 656.850. - }
SECTION 14a. ORS 743.524 is amended to read:
743.524. (1) An insurer may not offer a policy of group health
insurance to an association as the policyholder or offer coverage
under such a policy, whether issued in this or another state,
unless the Director of the Department of Consumer and Business
Services determines that the association satisfies the
requirements of an association under { - ORS 743.522 (1)(b) - }
{ + section 7 (2) of this 2013 Act + }.
(2) An insurer shall submit evidence to the director that the
association satisfies the requirements under { - ORS 743.522
(1)(b) - } { + section 7 (2) of this 2013 Act + }. The director
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shall review the evidence and may request additional evidence as
needed.
(3) An insurer shall submit to the director any changes in the
evidence submitted under subsection (2) of this section.
(4) The director may order an insurer to cease offering health
insurance to an association if the director determines that the
association does not meet the standards under { - ORS 743.522
(1)(b) - } { + section 7 (2) of this 2013 Act + }.
(5) The director may adopt rules to carry out this section.
SECTION 15. ORS 743.550 is amended to read:
743.550. (1) Student health insurance is subject to ORS
743.537, 743.540, 743.543, 743.546 and { - 743.549 - } { +
743.552 + }, except as provided in this section.
(2) Coverage under a student health insurance policy may be
mandatory for all students at the institution, voluntary for all
students at the institution, or mandatory for defined classes of
students and voluntary for other classes of students. As used in
this subsection, 'classes' refers to undergraduates, graduate
students, domestic students, international students or other like
classifications. Any differences based on a student's nationality
may be established only for the purpose of complying with federal
law in effect when the policy is issued.
(3) When coverage under a student health insurance policy is
mandatory, the policyholder may allow any student subject to the
policy to decline coverage if the student provides evidence
acceptable to the policyholder that the student has similar
health coverage.
(4) A student health insurance policy may provide for any
student to purchase optional supplemental coverage.
(5) Student health insurance coverage for athletic injuries
may:
(a) Exclude coverage for injuries of students who have not
obtained medical release for a similar injury; and
(b) Be provided in excess of or in addition to any other
coverage under any other health insurance policy, including a
student health insurance policy.
(6) A student health insurance policy may provide that coverage
under the policy is secondary to any other health insurance for
purposes of guidelines established under ORS 743.552.
(7) A student health insurance policy may provide, on request
by the policyholder, that all or any portion of any indemnities
provided by such policy on account of hospital, nursing, medical
or surgical services may, at the insurer's option, be paid
directly to the hospital or person rendering such services.
However, the amount of any such payment shall not exceed the
amount of benefit provided by the policy with respect to the
service or billing of the provider of aid. The amount of such
payments pursuant to one or more assignments shall not exceed the
amount of expenses incurred on account of such hospitalization or
medical or surgical aid.
(8) An insurer providing student health insurance as primary
coverage may negotiate and enter into contracts for alternative
rates of payment with providers and offer the benefit of such
alternative rates to insureds who select such providers. An
insurer may utilize such contracts by offering a choice of plans
at the time an insured enrolls, one of which provides benefits
only for services by members of a particular provider
organization with whom the insurer has an agreement. If an
insured chooses such a plan, benefits are payable only for
services rendered by a member of that provider organization,
Enrolled House Bill 2240 (HB 2240-B) Page 10
unless such services were requested by a member of such
organization or are rendered as the result of an emergency.
(9) Payments made under subsection (8) of this section shall
discharge the insurer's obligation with respect to the amount of
insurance paid.
(10) An insurer shall provide each student health insurance
policyholder with a current roster of institutional and
professional providers under contract to provide services at
alternative rates under the group policy and shall also make such
lists available for public inspection during regular business
hours at the insurer's principal office within this state.
(11) As used in this section, 'student health insurance' { +
:
(a) + } Means that form of health insurance under a policy
issued to a college, school or other institution of learning, a
school district or districts, or school jurisdictional unit, or
recognized student government at a public university listed in
ORS 352.002, or to the head, principal or governing board of any
such educational unit, who or which shall be deemed the
policyholder, that is available exclusively to students at the
college, school or other institution.
{ + (b) Does not include a student health benefit plan as
defined in section 4 of this 2013 Act. + }
SECTION 15a. ORS 743.552 is amended to read:
743.552. The Director of the Department of Consumer and
Business Services shall by rule establish guidelines for the
{ - application of ORS 743.549, - } { + coordination of
benefits for individual and small group health insurance, + }
including:
(1) The procedures by which persons insured under
{ - such - } { + the + } policies are to be made aware of the
existence of { - such - } a { + coordination of benefits + }
provision;
(2) The benefits which may be subject to such a provision;
(3) The effect of such a provision on the benefits provided;
(4) Establishment of the order of benefit determination; and
(5) Reasonable claim administration procedures to expedite
claim payments { + . + } { - under such a provision which shall
include a time limit of 14 days beyond which the insurer shall
not delay payment of a claim by reason of the application of
coordination of benefits provision. - }
SECTION 16. ORS 743.610, as amended by section 3, chapter 24,
Oregon Laws 2012, is amended to read:
743.610. (1) As used in this section:
(a) 'Covered person' means an individual who was a certificate
holder under a group health insurance policy:
(A) On the day before a qualifying event; and
(B) During the three-month period ending on the date of the
qualifying event.
(b) 'Qualified beneficiary' means:
(A) A spouse or dependent child of a covered person who, on the
day before a qualifying event, was insured under the covered
person's group health insurance policy; or
(B) A child born to or adopted by a covered person during the
period of the continuation of coverage under this section who
would have been insured under the covered person's policy if the
child had been born or adopted on the day before the qualifying
event.
(c) 'Qualifying event' means the loss of membership in a group
health insurance policy caused by:
Enrolled House Bill 2240 (HB 2240-B) Page 11
(A) Voluntary or involuntary termination of the employment of a
covered person;
(B) A reduction in hours worked by a covered person;
(C) A covered person becoming eligible for Medicare;
(D) A qualified beneficiary losing dependent child status under
a covered person's group health insurance policy;
(E) Termination of membership in the group covered by the group
health insurance policy; or
(F) The death of a covered person.
(2) { + (a) + } A { - group health insurance policy - }
{ + grandfathered health plan, as defined in ORS 743.730, + }
providing coverage { + under a group health insurance policy + }
for hospital or medical expenses, other than coverage limited to
expenses from accidents or specific diseases, must contain a
provision that a covered person and any qualified beneficiary may
continue coverage under the policy as provided in this section.
{ + (b) A group health insurance policy that provides
coverage for one or more of the essential health benefits, other
than a grandfathered health plan, must contain a provision that a
covered person and any qualified beneficiary may continue
coverage under the policy as provided in this section. + }
(3) Continuation of coverage is not available to a covered
person or qualified beneficiary who is eligible for:
(a) Medicare; or
(b) { + The same + } coverage { - for hospital or medical
expenses - } under any other program that was not covering the
covered person or qualified beneficiary on the day before a
qualifying event.
(4) The continued coverage { - need not include benefits for
dental, vision care or prescription drug expense, or any other
benefits under the policy other than hospital and medical expense
benefits - } { + must be offered in the same manner as it is
provided to other certificate holders under the group health
insurance policy + }.
(5) A covered person or qualified beneficiary { - who wishes
to continue coverage must provide the insurer with a written
request for continuation no later than 10 days after the later of
the date of a qualifying event or - } { + must submit a written
request for continuation of coverage to the insurer within the
time prescribed by the insurer, except that an insurer may not
require a request to be submitted less than 10 days after the
later of:
(a) The date of a qualifying event; or
(b) + } The date the insurer provides the notice required by
subsection (10) of this section.
(6) A covered person or qualified beneficiary who requests
continuation of coverage shall pay the premium on a monthly basis
and in advance to the insurer or to the employer or policyholder,
whichever the group policy provides. The required premium payment
may not exceed the group premium rate for the insurance being
continued under the group policy as of the date the premium
payment is due.
(7) Continuation of coverage as provided under this section
ends on the earliest of the following dates:
(a) Nine months after the date of the qualifying event that was
the basis for the continuation of coverage.
(b) The end of the period for which the last timely premium
payment for the coverage is received by the insurer.
Enrolled House Bill 2240 (HB 2240-B) Page 12
(c) The premium payment due date coinciding with or next
following the date that continuation of coverage ceases to be
available in accordance with subsection (3) of this section.
(d) The date that the policy is terminated. However, if the
policyholder replaces the terminated policy with similar coverage
under another group health insurance policy:
(A) The covered person and qualified beneficiaries may obtain
coverage under the replacement policy for the balance of the
period that the covered person or qualified beneficiary would
have remained covered under the terminated policy in accordance
with this section; and
(B) The terminated policy must continue to provide benefits to
the covered person and qualified beneficiaries to the extent of
that policy's accrued liabilities and extensions of benefits as
if the replacement had not occurred.
(8) A qualified beneficiary who is not eligible for
continuation of coverage under ORS 743.600 may continue coverage
under this section upon the dissolution of marriage with or the
death of the covered person in the same manner that a covered
person may exercise the right to continue coverage under this
section.
(9) A covered person rehired by an employer no later than nine
months after the layoff of the covered person by the employer may
not be subjected to a waiting period for coverage under the
employer's group health insurance policy if the covered person
was eligible for coverage at the time of the layoff, regardless
of whether the covered person continued coverage during the
layoff.
(10) If an insurer terminates the group health insurance
coverage of a covered person or qualified beneficiary without
providing replacement coverage that meets the criteria in
subsection (7)(d) of this section, the insurer shall provide
written notice to the covered person and any qualified
beneficiary no later than 10 days after the insurer is notified
of the qualifying event under subsection (5) of this section. The
notice shall include information prescribed by the Director of
the Department of Consumer and Business Services.
(11) This section applies only to employers who are not
required to make available continuation of health insurance
benefits under Titles X and XXII of the Consolidated Omnibus
Budget Reconciliation Act of 1985, as amended, P.L. 99-272, April
7, 1986.
SECTION 17. ORS 743.730, as amended by section 49, chapter 500,
Oregon Laws 2011, and section 20, chapter 38, Oregon Laws 2012,
is amended to read:
743.730. For purposes of ORS 743.730 to 743.773:
(1) 'Actuarial certification' means a written statement by a
member of the American Academy of Actuaries or other individual
acceptable to the Director of the Department of Consumer and
Business Services that a carrier is in compliance with the
provisions of ORS 743.736 { - , 743.760 or 743.761, - } based
upon the person's examination, including a review of the
appropriate records and of the actuarial assumptions and methods
used by the carrier in establishing premium rates for small
employer { - and portability - } health benefit plans.
(2) 'Affiliate' of, or person 'affiliated' with, a specified
person means any carrier who, directly or indirectly through one
or more intermediaries, controls or is controlled by or is under
common control with a specified person. For purposes of this
Enrolled House Bill 2240 (HB 2240-B) Page 13
definition, 'control' has the meaning given that term in ORS
732.548.
(3) 'Affiliation period' means, under the terms of a group
health benefit plan issued by a health care service contractor, a
period:
(a) That is applied uniformly and without regard to any health
status related factors to an enrollee or late enrollee { - in
lieu of a preexisting condition exclusion - } ;
(b) That must expire before any coverage becomes effective
under the plan for the enrollee or late enrollee;
(c) During which no premium shall be charged to the enrollee or
late enrollee; and
(d) That begins on the enrollee's or late enrollee's first date
of eligibility for coverage and runs concurrently with any
eligibility waiting period under the plan.
{ - (4) 'Basic health benefit plan' means a health benefit
plan that provides bronze plan coverage and that is approved by
the Department of Consumer and Business Services under ORS
743.736. - }
{ - (5) - } { + (4) + } 'Bona fide association' means an
association that
{ - meets the requirements of 42 U.S.C. 300gg-91 as amended and
in effect on March 23, 2010. - } { + :
(a) Has been in active existence for at least five years;
(b) Has been formed and maintained in good faith for purposes
other than obtaining insurance;
(c) Does not condition membership in the association on any
factor relating to the health status of an individual or the
individual's dependent or employee;
(d) Makes health insurance coverage that is offered through the
association available to all members of the association
regardless of the health status of the member or individuals who
are eligible for coverage through the member;
(e) Does not make health insurance coverage that is offered
through the association available other than in connection with a
member of the association;
(f) Has a constitution and bylaws; and
(g) Is not owned or controlled by a carrier, producer or
affiliate of a carrier or producer. + }
{ - (6) 'Bronze plan' means a health benefit plan that meets
the criteria for a bronze plan prescribed by the director by rule
pursuant to ORS 743.822 (2). - }
{ - (7) - } { + (5) + } 'Carrier { - , - } ' { - except
as provided in ORS 743.760, - } means any person who provides
health benefit plans in this state, including:
(a) A licensed insurance company;
(b) A health care service contractor;
(c) A health maintenance organization;
(d) An association or group of employers that provides benefits
by means of a multiple employer welfare arrangement and that:
(A) Is subject to ORS 750.301 to 750.341; or
(B) Is fully insured and otherwise exempt under ORS 750.303 (4)
but elects to be governed by ORS 743.733 to 743.737; or
(e) Any other person or corporation responsible for the payment
of benefits or provision of services.
{ - (8) - } { + (6) + } 'Catastrophic plan' means a health
benefit plan that meets the requirements for a catastrophic plan
under 42 U.S.C. 18022(e) and that is offered through the Oregon
Health Insurance Exchange.
Enrolled House Bill 2240 (HB 2240-B) Page 14
{ - (9) - } { + (7) + } 'Creditable coverage' means prior
health care coverage as defined in 42 U.S.C. 300gg as amended and
in effect on February 17, 2009, and includes coverage remaining
in force at the time the enrollee obtains new coverage.
{ - (10) - } { + (8) + } 'Dependent' means the spouse or
child of an eligible employee, subject to applicable terms of the
health benefit plan covering the employee.
{ - (11) - } { + (9) + } 'Eligible employee' means an
employee who works on a regularly scheduled basis, with a normal
work week of 17.5 or more hours. The employer may determine hours
worked for eligibility between 17.5 and 40 hours per week subject
to rules of the carrier. 'Eligible employee' does not include
employees who work on a temporary, seasonal or substitute basis.
Employees who have been employed by the employer for fewer than
90 days are not eligible employees unless the employer so allows.
{ - (12) - } { + (10) + } 'Employee' means any individual
employed by an employer.
{ - (13) - } { + (11) + } 'Enrollee' means an employee,
dependent of the employee or an individual otherwise eligible for
a group { - , - } { + or + } individual { - or
portability - } health benefit plan who has enrolled for
coverage under the terms of the plan.
{ - (14) - } { + (12) + } 'Exchange' means the health
insurance exchange administered by the Oregon Health Insurance
Exchange Corporation in accordance with ORS 741.310.
{ - (15) - } { + (13) + } 'Exclusion period' means a period
during which specified treatments or services are excluded from
coverage.
{ - (16) - } { + (14) + } 'Financial impairment' means that
a carrier is not insolvent and is:
(a) Considered by the director to be potentially unable to
fulfill its contractual obligations; or
(b) Placed under an order of rehabilitation or conservation by
a court of competent jurisdiction.
{ - (17)(a) - } { + (15)(a) + } 'Geographic average rate'
means the arithmetical average of the lowest premium and the
corresponding highest premium to be charged by a carrier in a
geographic area established by the director for the carrier's:
(A) Group health benefit plans offered to small employers; { +
or + }
(B) Individual health benefit plans { - ; or - } { + . + }
{ - (C) Portability health benefit plans. - }
(b) 'Geographic average rate' does not include premium
differences that are due to differences in benefit design { + ,
age, tobacco use + } or family composition.
{ - (18) - } { + (16) + } 'Grandfathered health plan' has
the meaning prescribed by the United States Secretaries of Labor,
Health and Human Services and the Treasury pursuant to 42 U.S.C.
18011(e).
{ - (19) - } { + (17) + } 'Group eligibility waiting
period' means, with respect to a group health benefit plan, the
period of employment or membership with the group that a
prospective enrollee must complete before plan coverage begins.
{ - (20)(a) - } { + (18)(a) + } 'Health benefit plan' means
any:
(A) Hospital expense, medical expense or hospital or medical
expense policy or certificate;
(B) Health care service contractor or health maintenance
organization subscriber contract; or
Enrolled House Bill 2240 (HB 2240-B) Page 15
(C) Plan provided by a multiple employer welfare arrangement or
by another benefit arrangement defined in the federal Employee
Retirement Income Security Act of 1974, as amended, to the extent
that the plan is subject to state regulation.
(b) 'Health benefit plan' does not include:
(A) Coverage for accident only, specific disease or condition
only, credit or disability income;
(B) Coverage of Medicare services pursuant to contracts with
the federal government;
(C) Medicare supplement insurance policies;
(D) Coverage of TRICARE services pursuant to contracts with the
federal government;
(E) Benefits delivered through a flexible spending arrangement
established pursuant to section 125 of the Internal Revenue Code
of 1986, as amended, when the benefits are provided in addition
to a group health benefit plan;
(F) Separately offered long term care insurance, including, but
not limited to, coverage of nursing home care, home health care
and community-based care;
(G) Independent, noncoordinated, hospital-only indemnity
insurance or other fixed indemnity insurance;
(H) Short term health insurance policies that are in effect for
periods of 12 months or less, including the term of a renewal of
the policy;
(I) Dental only coverage;
(J) Vision only coverage;
(K) Stop-loss coverage that meets the requirements of ORS
742.065;
(L) Coverage issued as a supplement to liability insurance;
(M) Insurance arising out of a workers' compensation or similar
law;
(N) Automobile medical payment insurance or insurance under
which benefits are payable with or without regard to fault and
that is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance; or
(O) Any employee welfare benefit plan that is exempt from state
regulation because of the federal Employee Retirement Income
Security Act of 1974, as amended.
(c) For purposes of this subsection, renewal of a short term
health insurance policy includes the issuance of a new short term
health insurance policy by an insurer to a policyholder within 60
days after the expiration of a policy previously issued by the
insurer to the policyholder.
{ - (21) 'Health statement' means any information that is
intended to inform the carrier or insurance producer of the
health status of an enrollee or prospective enrollee in a health
benefit plan. 'Health statement' includes the standard health
statement approved by the director under ORS 743.745. - }
{ - (22) - } { + (19) + } 'Individual coverage waiting
period' means a period in an individual health benefit plan
during which no premiums may be collected and health benefit plan
coverage issued is not effective.
{ + (20) 'Individual health benefit plan' means a health
benefit plan:
(a) That is issued to an individual policyholder; or
(b) That provides individual coverage through a trust,
association or similar group, regardless of the situs of the
policy or contract. + }
Enrolled House Bill 2240 (HB 2240-B) Page 16
{ - (23) - } { + (21) + } 'Initial enrollment period' means
a period of at least 30 days following commencement of the first
eligibility period for an individual.
{ - (24) - } { + (22) + } 'Late enrollee' means an
individual who enrolls in a group health benefit plan subsequent
to the initial enrollment period during which the individual was
eligible for coverage but declined to enroll. However, an
eligible individual shall not be considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg { - as amended and in effect on
February 17, 2009 - } { + or as prescribed by rule by the
Department of Consumer and Business Services + };
(b) The individual applies for coverage during an open
enrollment period;
(c) A court issues an order that coverage be provided for a
spouse or minor child under an employee's employer sponsored
health benefit plan and request for enrollment is made within 30
days after issuance of the court order;
(d) The individual is employed by an employer that offers
multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period;
or
(e) The individual's coverage under Medicaid, Medicare,
TRICARE, Indian Health Service or a publicly sponsored or
subsidized health plan, including, but not limited to, the
medical assistance program under ORS chapter 414, has been
involuntarily terminated within 63 days after applying for
coverage in a group health benefit plan.
{ - (25) - } { + (23) + } 'Minimal essential coverage' has
the meaning given that term in section 5000A(f) of the Internal
Revenue Code.
{ - (26) - } { + (24) + } 'Multiple employer welfare
arrangement' means a multiple employer welfare arrangement as
defined in section 3 of the federal Employee Retirement Income
Security Act of 1974, as amended, 29 U.S.C. 1002, that is subject
to ORS 750.301 to 750.341.
{ - (27) - } { + (25) + } 'Oregon Medical Insurance Pool'
means the pool created under ORS 735.610.
{ - (28) 'Preexisting condition exclusion' means a health
benefit plan provision applicable to an enrollee or late enrollee
that excludes coverage for services, charges or expenses incurred
during a specified period immediately following enrollment for a
condition for which medical advice, diagnosis, care or treatment
was recommended or received during a specified period immediately
preceding enrollment. For purposes of ORS 743.730 to 743.773: - }
{ - (a) Pregnancy does not constitute a preexisting condition
except as provided in ORS 743.766; - }
{ - (b) Genetic information does not constitute a preexisting
condition in the absence of a diagnosis of the condition related
to such information; and - }
{ - (c) Except for coverage under an individual grandfathered
health plan, a preexisting condition exclusion may not exclude
coverage for services, charges or expenses incurred by an
individual who is under 19 years of age. - }
{ + (26) 'Preexisting condition exclusion' means:
(a) Except for a grandfathered health plan, a limitation or
exclusion of benefits or a denial of coverage based on a medical
condition being present before the effective date of coverage or
before the date coverage is denied, whether or not any medical
Enrolled House Bill 2240 (HB 2240-B) Page 17
advice, diagnosis, care or treatment was recommended or received
for the condition before the date of coverage or denial of
coverage.
(b) With respect to a grandfathered health plan, a provision
applicable to an enrollee or late enrollee that excludes coverage
for services, charges or expenses incurred during a specified
period immediately following enrollment for a condition for which
medical advice, diagnosis, care or treatment was recommended or
received during a specified period immediately preceding
enrollment. For purposes of this paragraph pregnancy and genetic
information do not constitute preexisting conditions. + }
{ - (29) - } { + (27) + } 'Premium' includes insurance
premiums or other fees charged for a health benefit plan,
including the costs of benefits paid or reimbursements made to or
on behalf of enrollees covered by the plan.
{ - (30) - } { + (28) + } 'Rating period' means the
12-month calendar period for which premium rates established by a
carrier are in effect, as determined by the carrier.
{ - (31) - } { + (29) + } 'Representative' does not include
an insurance producer or an employee or authorized representative
of an insurance producer or carrier.
{ - (32) 'Silver plan' means an individual or small group
health benefit plan that meets the criteria for a silver plan
prescribed by the director by rule pursuant to ORS 743.822
(2). - }
{ - (33)(a) - } { + (30)(a) + } 'Small employer' means an
employer that employed an average of at least { - two - } { +
one + } but not more than 50 employees on business days during
the preceding calendar year, the majority of whom are employed
within this state, and that employs at least { - two eligible
employees on the date on which coverage takes effect under a
health benefit plan offered by the employer - } { + one
eligible employee on the first day of the plan year + }.
(b) Any person that is treated as a single employer under
{ - subsection (b), (c), (m) or (o) of - } section 414 { +
(b), (c), (m) or (o) + } of the Internal Revenue Code of 1986
shall be treated as one employer for purposes of this subsection.
(c) The determination of whether an employer that was not in
existence throughout the preceding calendar year is a small
employer shall be based on the average number of employees that
it is reasonably expected the employer will employ on business
days in the current calendar year.
SECTION 18. ORS 743.731 is amended to read:
743.731. The purposes of ORS 743.730 to 743.773 { + and
section 3 of this 2013 Act + } are:
(1) To promote the availability of health insurance coverage to
groups regardless of their enrollees' health status or claims
experience;
(2) To prevent abusive rating practices;
(3) To require disclosure of rating practices to purchasers of
small employer { - , portability - } and individual health
benefit plans;
(4) To { - establish limitations on - } { + prohibit + }
the use of preexisting condition exclusions { + except in
grandfathered health plans + };
{ - (5) To make basic health benefit plans available to all
small employers; - }
{ - (6) - } { + (5) + } To encourage the availability of
{ - portability and - } individual health benefit plans for
individuals who are not enrolled in group health benefit plans;
Enrolled House Bill 2240 (HB 2240-B) Page 18
{ - (7) - } { + (6) + } To improve renewability and
continuity of coverage for employers and covered individuals;
{ - (8) - } { + (7) + } To improve the efficiency and
fairness of the health insurance marketplace; and
{ - (9) - } { + (8) + } To ensure that health insurance
coverage in Oregon satisfies the requirements of the Health
Insurance Portability and Accountability Act of 1996 (P.L.
104-191) and the Patient Protection and Affordable Care Act (P.L.
111-148) as amended by the Health Care and Education
Reconciliation Act (P.L. 111-152), and that enforcement authority
for those requirements is retained by the Director of the
Department of Consumer and Business Services.
SECTION 19. ORS 743.733 is amended to read:
743.733. (1) If an affiliated group of employers is treated as
a single employer under { - subsection (b), (c), (m) or (o)
of - } section 414 { + (b), (c), (m) or (o) + } of the Internal
Revenue Code of 1986, a carrier may issue a single group health
benefit plan to the affiliated group on the basis of the number
of employees in the affiliated group if the group requests such
coverage.
{ - (2) If a carrier determines that an employer has more
than 50 employees, the carrier may provide a quote for a group
health benefit plan that is not subject to ORS 743.733 to
743.737. If the employer's workforce consists of at least two but
not more than 50 eligible employees, the carrier shall inform the
employer that if coverage is limited to the eligible employees,
the carrier must treat the employer as a small employer and shall
provide a separate quote on that basis. - }
{ - (3) - } { + (2) + } Subsequent to the issuance of a
health benefit plan to a small employer, { + other than a plan
issued through the Oregon Health Insurance Exchange, + } a
carrier shall determine annually the number of employees of the
employer for purposes of determining the employer's ongoing
eligibility as a small employer.
{ + (3)(a) + } { - The provisions of - } ORS 743.733 to
743.737 shall continue to apply to a health benefit plan issued
{ + outside of the exchange + } to a small employer until the
plan anniversary date following the date the employer no longer
meets the definition of a small employer.
{ + (b) ORS 743.733 to 743.737 shall continue to apply to an
employer that receives coverage through the exchange until the
employer no longer receives coverage through the exchange and is
no longer a small employer. + }
SECTION 20. ORS 743.734, as amended by section 13, chapter 500,
Oregon Laws 2011, is amended to read:
743.734. (1) Every health benefit plan shall be subject to the
provisions of ORS 743.733 to 743.737, if the plan provides health
benefits covering one or more employees of a small employer and
if any one of the following conditions is met:
(a) Any portion of the premium or benefits is paid by a small
employer or any eligible employee is reimbursed, whether through
wage adjustments or otherwise, by a small employer for any
portion of the health benefit plan premium; or
(b) The health benefit plan is treated by the employer or any
of the eligible employees as part of a plan or program for the
purposes of section 106, section 125 or section 162 of the
Internal Revenue Code of 1986, as amended.
{ - (2) Except as provided in ORS 743.733 to 743.737, 743.764
and 743A.012, no state law requiring the coverage or the offer of
coverage of a health care service or benefit applies to the basic
Enrolled House Bill 2240 (HB 2240-B) Page 19
health benefit plans offered or delivered to a small
employer. - }
{ - (3) - } { + (2) + } Except as otherwise provided by ORS
743.733 to 743.737 or other law, no health benefit plan offered
to a small employer shall:
(a) Inhibit a carrier from contracting with providers or groups
of providers with respect to health care services or benefits; or
(b) Impose any restriction on the ability of a carrier to
negotiate with providers regarding the level or method of
reimbursing care or services provided under health benefit plans.
{ - (4) Except to determine the application of a preexisting
condition exclusion for a late enrollee who is 19 years of age or
older, a carrier shall not use health statements when offering
small employer health benefit plans and shall not use any other
method to determine the actual or expected health status of
eligible enrollees. Nothing in this subsection shall prevent a
carrier from using health statements or other information after
enrollment for the purpose of providing services or arranging for
the provision of services under a health benefit plan. - }
{ - (5) Except as provided in this section and ORS 743.737, a
carrier shall not impose different terms or conditions on the
coverage, premiums or contributions of any eligible employee of a
small employer that are based on the actual or expected health
status of any eligible employee. - }
{ - (6)(a) - } { + (3)(a) + } A carrier may provide
different health benefit plans to different categories of
employees of a small employer { - that has at least 26 but no
more than 50 eligible employees - } when the employer has chosen
to establish different categories of employees in a manner that
does not relate to the actual or expected health status of such
employees or their dependents. The categories must be based on
bona fide employment-based classifications that are consistent
with the employer's usual business practice.
(b) Except as provided in ORS 743.736 { - (9) - } { +
(8) + }, a carrier that offers coverage to a small employer
{ - with no more than 25 eligible employees - } shall offer
coverage to all eligible employees of the small employer { - ,
without regard to the actual or expected health status of any
eligible employee - } .
(c) If a small employer elects to offer coverage to dependents
of eligible employees, the carrier shall offer coverage to all
dependents of eligible employees { - , without regard to the
actual or expected health status of any eligible dependent - } .
{ - (7) - } { + (4) + } Notwithstanding any other provision
of law, an insurer may not deny, delay or terminate participation
of an individual in a group health benefit plan or exclude
coverage otherwise provided to an individual under a group health
benefit plan based on a preexisting condition of the individual
{ - if the individual is under 19 years of age - } .
SECTION 21. ORS 743.736 is amended to read:
743.736. (1) As a condition of transacting business in the
small employer health insurance market in this state, a carrier
shall offer small employers { - an approved basic health
benefit plan and all of the other plans of the carrier that have
been - } { + all of the carrier's health benefit plans, + }
approved by the Department of Consumer and Business Services for
use in the small employer market { + , for which the small
employer is eligible + }.
Enrolled House Bill 2240 (HB 2240-B) Page 20
{ - (2) A carrier shall submit to the department, for
approval in accordance with ORS 742.003, the policy form or forms
containing its basic health benefit plan. - }
{ - (3) - } { + (2) + } A carrier that offers a health
benefit plan in the small employer market only { - through - }
{ + to + } one or more bona fide associations is not required
to offer that health benefit plan to small employers that are not
members of the bona fide association.
{ - (4) - } { + (3) + } A carrier shall issue to a small
employer any health benefit plan { - , including a basic health
benefit plan, - } that is offered by the carrier if the small
employer applies for the plan and agrees to make the required
premium payments and to satisfy the other provisions of the
health benefit plan.
{ - (5) - } { + (4) + } A multiple employer welfare
arrangement, professional or trade association or other similar
arrangement established or maintained to provide benefits to a
particular trade, business, profession or industry or their
subsidiaries
{ - shall - } { + may + } not issue coverage to a group or
individual that is not in the same trade, business, profession or
industry as that covered by the arrangement. The arrangement
shall accept all groups and individuals in the same trade,
business, profession or industry or their subsidiaries that apply
for coverage under the arrangement and that meet the requirements
for membership in the arrangement. For purposes of this
subsection, the requirements for membership in an arrangement
{ - shall - } { + may + } not include any requirements that
relate to the actual or expected health status of the prospective
enrollee.
{ - (6) - } { + (5) + } A carrier shall, pursuant to
subsection { - (4) - } { + (3) + } of this section, accept
applications from and offer coverage to a small employer group
covered under an existing health benefit plan regardless of
whether a prospective enrollee is excluded from coverage under
the existing plan because of late enrollment. When a carrier
accepts an application for a small employer group, the carrier
may continue to exclude the prospective enrollee excluded from
coverage by the replaced plan until the prospective enrollee
would have become eligible for coverage under that replaced plan.
{ - (7) - } { + (6) + } A carrier is not required to accept
applications from and offer coverage pursuant to subsection
{ - (4) - } { + (3) + } of this section if the department
finds that acceptance of an application or applications would
endanger the carrier's ability to fulfill its contractual
obligations or result in financial impairment of the carrier.
{ - (8) - } { + (7) + } A carrier shall market fairly all
health benefit plans { - , including basic health benefit
plans, - } that are offered by the carrier to small employers in
the geographical areas in which the carrier makes coverage
available or provides benefits.
{ - (9)(a) - } { + (8)(a) + } Subsection { - (4) - }
{ + (3) + } of this section does not require a carrier to offer
coverage to or accept applications from:
(A) A small employer if the small employer is not physically
located in the carrier's approved service area;
(B) An employee of a small employer if the employee does not
work or reside within the carrier's approved service areas; or
(C) Small employers located within an area where the carrier
reasonably anticipates, and demonstrates to the department, that
Enrolled House Bill 2240 (HB 2240-B) Page 21
it will not have the capacity in its network of providers to
deliver services adequately to the enrollees of those small
employer groups because of its obligations to existing small
employer group contract holders and enrollees.
(b) A carrier that does not offer coverage pursuant to
paragraph (a)(C) of this subsection { - shall - } { + may + }
not offer coverage in the applicable service area to new employer
groups other than small employers until the carrier resumes
enrolling groups of new small employers in the applicable area.
{ - (10) - } { + (9) + } For purposes of ORS 743.733 to
743.737, except as provided in this subsection, carriers that are
affiliated carriers or that are eligible to file a consolidated
tax return pursuant to ORS 317.715 shall be treated as one
carrier and any restrictions or limitations imposed by ORS
743.733 to 743.737 apply as if all health benefit plans delivered
or issued for delivery to small employers in this state by the
affiliated carriers were issued by one carrier. However, any
insurance company or health maintenance organization that is an
affiliate of a health care service contractor located in this
state, or any health maintenance organization located in this
state that is an affiliate of an insurance company or health care
service contractor, may treat the health maintenance organization
as a separate carrier and each health maintenance organization
that operates only one health maintenance organization in a
service area in this state may be considered a separate carrier.
{ - (11) - } { + (10) + } A carrier that elects to
discontinue offering all of its health benefit plans to small
employers under ORS 743.737
{ - (6)(e) - } { + (3)(e) + }, elects to discontinue renewing
all such plans or elects to discontinue offering and renewing all
such plans is prohibited from offering health benefit plans to
small employers in this state for a period of five years from one
of the following dates:
(a) The date of notice to the department pursuant to ORS
743.737 { - (6)(e) - } { + (3)(e) + }; or
(b) If notice is not provided under paragraph (a) of this
subsection, from the date on which the department provides notice
to the carrier that the department has determined that the
carrier has effectively discontinued offering health benefit
plans to small employers in this state.
{ - (12) - } { + (11) + } This section does not require a
carrier to actively market, offer, issue or accept applications
for a grandfathered health plan or from a small employer not
eligible for coverage under such a plan as provided by the
Patient Protection and Affordable Care Act (P.L. 111-148) as
amended by the Health Care and Education Reconciliation Act (P.L.
111-152).
SECTION 22. ORS 743.737 is amended to read:
743.737. { - (1) A preexisting condition exclusion in a small
employer health benefit plan shall apply only to a condition for
which medical advice, diagnosis, care or treatment was
recommended or received during the six-month period immediately
preceding the enrollment date of an enrollee or late enrollee. As
used in this section, the enrollment date of an enrollee shall be
the earlier of the effective date of coverage or the first day of
any required group eligibility waiting period and the enrollment
date of a late enrollee shall be the effective date of
coverage. - }
{ - (2) A preexisting condition exclusion in a small employer
health benefit plan shall expire as follows: - }
Enrolled House Bill 2240 (HB 2240-B) Page 22
{ - (a) For an enrollee, on the earlier of the following
dates: - }
{ - (A) Six months after the enrollee's effective date of
coverage; or - }
{ - (B) Ten months after the start of any required group
eligibility waiting period. - }
{ - (b) For a late enrollee, not later than 12 months after
the late enrollee's effective date of coverage. - }
{ - (3) In applying a preexisting condition exclusion to an
enrollee or late enrollee, except as provided in this subsection,
all small employer health benefit plans shall reduce the duration
of the provision by an amount equal to the enrollee's or late
enrollee's aggregate periods of creditable coverage if the most
recent period of creditable coverage is ongoing or ended within
63 days after the enrollment date in the new small employer
health benefit plan. The crediting of prior coverage in
accordance with this subsection shall be applied without regard
to the specific benefits covered during the prior period. This
subsection does not preclude, within a small employer health
benefit plan, application of: - }
{ + (1) A health benefit plan issued to a small employer:
(a) Must cover essential health benefits consistent with 42
U.S.C. 300gg-11.
(b) May: + }
{ - (a) - } { + (A) Require + } an affiliation period that
does not exceed two months for an enrollee or { - three
months - } { + 90 days + } for a late enrollee; { - or - }
{ - (b) - } { + (B) + } { + Impose + } an exclusion period
for specified covered services, as established under ORS 743.745,
applicable to all individuals enrolling for the first time in the
small employer health benefit plan { - . - } { + ; or + }
{ - (4) - } { + (C) + } { - A health benefit plan issued
to a small employer may - } Not apply a preexisting condition
exclusion to { - a person under 19 years of age - } { + any
enrollee + }.
{ - (5) - } { + (2) + } Late enrollees in a small employer
health benefit plan may be subjected to a group eligibility
waiting period { - of up to 12 months or, if 19 years of age or
older, may be subjected to a preexisting condition exclusion for
up to 12 months. If both a waiting period and a preexisting
condition exclusion are applicable to a late enrollee, the
combined period shall not exceed 12 months - } { + that does
not exceed 90 days + }.
{ - (6) - } { + (3) + } Each small employer health benefit
plan shall be renewable with respect to all eligible enrollees at
the option of the policyholder, small employer or contract holder
unless:
(a) The policyholder, small employer or contract holder fails
to pay the required premiums.
(b) The policyholder, small employer or contract holder or,
with respect to coverage of individual enrollees, an enrollee or
a representative of an enrollee engages in fraud or makes an
intentional misrepresentation of a material fact as prohibited by
the terms of the plan.
(c) The number of enrollees covered under the plan is less than
the number or percentage of enrollees required by participation
requirements under the plan.
(d) The small employer fails to comply with the contribution
requirements under the health benefit plan.
Enrolled House Bill 2240 (HB 2240-B) Page 23
(e) The carrier discontinues offering or renewing, or offering
and renewing, all of its small employer health benefit plans in
this state or in a specified service area within this state. In
order to discontinue plans under this paragraph, the carrier:
(A) Must give notice of the decision to the Department of
Consumer and Business Services and to all policyholders covered
by the plans;
(B) May not cancel coverage under the plans for 180 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in the entire state or,
except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel coverage under the plans for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in a specified service area
because of an inability to reach an agreement with the health
care providers or organization of health care providers to
provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and
renewing, all health benefit plans issued by the carrier in the
small employer market in this state or in the specified service
area.
(f) The carrier discontinues offering and renewing a small
employer health benefit plan in a specified service area within
this state because of an inability to reach an agreement with the
health care providers or organization of health care providers to
provide services under the plan within the service area. In order
to discontinue a plan under this paragraph, the carrier:
(A) Must give notice to the department and to all policyholders
covered by the plan;
(B) May not cancel coverage under the plan for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph; and
(C) Must offer in writing to each small employer covered by the
plan, all other small employer health benefit plans that the
carrier offers to small employers in the specified service
area. The carrier shall issue any such plans pursuant to the
provisions of ORS 743.733 to 743.737. The carrier shall offer the
plans at least 90 days prior to discontinuation.
(g) The carrier discontinues offering or renewing, or offering
and renewing, a health benefit plan, other than a grandfathered
health plan, for all small employers in this state or in a
specified service area within this state, other than a plan
discontinued under paragraph (f) of this subsection.
(h) The carrier discontinues renewing or offering and renewing
a grandfathered health plan for all small employers in this state
or in a specified service area within this state, other than a
plan discontinued under paragraph (f) of this subsection.
(i) With respect to plans that are being discontinued under
paragraph (g) or (h) of this subsection, the carrier must:
(A) Offer in writing to each small employer covered by the
plan, all other health benefit plans that the carrier offers to
small employers in the specified service area.
(B) Issue any such plans pursuant to the provisions of ORS
743.733 to 743.737.
(C) Offer the plans at least 90 days prior to discontinuation.
(D) Act uniformly without regard to the claims experience of
the affected policyholders or the health status of any current or
prospective enrollee.
Enrolled House Bill 2240 (HB 2240-B) Page 24
(j) The Director of the Department of Consumer and Business
Services orders the carrier to discontinue coverage in accordance
with procedures specified or approved by the director upon
finding that the continuation of the coverage would:
(A) Not be in the best interests of the enrollees; or
(B) Impair the carrier's ability to meet contractual
obligations.
(k) In the case of a small employer health benefit plan that
delivers covered services through a specified network of health
care providers, there is no longer any enrollee who lives,
resides or works in the service area of the provider network.
(L) In the case of a health benefit plan that is offered in the
small employer market only { - through - } { + to + } one or
more bona fide associations, the membership of an employer in the
association ceases and the termination of coverage is not related
to the health status of any enrollee.
{ - (7) - } { + (4) + } A carrier may modify a small
employer health benefit plan at the time of coverage renewal. The
modification is not a discontinuation of the plan under
subsection { - (6)(e) - } { + (3)(e) + }, (g) and (h) of this
section.
{ - (8) - } { + (5) + } Notwithstanding any provision of
subsection { - (6) - } { + (3) + } of this section to the
contrary, a carrier may not rescind the coverage of an enrollee
in a small employer health benefit plan unless:
(a) The enrollee or a person seeking coverage on behalf of the
enrollee:
(A) Performs an act, practice or omission that constitutes
fraud; or
(B) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the plan;
(b) The carrier provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
the enrollee; and
(c) The carrier provides notice of the rescission to the
department in the form, manner and time frame prescribed by the
department by rule.
{ - (9) - } { + (6) + } Notwithstanding any provision of
subsection { - (6) - } { + (3) + } of this section to the
contrary, a carrier may not rescind a small employer health
benefit plan unless:
(a) The small employer or a representative of the small
employer:
(A) Performs an act, practice or omission that constitutes
fraud; or
(B) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the plan;
(b) The carrier provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
each plan enrollee who would be affected by the rescission of
coverage; and
(c) The carrier provides notice of the rescission to the
department in the form, manner and time frame prescribed by the
department by rule.
{ - (10) - } { + (7)(a) + } A carrier may continue to
enforce reasonable employer participation and contribution
requirements on small employers { - applying for coverage - } .
However, participation and contribution requirements shall be
applied uniformly among all small employer groups with the same
number of eligible employees applying for coverage or receiving
Enrolled House Bill 2240 (HB 2240-B) Page 25
coverage from the carrier. In determining minimum participation
requirements, a carrier shall count only those employees who are
not covered by an existing group health benefit plan, Medicaid,
Medicare, TRICARE, Indian Health Service or a publicly sponsored
or subsidized health plan, including but not limited to the
medical assistance program under ORS chapter 414.
{ + (b) A carrier may not deny a small employer's application
for coverage under a health benefit plan based on participation
or contribution requirements but may require small employers that
do not meet participation or contribution requirements to enroll
during the open enrollment period beginning November 15 and
ending December 15. + }
{ - (11) - } { + (8) + } Premium rates for small employer
health benefit plans shall be subject to the following
provisions:
(a) Each carrier must file with the department the initial
geographic average rate and any changes in the geographic average
rate with respect to each health benefit plan issued by the
carrier to small employers.
{ - (b)(A) The premium rates charged during a rating period
for health benefit plans issued to small employers may not vary
from the geographic average rate by more than 50 percent on or
after January 1, 2008, except as provided in subparagraph (D) of
this paragraph - } .
{ - (B) - } { + (b)(A) + } The variations in premium rates
{ - described in subparagraph (A) of this paragraph - } { +
charged during a rating period for health benefit plans issued to
small employers + } shall be based solely on the factors
specified in subparagraph { - (C) - } { + (B) + } of this
paragraph. A carrier may elect which of the factors specified in
subparagraph { - (C) - } { + (B) + } of this paragraph apply
to premium rates for health benefit plans for small employers.
{ - The factors that are based on contributions or participation
may vary with the size of the employer. - } All other factors
must be applied in the same actuarially sound way to all small
employer health benefit plans.
{ - (C) - } { + (B) + } The variations in premium rates
described in subparagraph (A) of this paragraph may be based
{ + only + } on one or more of the following factors { + as
prescribed by the department by rule + }:
(i) The ages of enrolled employees and their dependents { + ,
except that the rate for adults may not vary by more than three
to one + };
{ - (ii) The level at which the small employer contributes to
the premiums payable for enrolled employees and their
dependents; - }
{ - (iii) The level at which eligible employees participate
in the health benefit plan; - }
{ - (iv) - } { + (ii) + } The level at which enrolled
employees and their dependents { + 18 years of age and older + }
engage in tobacco use { - ; - } { + , except that the rate may
not vary by more than 1.5 to one; + } { + and + }
{ - (v) The level at which enrolled employees and their
dependents engage in health promotion, disease prevention or
wellness programs; - }
{ - (vi) The period of time during which a small employer
retains uninterrupted coverage in force with the same carrier;
and - }
{ - (vii) - } { + (iii) + } Adjustments to reflect
{ - the provision of benefits not required to be covered by the
Enrolled House Bill 2240 (HB 2240-B) Page 26
basic health benefit plan and - } differences in family
composition.
{ - (D)(i) The premium rates determined in accordance with
this paragraph may be further adjusted by a carrier to reflect
the expected claims experience of the covered small employer, but
the extent of this adjustment may not exceed five percent of the
annual premium rate otherwise payable by the small employer. The
adjustment under this subparagraph may not be cumulative from
year to year. - }
{ - (ii) The premium rates adjusted under this subparagraph,
except rates for small employers with 25 or fewer employees, are
not subject to the provisions of subparagraph (A) of this
paragraph. - }
{ - (E) - } { + (C) + } A carrier shall apply the carrier's
schedule of premium rate variations as approved by the department
and in accordance with this paragraph. Except as otherwise
provided in this section, the premium rate established by a
carrier for a small employer health benefit plan shall apply
uniformly to all employees of the small employer enrolled in that
plan.
(c) Except as provided in paragraph (b) of this subsection, the
variation in premium rates between different health benefit plans
offered by a carrier to small employers must be based solely on
objective differences in plan design or coverage { + , age,
tobacco use and family composition + } and must not include
differences based on the risk characteristics of groups assumed
to select a particular health benefit plan.
(d) A carrier may not increase the rates of a health benefit
plan issued to a small employer more than once in a 12-month
period. Annual rate increases shall be effective on the plan
anniversary date of the health benefit plan issued to a small
employer. The percentage increase in the premium rate charged to
a small employer for a new rating period may not exceed the sum
of the following:
(A) The percentage change in the geographic average rate
measured from the first day of the prior rating period to the
first day of the new period; and
(B) Any adjustment attributable to changes in age { - , except
an additional adjustment may be made to reflect the provision of
benefits not required to be covered by the basic health benefit
plan - } and differences in family composition.
(e) Premium rates for small employer health benefit plans shall
comply with the requirements of this section.
{ - (12) - } { + (9) + } In connection with the offering
for sale of any health benefit plan to a small employer, each
carrier shall make a reasonable disclosure as part of its
solicitation and sales materials of:
(a) The full array of health benefit plans that are offered to
small employers by the carrier;
(b) The authority of the carrier to adjust rates { + and
premiums + }, and the extent to which the carrier will consider
age, { + tobacco use, + } family composition and geographic
factors in establishing and adjusting rates { - ; - } { + and
premiums; and
(c) The benefits and premiums for all health insurance coverage
for which the employer is qualified. + }
{ - (c) Provisions relating to renewability of policies and
contracts; and - }
{ - (d) Provisions affecting any preexisting condition
exclusion. - }
Enrolled House Bill 2240 (HB 2240-B) Page 27
{ - (13)(a) - } { + (10)(a) + } Each carrier shall maintain
at its principal place of business a complete and detailed
description of its rating practices and renewal underwriting
practices relating to its small employer health benefit plans,
including information and documentation that demonstrate that its
rating methods and practices are based upon commonly accepted
actuarial practices and are in accordance with sound actuarial
principles.
(b) A carrier offering a small employer health benefit plan
shall file with the department at least once every 12 months an
actuarial certification that the carrier is in compliance with
ORS 743.733 to 743.737 and that the rating methods of the carrier
are actuarially sound. Each certification shall be in a uniform
form and manner and shall contain such information as specified
by the department. A copy of each certification shall be retained
by the carrier at its principal place of business. { + A carrier
is not required to file the actuarial certification under this
paragraph if the department has approved the carrier's rate
filing within the preceding 12-month period. + }
(c) A carrier shall make the information and documentation
described in paragraph (a) of this subsection available to the
department upon request. Except as provided in ORS 743.018 and
except in cases of violations of ORS 743.733 to 743.737, the
information shall be considered proprietary and trade secret
information and shall not be subject to disclosure to persons
outside the department except as agreed to by the carrier or as
ordered by a court of competent jurisdiction.
{ - (14) - } { + (11) + } A carrier shall not provide any
financial or other incentive to any insurance producer that would
encourage the insurance producer to market and sell health
benefit plans of the carrier to small employer groups based on a
small employer group's anticipated claims experience.
{ - (15) - } { + (12) + } For purposes of this section, the
date a small employer health benefit plan is continued shall be
the anniversary date of the first issuance of the health benefit
plan.
{ - (16) - } { + (13) + } A carrier must include a
provision that offers coverage to all eligible employees of a
small employer and to all dependents of the eligible employees to
the extent the employer chooses to offer coverage to dependents.
{ - (17) - } { + (14) + } All small employer health benefit
plans shall contain special enrollment periods during which
eligible employees and dependents may enroll for coverage, as
provided { - in 42 U.S.C. 300gg as amended and in effect on
February 17, 2009 - } { + by federal law and rules adopted by
the department + }.
{ - (18) - } { + (15) + } A small employer health benefit
plan may not impose annual or lifetime limits on the dollar
amount of { - the - } essential health benefits
{ - prescribed by the United States Secretary of Health and
Human Services pursuant to 42 U.S.C. 300gg-11, except as
permitted by federal law - } .
{ - (19) - } { + (16) + } This section does not require a
carrier to actively market, offer, issue or accept applications
for a grandfathered health plan or from a small employer not
eligible for coverage under such a plan { - as provided by the
Patient Protection and Affordable Care Act (P.L. 111-148) as
amended by the Health Care and Education Reconciliation Act (P.L.
111-152) - } .
SECTION 23. ORS 743.745 is amended to read:
Enrolled House Bill 2240 (HB 2240-B) Page 28
743.745. { - (1) The Director of the Department of Consumer
and Business Services shall determine the form and level of
coverages under the basic health benefit plans pursuant to ORS
743.736 to be made available by carriers and the portability
health benefit plans to be made available pursuant to ORS 743.760
or 743.761. The director may take into consideration the levels
of health benefit plans provided in Oregon and the appropriate
medical and economic factors and shall establish benefit levels,
cost sharing, exclusions and limitations. The health benefit
plans described in this section may include cost containment
features including, but not limited to: - }
{ - (a) Preferred provider provisions; - }
{ - (b) Utilization review of health care services including
review of medical necessity of hospital and physician
services; - }
{ - (c) Case management benefit alternatives; - }
{ - (d) Other managed care provisions; - }
{ - (e) Selective contracting with hospitals, physicians and
other health care providers; and - }
{ - (f) Reasonable benefit differentials applicable to
participating and nonparticipating providers. - }
{ - (2) - } { + (1) + } In order to ensure the broadest
availability of small employer { - , portability - } and
individual health benefit plans, the { - director - } { +
Department of Consumer and Business Services + } may approve
market conduct and other requirements for carriers and insurance
producers, including:
(a) Registration by each carrier with the department { - of
Consumer and Business Services - } of the carrier's intention to
offer group health benefit plans under ORS 743.733 to 743.737 or
individual health benefit plans, or both.
(b) To the extent deemed necessary by the { - director - }
{ + department + } to ensure the fair distribution of high-risk
individuals and groups among carriers, periodic reports by
carriers and insurance producers concerning small employer { - ,
portability - } and individual health benefit plans issued,
provided that reporting requirements shall be limited to
information concerning case characteristics and numbers of health
benefit plans in various categories marketed or issued to small
employers and individuals.
(c) Methods concerning periodic demonstration by carriers
offering health benefit plans to individuals or small employers
and insurance producers that the carriers and insurance producers
are marketing or issuing health benefit plans in fulfillment of
the purposes of ORS 743.730 to 743.773.
{ - (3) - } { + (2) + } The { - director shall develop a
standard health statement to be used for all late enrollees and
by all carriers offering individual policies of health
insurance. - } { + department may require carriers and
insurance producers offering health benefit plans to individuals
or small employers to use the open and special enrollment periods
prescribed by the department by rule. + }
{ - (4) - } { + (3) + } { - The director shall develop a
list of the specified services - } For small employer { - and
portability - } plans { + , the department may specify
services + } for which carriers may impose an exclusion period,
the duration of the allowable exclusion period for each specified
service and the manner in which credit will be given for
exclusion periods imposed pursuant to prior health insurance
coverage.
Enrolled House Bill 2240 (HB 2240-B) Page 29
SECTION 24. ORS 743.748, as amended by section 18, chapter 500,
Oregon Laws 2011, is amended to read:
743.748. (1) Each carrier offering a health benefit plan shall
submit to the Director of the Department of Consumer and Business
Services on or before April 1 of each year a report that
contains:
(a) The following information for the preceding year that is
derived from the exhibit of premiums, enrollment and utilization
included in the carrier's annual report:
(A) The total number of members;
(B) The total amount of premiums;
(C) The total amount of costs for claims;
(D) The medical loss ratio;
(E) The average amount of premiums per member per month; and
(F) The percentage change in the average premium per member per
month, measured from the previous year.
(b) The following aggregate financial information for the
preceding year that is derived from the carrier's annual report:
(A) The total amount of general administrative expenses,
including identification of the five largest nonmedical
administrative expenses and the assessment against the carrier
for the Oregon Medical Insurance Pool;
(B) The total amount of the surplus maintained;
(C) The total amount of the reserves maintained for unpaid
claims;
(D) The total net underwriting gain or loss; and
(E) The carrier's net income after taxes.
(2) A carrier shall electronically submit the information
described in subsection (1) of this section in a format and
according to instructions prescribed by the Department of
Consumer and Business Services by rule.
(3) The department shall evaluate the reporting requirements
under subsection (1)(a) of this section by the following market
segments:
(a) Individual health benefit plans;
(b) Health benefit plans for small employers;
(c) Health benefit plans for employers described in ORS
743.733; and
(d) Health benefit plans for employers { - with more than 50
employees - } { + that are not small employers + }.
(4) The department shall make the information reported under
this section available to the public through a searchable public
website on the Internet.
SECTION 25. ORS 743.751 is amended to read:
743.751. { - (1) Except to determine the application of a
preexisting condition exclusion for a late enrollee who is 19
years of age or older or as prescribed by the Department of
Consumer and Business Services by rule, a carrier offering group
health benefit plans shall not use health statements when
offering such plans to a group of two or more prospective
certificate holders and shall not use any other method to
determine the actual or expected health status of eligible
prospective enrollees. Nothing in this section shall prevent a
carrier from using health statements or other information after
enrollment for the purpose of providing services or arranging for
the provision of services under a health benefit plan or from
obtaining aggregate group information related to historical
medical claims expenses and health behavior surveys for rating
purposes. - }
Enrolled House Bill 2240 (HB 2240-B) Page 30
{ - (2) Subsection (1) of this section applies only to group
health benefit plans that are not small employer health benefit
plans. - }
{ + (1) Except for an individual grandfathered health plan, a
carrier may require an applicant for individual or small group
health benefit plan coverage to provide health-related
information only for the purpose of health care management and
may not use the information to deny coverage.
(2) Except for an individual grandfathered health plan, if a
carrier requires an applicant to provide health-related
information, the carrier must also notify the applicant, in the
form and manner prescribed by the Department of Consumer and
Business Services, that the information may not be used to deny
coverage. + }
SECTION 26. ORS 743.752 is amended to read:
743.752. (1) Except in the case of a late enrollee and as
otherwise provided in this section, a carrier offering a group
health benefit plan to a group of two or more prospective
certificate holders shall not decline to offer coverage to any
eligible prospective enrollee and shall not impose different
terms or conditions on the coverage, premiums or contributions of
any enrollee in the group that are based on the actual or
expected health status of the enrollee.
(2) A carrier that elects to discontinue offering all of its
group health benefit plans under ORS 743.754 { - (6)(e) - }
{ + (5)(e) + }, elects to discontinue renewing all such plans
or elects to discontinue offering and renewing all such plans is
prohibited from offering health benefit plans in the group market
in this state for a period of five years from one of the
following dates:
(a) The date of notice to the Director of the Department of
Consumer and Business Services pursuant to ORS 743.754
{ - (6)(e) - } { + (5)(e) + }; or
(b) If notice is not provided under paragraph (a) of this
subsection, from the date on which the director provides notice
to the carrier that the director has determined that the carrier
has effectively discontinued offering group health benefit plans
in this state.
(3) Subsection (1) of this section applies only to group health
benefit plans that are not small employer health benefit plans.
(4) Nothing in this section shall prohibit an employer from
providing different group health benefit plans to various
categories of employees as defined by the employer nor prohibit
an employer from providing health benefit plans through different
carriers so long as the employer's categories of employees are
established in a manner that does not relate to the actual or
expected health status of the employees or their dependents.
(5) A multiple employer welfare arrangement, professional or
trade association, or other similar arrangement established or
maintained to provide benefits to a particular trade, business,
profession or industry or their subsidiaries, shall not issue
coverage to a group or individual that is not in the same trade,
business, profession or industry or their subsidiaries as that
covered by the arrangement. The arrangement shall accept all
groups and individuals in the same trade, business, profession or
industry or their subsidiaries that apply for coverage under the
arrangement and that meet the requirements for membership in the
arrangement. For purposes of this subsection, the requirements
for membership in an arrangement shall not include any
Enrolled House Bill 2240 (HB 2240-B) Page 31
requirements that relate to the actual or expected health status
of the prospective enrollee.
SECTION 27. ORS 743.754 is amended to read:
743.754. The following requirements apply to all group health
benefit plans other than small employer health benefit plans
covering two or more certificate holders:
{ - (1) A preexisting condition exclusion shall apply only to
a condition for which medical advice, diagnosis, care or
treatment was recommended or received during the six-month period
immediately preceding the enrollment date of an enrollee or late
enrollee. As used in this section, the enrollment date of an
enrollee shall be the earlier of the effective date of coverage
or the first day of any required group eligibility waiting period
and the enrollment date of a late enrollee shall be the effective
date of coverage. - }
{ - (2) A preexisting condition exclusion may not apply to a
person under 19 years of age and shall expire as follows: - }
{ - (a) For an enrollee, on the earlier of the following
dates: - }
{ - (A) Six months after the enrollee's effective date of
coverage; or - }
{ - (B) Twelve months after the start of any required group
eligibility waiting period. - }
{ - (b) For a late enrollee, not later than 12 months after
the late enrollee's effective date of coverage. - }
{ - (3) In applying a preexisting condition exclusion to an
enrollee or late enrollee who is 19 years of age or older, except
as provided in this subsection, all plans shall reduce the
duration of the provision by an amount equal to the enrollee's or
late enrollee's aggregate periods of creditable coverage if the
most recent period of creditable coverage is ongoing or ended
within 63 days after the enrollment date in the new plan. The
crediting of prior coverage in accordance with this subsection
shall be applied without regard to the specific benefits covered
during the prior period. This subsection does not preclude,
within a plan, application of: - }
{ + (1) Except in the case of a late enrollee and except as
otherwise provided in this section, a carrier offering a group
health benefit plan may not decline to offer coverage to any
eligible prospective enrollee and may not impose different terms
or conditions on the coverage, premiums or contributions of any
enrollee in the group that are based on the actual or expected
health status of the enrollee.
(2) A group health benefit plan may not apply a preexisting
condition exclusion to any enrollee but may impose: + }
(a) An affiliation period that does not exceed two months for
an enrollee or three months for a late enrollee; or
(b) An exclusion period for specified covered services
applicable to all individuals enrolling for the first time in the
plan.
{ - (4) - } { + (3) + } Late enrollees may be subjected to
a group eligibility waiting period { - of up to 12 months or,
if 19 years of age or older, may be subjected to a preexisting
condition exclusion for up to 12 months. If both a waiting period
and a preexisting condition exclusion are applicable to a late
enrollee, the combined period shall not exceed 12 months - }
{ + that does not exceed 90 days + }.
{ - (5) - } { + (4) + } Each { + group health benefit + }
plan shall contain a special enrollment period during which
eligible employees and dependents may enroll for coverage, as
Enrolled House Bill 2240 (HB 2240-B) Page 32
provided { - in 42 U.S.C. 300gg as amended and in effect on
February 17, 2009 - } { + by federal law and rules adopted by
the Department of Consumer and Business Services + }.
{ - (6) - } { + (5) + } Each { + group health benefit + }
plan shall be renewable with respect to all eligible enrollees at
the option of the policyholder unless:
(a) The policyholder fails to pay the required premiums.
(b) The policyholder or, with respect to coverage of individual
enrollees, an enrollee or a representative of an enrollee engages
in fraud or makes an intentional misrepresentation of a material
fact as prohibited by the terms of the plan.
(c) The number of enrollees covered under the plan is less than
the number or percentage of enrollees required by participation
requirements under the plan.
(d) The policyholder fails to comply with the contribution
requirements under the plan.
(e) The carrier discontinues offering or renewing, or offering
and renewing, all of its group { + health benefit + } plans in
this state or in a specified service area within this state. In
order to discontinue plans under this paragraph, the carrier:
(A) Must give notice of the decision to the department { - of
Consumer and Business Services - } and to all policyholders
covered by the plans;
(B) May not cancel coverage under the plans for 180 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in the entire state or,
except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel coverage under the plans for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in a specified service area
because of an inability to reach an agreement with the health
care providers or organization of health care providers to
provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and
renewing, all { + health benefit + } plans issued by the carrier
in the group market in this state or in the specified service
area.
(f) The carrier discontinues offering and renewing a group
{ + health benefit + } plan in a specified service area within
this state because of an inability to reach an agreement with the
health care providers or organization of health care providers to
provide services under the plan within the service area. In order
to discontinue a plan under this paragraph, the carrier:
(A) Must give notice of the decision to the department and to
all policyholders covered by the plan;
(B) May not cancel coverage under the plan for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph; and
(C) Must offer in writing to each policyholder covered by the
plan, all other group health benefit plans that the carrier
offers in the specified service area. The carrier shall offer the
plans at least 90 days prior to discontinuation.
(g) The carrier discontinues offering or renewing, or offering
and renewing, a { + group + } health benefit plan, other than a
grandfathered health plan, for all groups in this state or in a
specified service area within this state, other than a plan
discontinued under paragraph (f) of this subsection.
(h) The carrier discontinues renewing or offering and renewing
a grandfathered health plan for all groups in this state or in a
Enrolled House Bill 2240 (HB 2240-B) Page 33
specified service are within this state, other than a plan
discontinued under paragraph (f) of this subsection.
(i) With respect to plans that are being discontinued under
paragraph (g) or (h) of this subsection, the carrier must:
(A) Offer in writing to each policyholder covered by the plan,
one or more health benefit plans that the carrier offers { + to
groups + } in the specified service area.
(B) Offer the plans at least 90 days prior to discontinuation.
(C) Act uniformly without regard to the claims experience of
the affected policyholders or the health status of any current or
prospective enrollee.
(j) The Director of the Department of Consumer and Business
Services orders the carrier to discontinue coverage in accordance
with procedures specified or approved by the director upon
finding that the continuation of the coverage would:
(A) Not be in the best interests of the enrollees; or
(B) Impair the carrier's ability to meet contractual
obligations.
(k) In the case of a { + group health benefit + } plan that
delivers covered services through a specified network of health
care providers, there is no longer any enrollee who lives,
resides or works in the service area of the provider network.
(L) In the case of a { + health benefit + } plan that is
offered in the group market only { - through - } { + to + }
one or more bona fide associations, the membership of an employer
in the association ceases and the termination of coverage is not
related to the health status of any enrollee.
{ - (7) - } { + (6) + } A carrier may modify a { + group
health benefit + } plan at the time of coverage renewal. The
modification is not a discontinuation of the plan under
subsection { - (6)(e) - } { + (5)(e) + }, (g) and (h) of this
section.
{ - (8) - } { + (7) + } Notwithstanding any provision of
subsection { - (6) - } { + (5) + } of this section to the
contrary, a carrier may not rescind the coverage of an enrollee
under { - the - } { + a group health benefit + } plan unless:
(a) The enrollee:
(A) Performs an act, practice or omission that constitutes
fraud; or
(B) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the plan;
(b) The carrier provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
the enrollee; and
(c) The carrier provides notice of the rescission to the
department in the form, manner and time frame prescribed by the
department by rule.
{ - (9) - } { + (8) + } Notwithstanding any provision of
subsection { - (6) - } { + (5) + } of this section to the
contrary, a carrier may not rescind a { + group health
benefit + } plan unless:
(a) The plan sponsor or a representative of the plan sponsor:
(A) Performs an act, practice or omission that constitutes
fraud; or
(B) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the plan;
(b) The carrier provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
each plan enrollee who would be affected by the rescission of
coverage; and
Enrolled House Bill 2240 (HB 2240-B) Page 34
(c) The carrier provides notice of the rescission to the
department in the form, manner and time frame prescribed by the
department by rule.
{ - (10) - } { + (9) + } A carrier that continues to offer
coverage in the group market in this state is not required to
offer coverage in all of the carrier's group { + health
benefit + } plans. If a carrier, however, elects to continue a
plan that is closed to new policyholders instead of offering
alternative coverage in its other group { + health benefit + }
plans, the coverage for all existing policyholders in the closed
plan is renewable in accordance with subsection { - (6) - }
{ + (5) + } of this section.
{ - (11) - } { + (10) + } A group health benefit plan may
not impose annual or lifetime limits on the dollar amount of
{ - the - } essential health benefits { - prescribed by the
United States Secretary of Health and Human Services pursuant to
42 U.S.C. 300gg-11, except as permitted by federal law - } .
{ - (12) - } { + (11) + } This section does not require a
carrier to actively market, offer, issue or accept applications
for a grandfathered health plan or from a group not eligible for
coverage under such a plan { - as provided by the Patient
Protection and Affordable Care Act (P.L. 111-148) as amended by
the Health Care and Education Reconciliation Act (P.L.
111-152) - } .
SECTION 28. ORS 743.766, as amended by section 4, chapter 24,
Oregon Laws 2012, is amended to read:
743.766. { - (1) All carriers that offer an individual health
benefit plan and evaluate the health status of individuals for
purposes of eligibility shall use the standard health statement
established under ORS 743.745 and may not use any other method to
determine the health status of an individual. Nothing in this
subsection shall prevent a carrier from using health information
after enrollment for the purpose of providing services or
arranging for the provision of services under a health benefit
plan. - }
{ - (2)(a) If an individual is accepted for coverage under an
individual health benefit plan, the carrier shall not impose
exclusions or limitations other than: - }
{ - (A) A preexisting condition exclusion that complies with
the following requirements: - }
{ - (i) The exclusion applies only to a condition for which
medical advice, diagnosis, care or treatment was recommended or
received during the six-month period immediately preceding the
individual's effective date of coverage; - }
{ - (ii) The exclusion expires no later than six months after
the individual's effective date of coverage; and - }
{ - (iii) Except for grandfathered health plans, the
exclusion does not apply to individuals who are under 19 years of
age; - }
{ - (B) An individual coverage waiting period of 90 days;
or - }
{ - (C) An exclusion period for specified covered services
applicable to all individuals enrolling for the first time in the
individual health benefit plan. - }
{ - (b) Except for grandfathered health plans, pregnancy of
individuals who are under 19 years of age may not constitute a
preexisting condition for purposes of this section. - }
{ + (1) With respect to coverage under an individual health
benefit plan, a carrier:
Enrolled House Bill 2240 (HB 2240-B) Page 35
(a) May not impose an individual coverage waiting period that
exceeds 90 days.
(b) May impose an exclusion period for specified covered
services applicable to all individuals enrolling for the first
time in the individual health benefit plan.
(c) With respect to individual coverage under a grandfathered
health plan, a carrier may not impose a preexisting condition
exclusion unless the exclusion complies with the following
requirements:
(A) The exclusion applies only to a condition for which medical
advice, diagnosis, care or treatment was recommended or received
during the six-month period immediately preceding the
individual's effective date of coverage.
(B) The exclusion expires no later than six months after the
individual's effective date of coverage. + }
{ - (3) - } { + (2) + } If the carrier elects to restrict
coverage { - through the application of a preexisting condition
exclusion or an individual coverage waiting period provision - }
{ + as described in subsection (1) of this section + }, the
carrier shall reduce the duration of the { - provision - }
{ + period during which the restriction is imposed + } by an
amount equal to the individual's aggregate periods of creditable
coverage if the most recent period of creditable coverage is
ongoing or ended within 63 days after the effective date of
coverage in the new individual health benefit plan. The crediting
of prior coverage in accordance with this subsection shall be
applied without regard to the specific benefits covered during
the prior period.
{ - (4) If an eligible prospective enrollee is rejected for
coverage under an individual health benefit plan, the prospective
enrollee shall be eligible to apply for coverage under the Oregon
Medical Insurance Pool. - }
{ + (3) An individual health benefit plan other than a
grandfathered health plan must cover, at a minimum, all essential
health benefits. + }
{ - (5) - } { + (4) + } { - If a carrier accepts an
individual for coverage under - } { + A carrier shall renew + }
an individual health benefit plan, { + including a health
benefit plan issued through a bona fide association, + }
{ - the carrier shall renew the policy - } unless:
(a) The policyholder fails to pay the required premiums.
(b) The policyholder or a representative of the policyholder
engages in fraud or makes an intentional misrepresentation of a
material fact as prohibited by the terms of the policy.
(c) The carrier discontinues offering or renewing, or offering
and renewing, all of its individual health benefit plans in this
state or in a specified service area within this state. In order
to discontinue the plans under this paragraph, the carrier:
(A) Must give notice of the decision to the Department of
Consumer and Business Services and to all policyholders covered
by the plans;
(B) May not cancel coverage under the plans for 180 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in the entire state or,
except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel coverage under the plans for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in a specified service area
because of an inability to reach an agreement with the health
Enrolled House Bill 2240 (HB 2240-B) Page 36
care providers or organization of health care providers to
provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and
renewing, all health benefit plans issued by the carrier in the
individual market in this state or in the specified service area.
(d) The carrier discontinues offering and renewing an
individual health benefit plan in a specified service area within
this state because of an inability to reach an agreement with the
health care providers or organization of health care providers to
provide services under the plan within the service area. In order
to discontinue a plan under this paragraph, the carrier:
(A) Must give notice of the decision to the department and to
all policyholders covered by the plan;
(B) May not cancel coverage under the plan for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph; and
(C) Must offer in writing to each policyholder covered by the
plan, all other individual health benefit plans that the carrier
offers in the specified service area. The carrier shall offer the
plans at least 90 days prior to discontinuation.
(e) The carrier discontinues offering or renewing, or offering
and renewing, an individual health benefit plan, other than a
grandfathered health plan, for all individuals in this state or
in a specified service area within this state, other than a plan
discontinued under paragraph (d) of this subsection.
(f) The carrier discontinues renewing or offering and renewing
a grandfathered health plan for all individuals in this state or
in a specified service area within this state, other than a plan
discontinued under paragraph (d) of this subsection.
(g) With respect to plans that are being discontinued under
paragraph (e) or (f) of this subsection, the carrier must:
(A) Offer in writing to each policyholder covered by the plan,
all health benefit plans that the carrier offers to individuals
in the specified service area.
(B) Offer the plans at least 90 days prior to discontinuation.
(C) Act uniformly without regard to the claims experience of
the affected policyholders or the health status of any current or
prospective enrollee.
(h) The Director of the Department of Consumer and Business
Services orders the carrier to discontinue coverage in accordance
with procedures specified or approved by the director upon
finding that the continuation of the coverage would:
(A) Not be in the best interests of the enrollee; or
(B) Impair the carrier's ability to meet its contractual
obligations.
(i) In the case of an individual health benefit plan that
delivers covered services through a specified network of health
care providers, the enrollee no longer lives, resides or works in
the service area of the provider network and the termination of
coverage is not related to the health status of any enrollee.
(j) In the case of a health benefit plan that is offered in the
individual market only through one or more bona fide
associations, the membership of an individual in the association
ceases and the termination of coverage is not related to the
health status of any enrollee.
{ - (6) - } { + (5) + } A carrier may modify an individual
health benefit plan at the time of coverage renewal. The
modification is not a discontinuation of the plan under
subsection { - (5)(c) - } { + (4)(c) + }, (e) and (f) of this
section.
Enrolled House Bill 2240 (HB 2240-B) Page 37
{ - (7) - } { + (6) + } Notwithstanding any other provision
of this section, and subject to the provisions of ORS 743.894 (2)
and (4), a carrier may rescind an individual health benefit plan
if the policyholder or a representative of the policyholder:
(a) Performs an act, practice or omission that constitutes
fraud; or
(b) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the policy.
{ - (8) A carrier that withdraws from the market for
individual health benefit plans must continue to renew its
portability health benefit plans that have been approved pursuant
to ORS 743.761. - }
{ - (9) - } { + (7) + } A carrier that continues to offer
coverage in the individual market in this state is not required
to offer coverage in all of the carrier's individual health
benefit plans. However, if a carrier elects to continue a plan
that is closed to new individual policyholders instead of
offering alternative coverage in its other individual health
benefit plans, the coverage for all existing policyholders in the
closed plan is renewable in accordance with subsection
{ - (5) - } { + (4) + } of this section.
{ - (10) - } { + (8) + } An individual health benefit plan
may not impose annual or lifetime limits on the dollar amount of
{ - the - } essential health benefits { - prescribed by the
United States Secretary of Health and Human Services pursuant to
42 U.S.C. 300gg-11, except as permitted by federal law - } .
{ - (11) - } { + (9) + } This section does not require a
carrier to actively market, offer, issue or accept applications
for a grandfathered health plan or from an individual not
eligible for coverage under such a plan { - as provided by the
Patient Protection and Affordable Care Act (P.L. 111-148) as
amended by the Health Care and Education Reconciliation Act (P.L.
111-152) - } .
SECTION 29. ORS 743.767 is amended to read:
743.767. Premium rates for individual health benefit plans
shall be subject to the following provisions:
(1) Each carrier must file the carrier's initial geographic
average rate and any changes to the geographic average rate for
its individual health benefit plans with the Director of the
Department of Consumer and Business Services.
(2) The premium rates charged during a rating period for
individual health benefit plans issued to individuals shall not
vary from the individual geographic average rate, except that the
premium rate may be adjusted to reflect differences in benefit
design, { + age, tobacco use and + } family composition
{ - and age - } . For age adjustments to the individual plans, a
carrier shall apply uniformly its schedule of age adjustments for
individual health benefit plans as approved by the director.
(3) A carrier may not increase the rates of an individual
health benefit plan more than once in a 12-month period except as
approved by the director. Annual rate increases shall be
effective on the anniversary date of the individual health
benefit plan's issuance. The percentage increase in the premium
rate charged for an individual health benefit plan for a new
rating period may not exceed the sum of the following:
(a) The percentage change in the carrier's geographic average
rate for its individual health benefit plan measured from the
first day of the prior rating period to the first day of the new
period; and
Enrolled House Bill 2240 (HB 2240-B) Page 38
(b) Any adjustment attributable to { - changes in age and - }
differences in benefit design { + , age, tobacco use + } and
family composition.
{ - (4) Notwithstanding any other provision of this section,
a carrier that imposes an individual coverage waiting period
pursuant to ORS 743.766 may impose a monthly premium rate
surcharge for a period not to exceed six months and in an amount
not to exceed the percentage by which the rates for coverage
under the Oregon Medical Insurance Pool exceed the rates
established by the Oregon Medical Insurance Pool Board as
applicable for individual risks under ORS 735.625. The surcharge
shall be approved by the Director of the Department of Consumer
and Business Services and, in combination with the waiting
period, shall not exceed the actuarial value of a six-month
preexisting condition exclusion. - }
{ + (4) A carrier offering an individual health benefit plan
in this state shall include:
(a) In one risk pool, all of the insureds residing in this
state who are covered in the carrier's individual health benefit
plans that are not grandfathered health plans or student health
plans; and
(b) In a separate risk pool, all of the insureds residing in
this state who are covered in the carrier's individual
grandfathered health plans. + }
SECTION 30. ORS 743.777 is amended to read:
743.777. (1) As used in subsections (2) to (6) of this section:
(a) 'Explanation of benefits' means claim processing advice or
notification of action on claims.
(b) 'Payment, remittance and reconciliation information ' means
all information required for premium billing or invoicing,
facilitating timely electronic payment of premiums due,
delinquency notification, final billing notification or
termination of coverage.
(c) 'Plan renewal information' means all correspondence and
materials related to an offer to renew insurance provided by an
insurer to a health insurance purchaser.
(d) 'Quote information' means all correspondence and materials
related to an offer to insure or a rate quotation provided by an
insurer to a health insurance purchaser.
(e) 'Sale and enrollment information' means all information
documenting the sale of a policy or certificate of health
insurance, the renewal of a policy or certificate of health
insurance, the enrollment of members in a group health insurance
plan or the enrollment of an individual in an individual health
insurance plan, including but not limited to:
(A) The application for insurance;
(B) Initial and ongoing documentation required by the insurer
to be provided by an insured to establish eligibility and
enrollment, adjudicate and process claims and prove prior
creditable coverage or duplicate coverage;
(C) Premium information;
(D) Documentation of the payment of a premium; and
(E) Membership identification cards.
(2) In the administration of small employer group health
insurance or individual health insurance, an insurer may
communicate one or more of the following by electronic means:
(a) Quote information.
(b) Sale and enrollment information.
(c) Payment, remittance and reconciliation information.
(d) Explanation of benefits.
Enrolled House Bill 2240 (HB 2240-B) Page 39
(e) Plan renewal information.
(f) Notifications required by law.
(g) Other communications, documentation, revisions or materials
otherwise provided on paper.
(3) Electronic administration of small employer group or
individual health insurance plans shall be transacted using
secure systems specifically designed by the insurer for the
purpose of electronic health insurance administration.
(4) An insurer who elects to offer discounted rates for a
health insurance plan utilizing electronic administration shall
include the schedule of discounts for utilization of electronic
administration as part of a small employer group health insurance
or individual health insurance rate filing. The rate discounts
may be graduated and must be proportionate to the amount of
administrative cost savings the insurer anticipates as a result
of the use of electronic transactions described in subsections
(2) and (3) of this section.
(5) Discounted rates allowed under subsections (4) to (6) of
this section shall be applied uniformly to all similarly situated
small employer group or individual health insurance purchasers of
an insurer.
(6) Discounts in premium rates under subsections (4) to (6) of
this section are not premium rate variations for purposes of ORS
743.737 { - (11) - } { + (8) + } or 743.767.
(7) Subsections (1) to (6) of this section do not require an
insurer to offer discounted rates for a health insurance plan
utilizing electronic administration or require a small employer
group or an individual health insurance purchaser to use
electronic administration.
SECTION 31. ORS 743.822, as amended by section 8, chapter 24,
Oregon Laws 2012, and section 21, chapter 38, Oregon Laws 2012,
is amended to read:
743.822. (1) In each individual or small group market { + , + }
in which a carrier offers a health benefit plan through { - the
exchange - } or outside of the { + Oregon Health Insurance + }
Exchange, { - a - } { + the + } carrier must offer to
residents of this state { - bronze and silver plans - } { + a
bronze and a silver plan + } approved by the Department of
Consumer and Business Services as meeting the requirements of
subsection (2) of this section.
(2) The { - Director of the Department of Consumer and
Business Services - } { + department + } shall prescribe by
rule the { - : - }
{ - (a) Requirements for a bronze plan to ensure that a
bronze plan offered in this state is actuarially equivalent to 60
percent of the full actuarial value of benefits included in the
essential health benefits package prescribed by the United States
Secretary of Health and Human Services under 42 U.S.C.
18022(a). - }
{ - (b) Requirements for a silver plan to ensure that a
silver plan offered in this state is actuarially equivalent to 70
percent of the full actuarial value of benefits included in the
essential health benefits package prescribed by the United States
Secretary of Health and Human Services under 42 U.S.C.
18022(a). - }
{ - (c) - } form, level of coverage and benefit design for
the bronze and silver plans { - to be used by carriers in the
individual and small group market in this state. - } { + that
must be offered under subsection (1) of this section. + }
Enrolled House Bill 2240 (HB 2240-B) Page 40
(3) As used in this section, 'health benefit plan' has the
meaning given that term in ORS 743.730.
SECTION 32. ORS 743.894 is amended to read:
743.894. (1) As used in this section, 'rescind' means to
retroactively cancel or discontinue coverage under a health
benefit plan or group or individual health insurance policy for
reasons other than failure to timely pay required premiums or
required contributions toward the cost of coverage.
(2) An insurer may not rescind coverage of an individual under
a health benefit plan or group or individual health insurance
policy unless:
(a) The individual or a person seeking coverage on behalf of
the individual:
(A) Performs an act, practice or omission that constitutes
fraud; or
(B) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the plan or policy; and
(b) The insurer provides at least 30 days' advance written
notice, in the form and manner prescribed by the Department of
Consumer and Business Services, to the individual.
(3) An insurer may not rescind coverage of a group under a
health benefit plan unless:
(a) The plan sponsor:
(A) Performs an act, practice or omission that constitutes
fraud; or
(B) Makes an intentional misrepresentation of a material fact
as prohibited by the terms of the plan; and
(b) The insurer provides at least 30 days' advance written
notice, in the form and manner prescribed by the department, to
each plan enrollee or policy holder who would be affected by the
rescission of coverage.
(4) An insurer that rescinds a plan or policy must provide
notice of the rescission to the department in the form, manner
and time frame prescribed by the department by rule. { +
(5) This section does not apply to long term care insurance
that is subject to ORS 743.650 to 743.665. + }
SECTION 33. ORS 743A.090 is amended to read:
743A.090. (1) All individual and group health benefit plans, as
defined in ORS 743.730, that include coverage for a family member
of the insured shall also provide that the health insurance
benefits applicable for children in the family shall be payable
with respect to:
(a) A child of the insured from the moment of birth; and
(b) An adopted child effective upon placement for adoption.
(2) The coverage of natural and adopted children required by
subsection (1) of this section shall consist of coverage of
preventive health services and treatment of injury or sickness,
including the necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities.
(3) If payment of an additional premium is required to provide
coverage for a child, the policy may require that notification of
the birth of the child or of the placement for adoption of the
child and payment of the premium be furnished to the insurer
within 31 days after the date of birth or date of placement in
order to effectuate the coverage required by this section and to
have the coverage extended beyond the 31-day period.
(4) In any case in which a policy provides coverage for
dependent children of participants or beneficiaries, the policy
shall provide benefits to dependent children placed with
participants or beneficiaries for adoption under the same terms
Enrolled House Bill 2240 (HB 2240-B) Page 41
and conditions as apply to the natural, dependent children of the
participants and beneficiaries, regardless of whether the
adoption has become final.
{ - (5) This section does not prohibit an insurer from
denying or limiting coverage based on a preexisting condition of
a child who is 19 years of age or older. - }
{ - (6) - } { + (5) + } As used in this section:
(a) 'Child' means an individual who is under 26 years of age.
(b) 'Placement for adoption' means the assumption and retention
by a person of a legal obligation for total or partial support of
a child in anticipation of the adoption of the child. The
child's placement with a person terminates upon the termination
of such legal obligations.
{ - (7) - } { + (6) + } The provisions of ORS 743A.001 do
not apply to this section.
SECTION 34. ORS 743A.192 is amended to read:
743A.192. (1) A health benefit plan, as defined in ORS 743.730
{ - , - } { + :
(a) + } Shall provide coverage for the routine costs of the
care of patients enrolled in and participating in
{ - qualifying - } { + approved + } clinical trials { - . - }
{ + ;
(b) May not exclude, limit or impose additional conditions on
the coverage of the routine costs for items and services
furnished in connection with participation in an approved
clinical trial; and
(c) May not include provisions that discriminate against an
individual on the basis of the individual's participation in an
approved clinical trial. + }
(2) As used in { - subsection (1) of - } this section,
'routine costs':
(a) Means { + all + } medically necessary conventional care,
items or services { - covered by - } { + consistent with the
coverage provided by + } the health benefit plan if typically
provided { - absent - } { + to a patient who is not enrolled
in + } a clinical trial.
(b) Does not include:
(A) The drug, device or service being tested in the
{ + approved + } clinical trial unless the drug, device or
service would be covered for that indication by the health
benefit plan if provided outside of { - a - } { + an
approved + } clinical trial;
(B) Items or services required solely for the provision of the
drug device or service being tested in the clinical trial;
(C) Items or services required solely for the clinically
appropriate monitoring of the drug, device or service being
tested in the clinical trial;
{ - (D) Items or services required solely for the prevention,
diagnosis or treatment of complications arising from the
provision of the drug, device or service being tested in the
clinical trial; - }
{ - (E) - } { + (D) + } Items or services that are provided
solely to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient;
{ - (F) - } { + (E) + } Items or services customarily
provided by a clinical trial sponsor free of charge to any
participant in the clinical trial; or
{ - (G) - } { + (F) + } Items or services that are not
covered by the health { + benefit + } plan if provided outside
of the clinical trial.
Enrolled House Bill 2240 (HB 2240-B) Page 42
(3) As used in { - subsection (1) of - } this section,
{ - ' qualifying - } { + 'approved + } clinical trial' means
a clinical trial that is:
(a) Funded by the National Institutes of Health, the Centers
for Disease Control and Prevention, the Agency for Healthcare
Research and Quality, the Centers for Medicare and Medicaid
Services, the United States Department of Defense or the United
States Department of Veterans Affairs;
(b) Supported by a center or cooperative group that is funded
by the National Institutes of Health, the Centers for Disease
Control and Prevention, the Agency for Healthcare Research and
Quality, the Centers for Medicare and Medicaid Services, the
United States Department of Defense or the United States
Department of Veterans Affairs;
(c) Conducted as an investigational new drug application, an
investigational device exemption or a biologics license
application subject to approval by the United States Food and
Drug Administration; or
(d) Exempt by federal law from the requirement to submit an
investigational new drug application to the United States Food
and Drug Administration.
(4) The coverage required by this section may be subject to
provisions of the health benefit plan that apply to other
benefits within the same category, including but not limited to
copayments, deductibles and coinsurance.
(5) An insurer that provides coverage required by this section
is not, based upon that coverage, liable for any adverse effects
of the { + approved + } clinical trial.
{ + (6) This section is exempt from ORS 743A.001. + }
SECTION 35. ORS 746.015 is amended to read:
746.015. (1) No person shall make or permit any unfair
discrimination between individuals of the same class and equal
expectation of life, or between risks of essentially the same
degree of hazard, in the availability of insurance, in the
application of rates for insurance, in the dividends or other
benefits payable under insurance policies, or in any other terms
or conditions of insurance policies.
(2) Discrimination by an insurer in the application of its
underwriting standards or rates based solely on an individual's
physical disability is prohibited, unless such action is based on
sound actuarial principles or is related to actual or reasonably
anticipated experience. For purposes of this subsection, '
physical disability' shall include, but not be limited to,
blindness, deafness, hearing or speaking impairment or loss, or
partial loss, of function of one or more of the upper or lower
extremities.
(3) Discrimination by an insurer in the application of its
underwriting standards or rates based solely upon an insured's or
applicant's attaining or exceeding 65 years of age is prohibited,
unless such discrimination is clearly based on sound actuarial
principles or is related to actual or reasonably anticipated
experience.
(4)(a) An insurer may not, on the basis of the status of an
insured or prospective insured as a victim of domestic violence
or sexual violence, do any of the following:
(A) Deny, cancel or refuse to issue or renew an insurance
policy;
(B) Demand or require a greater premium or payment;
Enrolled House Bill 2240 (HB 2240-B) Page 43
(C) Designate domestic violence or sexual violence, physical or
mental injuries sustained as a result of domestic violence or
sexual violence or treatment received for such injuries as a
{ - preexisting - } condition for which coverage will be
denied or reduced;
(D) Exclude or limit coverage for losses or deny a claim; or
(E) Fix any lower rate for or discriminate in the fees or
commissions of an insurance producer for writing or renewing a
policy.
(b) The fact that an insured or prospective insured is or has
been a victim of domestic violence or sexual violence shall not
be considered a permitted underwriting or rating criterion.
(c) Nothing in this subsection prohibits an insurer from taking
an action described in paragraph (a) of this subsection if the
action is otherwise permissible by law and is taken in the same
manner and to the same extent with respect to all insureds and
prospective insureds without regard to whether the insured or
prospective insured is a victim of domestic violence or sexual
violence.
(d) An insurer that complies in good faith with the
requirements of this subsection shall not be subject to civil
liability due to such compliance.
(e) For purposes of this subsection, 'domestic violence ' means
the occurrence of one or more of the following acts between
family or household members:
(A) Attempting to cause or intentionally or knowingly causing
physical injury;
(B) Intentionally or knowingly placing another in fear of
imminent serious physical injury; or
(C) Committing sexual abuse in any degree as defined in ORS
163.415, 163.425 and 163.427.
(f) For purposes of this subsection, 'sexual violence ' means
the commission of a sexual offense described in ORS 163.305 to
163.467, 163.427 or 163.525.
(5) If the Director of the Department of Consumer and Business
Services has reason to believe that an insurer in the application
of its underwriting standards or rates is not complying with the
requirements of this section, the director shall, unless the
director has reason to believe the noncompliance is willful, give
notice in writing to the insurer stating in what manner such
noncompliance is alleged to exist and specifying a reasonable
time, not less than 10 days after the date of mailing, in which
the noncompliance may be corrected.
(6)(a) If the director has reason to believe that noncompliance
by an insurer with the requirements of this section is willful,
or if, within the period prescribed by the director in the notice
required by subsection (5) of this section, the insurer does not
make the changes necessary to correct the noncompliance specified
by the director or establish to the satisfaction of the director
that such specified noncompliance does not exist, the director
may hold a hearing in connection therewith. Not less than 10 days
before the date of such hearing the director shall mail to the
insurer written notice of the hearing, specifying the matters to
be considered.
(b) If, after the hearing, the director finds that the
insurer's application of its underwriting standards or rates
violates the requirements of this section, the director may issue
an order specifying in what respects such violation exists and
stating when, within a reasonable period of time, further such
application shall be prohibited. If the director finds that the
Enrolled House Bill 2240 (HB 2240-B) Page 44
violation was willful, the director may suspend or revoke the
certificate of authority of the insurer.
(7) Affiliated workers' compensation insurers having
reinsurance agreements which result in one carrier ceding 80
percent or more of its workers' compensation premium to the
other, while utilizing different workers' compensation rate
levels without objective evidence to support such differences,
shall be presumed to be engaging in unfair discrimination.
SECTION 35a. ORS 746.045 is amended to read:
746.045. { + (1) + } No person shall personally or otherwise
offer, promise, allow, give, set off, pay or receive, directly or
indirectly, any rebate of or rebate of part of the premium
payable on an insurance policy or the insurance producer's
commission thereon, or earnings, profit, dividends or other
benefit founded, arising, accruing or to accrue on or from the
policy, or any other valuable consideration or inducement to or
for insurance on any domestic risk, which is not specified in the
policy. { +
(2) A premium discount or rebate is not prohibited by this
section if the discount or rebate is:
(a) Offered in connection with a program of health promotion or
disease prevention, as described in 42 U.S.C. 300gg-4;
(b) Paid for participation in a program to promote healthy
behaviors under ORS 743.824; or
(c) Offered in connection with a wellness program defined by
the Department of Consumer and Business Services by rule. + }
{ +
PORTABILITY HEALTH PLANS + }
SECTION 36. ORS 743.019 is amended to read:
743.019. (1) When an insurer files a schedule or table of
premium rates for individual { - , portability - } or small
employer health insurance under ORS 743.018, the Director of the
Department of Consumer and Business Services shall open a 30-day
public comment period on the rate filing that begins on the date
the insurer files the schedule or table of premium rates. The
director shall post all comments to the website of the Department
of Consumer and Business Services without delay.
(2) The director shall give written notice to an insurer
approving or disapproving a rate filing or, with the written
consent of the insurer, modifying a rate filing submitted under
ORS 743.018 no later than 10 business days after the close of the
public comment period. The notice shall comply with the
requirements of ORS 183.415.
SECTION 37. ORS 743.804, as amended by section 6, chapter 24,
Oregon Laws 2012, is amended to read:
743.804. All insurers offering a health benefit plan in this
state shall:
(1) Provide to all enrollees directly or in the case of a group
policy to the employer or other policyholder for distribution to
enrollees, to all applicants, and to prospective applicants upon
request, the following information:
(a) The insurer's written policy on the rights of enrollees,
including the right:
(A) To participate in decision making regarding the enrollee's
health care.
(B) To be treated with respect and with recognition of the
enrollee's dignity and need for privacy.
(C) To have grievances handled in accordance with this section.
Enrolled House Bill 2240 (HB 2240-B) Page 45
(D) To be provided with the information described in this
section.
(b) An explanation of the procedures described in subsection
(2) of this section for making coverage determinations and
resolving grievances. The explanation must be culturally and
linguistically appropriate, as prescribed by the department by
rule, and must include:
(A) The procedures for requesting an expedited response to an
internal appeal under subsection (2)(d) of this section or for
requesting an expedited external review of an adverse benefit
determination;
(B) A statement that if an insurer does not comply with the
decision of an independent review organization under ORS 743.862,
the enrollee may sue the insurer under ORS 743.864;
(C) The procedure to obtain assistance available from the
insurer, if any, and from the Department of Consumer and Business
Services in filing grievances; and
(D) A description of the process for filing a complaint with
the department.
(c) A summary of benefits and an explanation of coverage in a
form and manner prescribed by the department by rule.
(d) A summary of the insurer's policies on prescription drugs,
including:
(A) Cost-sharing differentials;
(B) Restrictions on coverage;
(C) Prescription drug formularies;
(D) Procedures by which a provider with prescribing authority
may prescribe drugs not included on the formulary;
(E) Procedures for the coverage of prescription drugs not
included on the formulary; and
(F) A summary of the criteria for determining whether a drug is
experimental or investigational.
(e) A list of network providers and how the enrollee can obtain
current information about the availability of providers and how
to access and schedule services with providers, including clinic
and hospital networks.
(f) Notice of the enrollee's right to select a primary care
provider and specialty care providers.
(g) How to obtain referrals for specialty care in accordance
with ORS 743.856.
(h) Restrictions on services obtained outside of the insurer's
network or service area.
(i) The availability of continuity of care as required by ORS
743.854.
(j) Procedures for accessing after-hours care and emergency
services as required by ORS 743A.012.
(k) Cost-sharing requirements and other charges to enrollees.
(L) Procedures, if any, for changing providers.
(m) Procedures, if any, by which enrollees may participate in
the development of the insurer's corporate policies.
(n) A summary of how the insurer makes decisions regarding
coverage and payment for treatment or services, including a
general description of any prior authorization and utilization
control requirements that affect coverage or payment.
(o) Disclosure of any risk-sharing arrangement the insurer has
with physicians or other providers.
(p) A summary of the insurer's procedures for protecting the
confidentiality of medical records and other enrollee
information.
Enrolled House Bill 2240 (HB 2240-B) Page 46
(q) An explanation of assistance provided to
non-English-speaking enrollees.
(r) Notice of the information available from the department
that is filed by insurers as required under ORS 743.807, 743.814
and 743.817.
(2) Establish procedures for making coverage determinations and
resolving grievances that provide for all of the following:
(a) Timely notice of adverse benefit determinations in a form
and manner approved by the department or prescribed by the
department by rule.
(b) A method for recording all grievances, including the nature
of the grievance and significant action taken.
(c) Written decisions meeting criteria established by the
Director of the Department of Consumer and Business Services by
rule.
(d) An expedited response to a request for an internal appeal
that accommodates the clinical urgency of the situation.
(e) At least one but not more than two levels of internal
appeal for group health benefit plans and one level of internal
appeal for individual { - and portability - } health benefit
plans. If an insurer provides:
(A) Two levels of internal appeal, a person who was involved in
the consideration of the initial denial or the first level of
internal appeal may not be involved in the second level of
internal appeal; and
(B) No more than one level of internal appeal, a person who was
involved in the consideration of the initial denial may not be
involved in the internal appeal.
(f)(A) An external review that meets the requirements of ORS
743.857, 743.859 and 743.861 and is conducted in a manner
approved by the department or prescribed by the department by
rule, after the enrollee has exhausted internal appeals or after
the enrollee has been deemed to have exhausted internal appeals.
(B) An enrollee shall be deemed to have exhausted internal
appeals if an insurer fails to strictly comply with this section
and federal requirements for internal appeals.
(g) The opportunity for the enrollee to receive continued
coverage of an approved and ongoing course of treatment under the
health benefit plan pending the conclusion of the internal appeal
process.
(h) The opportunity for the enrollee or any authorized
representative chosen by the enrollee to:
(A) Submit for consideration by the insurer any written
comments, documents, records and other materials relating to the
adverse benefit determination; and
(B) Receive from the insurer, upon request and free of charge,
reasonable access to and copies of all documents, records and
other information relevant to the adverse benefit determination.
(3) Establish procedures for notifying affected enrollees of:
(a) A change in or termination of any benefit; and
(b)(A) The termination of a primary care delivery office or
site; and
(B) Assistance available to enrollees in selecting a new
primary care delivery office or site.
(4) Provide the information described in subsection (2) of this
section and ORS 743.859 at each level of internal appeal to an
enrollee who is notified of an adverse benefit determination or
to an enrollee who files a grievance.
(5) Upon the request of an enrollee, applicant or prospective
applicant, provide:
Enrolled House Bill 2240 (HB 2240-B) Page 47
(a) The insurer's annual report on grievances and internal
appeals submitted to the department under subsection (8) of this
section.
(b) A description of the insurer's efforts, if any, to monitor
and improve the quality of health services.
(c) Information about the insurer's procedures for
credentialing network providers.
(6) Provide, upon the request of an enrollee, a written summary
of information that the insurer may consider in its utilization
review of a particular condition or disease, to the extent the
insurer maintains such criteria. Nothing in this subsection
requires an insurer to advise an enrollee how the insurer would
cover or treat that particular enrollee's disease or condition.
Utilization review criteria that are proprietary shall be subject
to oral disclosure only.
(7) Maintain for a period of at least six years written records
that document all grievances described in ORS 743.801 (4)(a) and
make the written records available for examination by the
department or by an enrollee or authorized representative of an
enrollee with respect to a grievance made by the enrollee. The
written records must include but are not limited to the
following:
(a) Notices and claims associated with each grievance.
(b) A general description of the reason for the grievance.
(c) The date the grievance was received by the insurer.
(d) The date of the internal appeal or the date of any internal
appeal meeting held concerning the appeal.
(e) The result of the internal appeal at each level of appeal.
(f) The name of the covered person for whom the grievance was
submitted.
(8) Provide an annual summary to the department of the
insurer's aggregate data regarding grievances, internal appeals
and requests for external review in a format prescribed by the
department to ensure consistent reporting on the number, nature
and disposition of grievances, internal appeals and requests for
external review.
(9) Allow the exercise of any rights described in this section
by an authorized representative.
SECTION 37a. { + (1) A carrier may not provide coverage under
a portability health benefit plan in this state after December
31, 2013.
(2) A carrier discontinuing a portability health benefit plan
in accordance with this section must comply with the requirements
of ORS 743.737, 743.766 (4)(c) and 743.769. + }
SECTION 38. { + The Director of the Department of Consumer and
Business Services may take any action before the operative date
specified in section 64 of this 2013 Act that is necessary to
implement the relevant provisions on and after the operative date
specified in section 64 of this 2013 Act. + }
{ +
MODIFICATIONS TO HEALTH CARE FOR ALL OREGON CHILDREN PROGRAM + }
SECTION 39. ORS 414.231 is amended to read:
414.231. (1) As used in this section, 'child' means a person
under 19 years of age.
(2) The Health Care for All Oregon Children program is
established to make affordable, accessible health care available
to all of Oregon's children. The program is composed of:
Enrolled House Bill 2240 (HB 2240-B) Page 48
(a) Medical assistance funded in whole or in part by Title XIX
of the Social Security Act, by the State Children's Health
Insurance Program under Title XXI of the Social Security Act and
by moneys appropriated or allocated for that purpose by the
Legislative Assembly; and
(b) A private health option administered by the Office of
Private Health Partnerships under ORS 414.826.
(3) A child is eligible for { - the program - } { + medical
assistance under either subsection (2)(a) or (b) of this
section + } if the child is lawfully present in this state and
the income of the child's family is at or below 300 percent of
the federal poverty guidelines. There is no asset limit to
qualify for the program. { + The Department of Human Services
or the Oregon Health Authority may prescribe by rule additional
eligibility criteria for medical assistance described in
subsection (2)(a) and (b) of this section consistent with federal
requirements for receiving federal financial participation in the
costs of the program and consistent with this section. + }
(4)(a) A child receiving medical assistance { - under the
program - } { + through the Health Care for All Oregon Children
program + } is continuously eligible for a minimum period of 12
months { + or until the child reaches 19 years of age, whichever
comes first + }.
(b) The department { - of Human Services - } { + or the
authority + } shall reenroll a child for successive 12-month
periods of enrollment as long as the child is eligible for
medical assistance on the date of reenrollment { + and the child
has not yet reached 19 years of age + }.
(c) { - The department may not require - } { + A child may
not be required to submit + } a new application as a condition of
reenrollment under paragraph (b) of this subsection { - and - }
{ + , and the department or the authority + } must determine the
child's eligibility for medical assistance using information and
sources available to the department { + or the authority + } or
documentation { + that is + } readily available { + to the
child or the child's caretaker + }.
(5) Except for medical assistance funded by Title XIX of the
Social Security Act, the department or the { - Oregon
Health - } authority may prescribe by rule a period of
uninsurance prior to enrollment in the program.
{ +
ABOLISHMENT OF OFFICE OF PRIVATE HEALTH PARTNERSHIPS + }
{ +
AND FAMILY HEALTH INSURANCE ASSISTANCE PROGRAM + }
SECTION 40. { + (1) The Office of Private Health Partnerships
is abolished. On the operative date of this section, the tenure
of office of the Administrator of the Office of Private Health
Partnerships and the deputy director of the Office of Private
Health Partnerships ceases.
(2) The unexpended balances of amounts in the Family Health
Insurance Assistance Program Account and other amounts authorized
to be expended by the office for the biennium beginning July 1,
2013, from revenues dedicated, continuously appropriated,
appropriated or otherwise made available to the office for the
purpose of administering the Family Health Insurance Assistance
Program are transferred to the Oregon Health Authority Fund
established in ORS 413.101 and are available for expenditure by
the Oregon Health Authority for the biennium beginning July 1,
Enrolled House Bill 2240 (HB 2240-B) Page 49
2013, for the purpose of administering and enforcing the duties,
functions and powers of the office with respect to the Family
Health Insurance Assistance Program.
(3) Nothing in this section, the amendments to ORS 192.556,
410.080, 413.011, 413.032, 413.201, 414.041, 414.231, 414.826,
414.828, 414.839 and 433.443 and section 1, chapter 867, Oregon
Laws 2009, by sections 42 to 53 of this 2013 Act or the repeal of
ORS 414.831, 414.841, 414.842, 414.844, 414.846, 414.848,
414.851, 414.852, 414.854, 414.856, 414.858, 414.861, 414.862,
414.864, 414.866, 414.868, 414.870, 414.872, 735.700, 735.701,
735.702, 735.703, 735.705, 735.707, 735.709, 735.710 and 735.712
by section 65 of this 2013 Act:
(a) Relieves a person of a liability, duty or obligation
accruing under or with respect to the duties, functions and
powers of the office. The authority may undertake the collection
or enforcement of any such liability, duty or obligation.
(b) Affects any action, proceeding or prosecution involving or
with respect to the duties, functions and powers of the office
that were begun before and pending on the operative date of this
section, except that the authority is substituted for the office
in the action, proceeding or prosecution.
(4) The rights and obligations of the office legally incurred
under contracts, leases and business transactions executed,
entered into or begun before the operative date of this section
are transferred to the authority. For the purpose of succession
to these rights and obligations, the authority is a continuation
of the office.
(5) Notwithstanding the abolishment of the office by subsection
(1) of this section, the rules of the office in effect on the
operative date of this section continue in effect until
superseded or repealed by rules of the authority. References in
rules of the office to the office or an officer or employee of
the office are considered to be references to the authority or an
officer or employee of the authority.
(6) Whenever, in any statutory law or resolution of the
Legislative Assembly or in any rule, document, record or
proceeding authorized by the Legislative Assembly, reference is
made to the office or an officer or employee of the office, the
reference is considered to be a reference to the authority or an
officer or employee of the authority. + }
SECTION 41. { + The Director of the Oregon Health Authority
and the Administrator of the Office of Private Health
Partnerships may take any action before the operative date
specified in section 64 of this 2013 Act that is necessary to
enable the director and the administrator to carry out section 40
of this 2013 Act. + }
SECTION 42. ORS 192.556 is amended to read:
192.556. As used in ORS 192.553 to 192.581:
(1) 'Authorization' means a document written in plain language
that contains at least the following:
(a) A description of the information to be used or disclosed
that identifies the information in a specific and meaningful way;
(b) The name or other specific identification of the person or
persons authorized to make the requested use or disclosure;
(c) The name or other specific identification of the person or
persons to whom the covered entity may make the requested use or
disclosure;
(d) A description of each purpose of the requested use or
disclosure, including but not limited to a statement that the use
or disclosure is at the request of the individual;
Enrolled House Bill 2240 (HB 2240-B) Page 50
(e) An expiration date or an expiration event that relates to
the individual or the purpose of the use or disclosure;
(f) The signature of the individual or personal representative
of the individual and the date;
(g) A description of the authority of the personal
representative, if applicable; and
(h) Statements adequate to place the individual on notice of
the following:
(A) The individual's right to revoke the authorization in
writing;
(B) The exceptions to the right to revoke the authorization;
(C) The ability or inability to condition treatment, payment,
enrollment or eligibility for benefits on whether the individual
signs the authorization; and
(D) The potential for information disclosed pursuant to the
authorization to be subject to redisclosure by the recipient and
no longer protected.
(2) 'Covered entity' means:
(a) A state health plan;
(b) A health insurer;
(c) A health care provider that transmits any health
information in electronic form to carry out financial or
administrative activities in connection with a transaction
covered by ORS 192.553 to 192.581; or
(d) A health care clearinghouse.
(3) 'Health care' means care, services or supplies related to
the health of an individual.
(4) 'Health care operations' includes but is not limited to:
(a) Quality assessment, accreditation, auditing and improvement
activities;
(b) Case management and care coordination;
(c) Reviewing the competence, qualifications or performance of
health care providers or health insurers;
(d) Underwriting activities;
(e) Arranging for legal services;
(f) Business planning;
(g) Customer services;
(h) Resolving internal grievances;
(i) Creating deidentified information; and
(j) Fundraising.
(5) 'Health care provider' includes but is not limited to:
(a) A psychologist, occupational therapist, regulated social
worker, professional counselor or marriage and family therapist
licensed or otherwise authorized to practice under ORS chapter
675 or an employee of the psychologist, occupational therapist,
regulated social worker, professional counselor or marriage and
family therapist;
(b) A physician, podiatric physician and surgeon, physician
assistant or acupuncturist licensed under ORS chapter 677 or an
employee of the physician, podiatric physician and surgeon,
physician assistant or acupuncturist;
(c) A nurse or nursing home administrator licensed under ORS
chapter 678 or an employee of the nurse or nursing home
administrator;
(d) A dentist licensed under ORS chapter 679 or an employee of
the dentist;
(e) A dental hygienist or denturist licensed under ORS chapter
680 or an employee of the dental hygienist or denturist;
Enrolled House Bill 2240 (HB 2240-B) Page 51
(f) A speech-language pathologist or audiologist licensed under
ORS chapter 681 or an employee of the speech-language pathologist
or audiologist;
(g) An emergency medical services provider licensed under ORS
chapter 682;
(h) An optometrist licensed under ORS chapter 683 or an
employee of the optometrist;
(i) A chiropractic physician licensed under ORS chapter 684 or
an employee of the chiropractic physician;
(j) A naturopathic physician licensed under ORS chapter 685 or
an employee of the naturopathic physician;
(k) A massage therapist licensed under ORS 687.011 to 687.250
or an employee of the massage therapist;
(L) A direct entry midwife licensed under ORS 687.405 to
687.495 or an employee of the direct entry midwife;
(m) A physical therapist licensed under ORS 688.010 to 688.201
or an employee of the physical therapist;
(n) A medical imaging licensee under ORS 688.405 to 688.605 or
an employee of the medical imaging licensee;
(o) A respiratory care practitioner licensed under ORS 688.815
or an employee of the respiratory care practitioner;
(p) A polysomnographic technologist licensed under ORS 688.819
or an employee of the polysomnographic technologist;
(q) A pharmacist licensed under ORS chapter 689 or an employee
of the pharmacist;
(r) A dietitian licensed under ORS 691.405 to 691.485 or an
employee of the dietitian;
(s) A funeral service practitioner licensed under ORS chapter
692 or an employee of the funeral service practitioner;
(t) A health care facility as defined in ORS 442.015;
(u) A home health agency as defined in ORS 443.005;
(v) A hospice program as defined in ORS 443.850;
(w) A clinical laboratory as defined in ORS 438.010;
(x) A pharmacy as defined in ORS 689.005;
(y) A diabetes self-management program as defined in ORS
743A.184; and
(z) Any other person or entity that furnishes, bills for or is
paid for health care in the normal course of business.
(6) 'Health information' means any oral or written information
in any form or medium that:
(a) Is created or received by a covered entity, a public health
authority, an employer, a life insurer, a school, a university or
a health care provider that is not a covered entity; and
(b) Relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(7) 'Health insurer' means:
(a) An insurer as defined in ORS 731.106 who offers:
(A) A health benefit plan as defined in ORS 743.730;
(B) A short term health insurance policy, the duration of which
does not exceed six months including renewals;
(C) A student health insurance policy;
(D) A Medicare supplemental policy; or
(E) A dental only policy.
(b) The Oregon Medical Insurance Pool operated by the Oregon
Medical Insurance Pool Board under ORS 735.600 to 735.650.
Enrolled House Bill 2240 (HB 2240-B) Page 52
(8) 'Individually identifiable health information' means any
oral or written health information in any form or medium that is:
(a) Created or received by a covered entity, an employer or a
health care provider that is not a covered entity; and
(b) Identifiable to an individual, including demographic
information that identifies the individual, or for which there is
a reasonable basis to believe the information can be used to
identify an individual, and that relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(9) 'Payment' includes but is not limited to:
(a) Efforts to obtain premiums or reimbursement;
(b) Determining eligibility or coverage;
(c) Billing activities;
(d) Claims management;
(e) Reviewing health care to determine medical necessity;
(f) Utilization review; and
(g) Disclosures to consumer reporting agencies.
(10) 'Personal representative' includes but is not limited to:
(a) A person appointed as a guardian under ORS 125.305,
419B.370, 419C.481 or 419C.555 with authority to make medical and
health care decisions;
(b) A person appointed as a health care representative under
ORS 127.505 to 127.660 or a representative under ORS 127.700 to
127.737 to make health care decisions or mental health treatment
decisions;
(c) A person appointed as a personal representative under ORS
chapter 113; and
(d) A person described in ORS 192.573.
(11)(a) 'Protected health information' means individually
identifiable health information that is maintained or transmitted
in any form of electronic or other medium by a covered entity.
(b) 'Protected health information' does not mean individually
identifiable health information in:
(A) Education records covered by the federal Family Educational
Rights and Privacy Act (20 U.S.C. 1232g);
(B) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); or
(C) Employment records held by a covered entity in its role as
employer.
(12) 'State health plan' means:
(a) Medical assistance as defined in ORS 414.025;
(b) The Health Care for All Oregon Children program; { +
or + }
{ - (c) The Family Health Insurance Assistance Program
established in ORS 414.841 to 414.864; or - }
{ - (d) - } { + (c) + } Any medical assistance or premium
assistance program operated by the Oregon Health Authority.
(13) 'Treatment' includes but is not limited to:
(a) The provision, coordination or management of health care;
and
(b) Consultations and referrals between health care providers.
SECTION 43. ORS 410.080 is amended to read:
410.080. (1) The Department of Human Services is the designated
single state agency for all federal programs under ORS 409.010
and 410.040 to 410.300 except that the Oregon Health Authority is
the single state agency responsible for supervising the
administration of all programs funded by Title XIX or Title XXI
Enrolled House Bill 2240 (HB 2240-B) Page 53
of the Social Security Act as provided in ORS 413.032
{ - (1)(j) - } { + (1)(i) + }.
(2) Except as provided in ORS 410.070 (2)(d) and 410.100, the
administration of services to clients under ORS 410.040 to
410.300 shall be through area agencies, and shall comply with all
applicable federal regulations.
SECTION 44. ORS 413.011, as amended by section 15, chapter 38,
Oregon Laws 2012, is amended to read:
413.011. (1) The duties of the Oregon Health Policy Board are
to:
(a) Be the policy-making and oversight body for the Oregon
Health Authority established in ORS 413.032 and all of the
authority's departmental divisions.
(b) Develop and submit a plan to the Legislative Assembly by
December 31, 2010, to provide and fund access to affordable,
quality health care for all Oregonians by 2015.
(c) Develop a program to provide health insurance premium
assistance to all low and moderate income individuals who are
legal residents of Oregon.
(d) Establish and continuously refine uniform, statewide health
care quality standards for use by all purchasers of health care,
third-party payers and health care providers as quality
performance benchmarks.
(e) Establish evidence-based clinical standards and practice
guidelines that may be used by providers.
(f) Approve and monitor community-centered health initiatives
described in ORS 413.032 { - (1)(i) - } { + (1)(h) + } that
are consistent with public health goals, strategies, programs and
performance standards adopted by the Oregon Health Policy Board
to improve the health of all Oregonians, and shall regularly
report to the Legislative Assembly on the accomplishments and
needed changes to the initiatives.
(g) Establish cost containment mechanisms to reduce health care
costs.
(h) Ensure that Oregon's health care workforce is sufficient in
numbers and training to meet the demand that will be created by
the expansion in health coverage, health care system
transformations, an increasingly diverse population and an aging
workforce.
(i) Work with the Oregon congressional delegation to advance
the adoption of changes in federal law or policy to promote
Oregon's comprehensive health reform plan.
(j) Establish a health benefit package in accordance with ORS
741.340 to be used as the baseline for all health benefit plans
offered through the Oregon Health Insurance Exchange.
(k) { - By December 31, 2010, - } Investigate and report
{ + annually + } to the Legislative Assembly { - , and annually
thereafter, - } on the feasibility and advisability of future
changes to the health insurance market in Oregon, including but
not limited to the following:
(A) A requirement for every resident to have health insurance
coverage.
(B) A payroll tax as a means to encourage employers to continue
providing health insurance to their employees.
(C) The implementation of a system of interoperable electronic
health records utilized by all health care providers in this
state.
(L) Meet cost-containment goals by structuring reimbursement
rates to reward comprehensive management of diseases, quality
outcomes and the efficient use of resources by promoting
Enrolled House Bill 2240 (HB 2240-B) Page 54
cost-effective procedures, services and programs including,
without limitation, preventive health, dental and primary care
services, web-based office visits, telephone consultations and
telemedicine consultations.
(m) Oversee the expenditure of moneys from the Health Care
Workforce Strategic Fund to support grants to primary care
providers and rural health practitioners, to increase the number
of primary care educators and to support efforts to create and
develop career ladder opportunities.
(n) Work with the Public Health Benefit Purchasers Committee,
administrators of the medical assistance program and the
Department of Corrections to identify uniform contracting
standards for health benefit plans that achieve maximum quality
and cost outcomes and align the contracting standards for all
state programs to the greatest extent practicable.
(2) The Oregon Health Policy Board is authorized to:
(a) Subject to the approval of the Governor, organize and
reorganize the authority as the board considers necessary to
properly conduct the work of the authority.
(b) Submit directly to the Legislative Counsel, no later than
October 1 of each even-numbered year, requests for measures
necessary to provide statutory authorization to carry out any of
the board's duties or to implement any of the board's
recommendations. The measures may be filed prior to the beginning
of the legislative session in accordance with the rules of the
House of Representatives and the Senate.
(3) If the board or the authority is unable to perform, in
whole or in part, any of the duties described in ORS 413.006 to
413.042, 413.101 and 741.340 without federal approval, the
authority is authorized to request, in accordance with ORS
413.072, waivers or other approval necessary to perform those
duties. The authority shall implement any portions of those
duties not requiring legislative authority or federal approval,
to the extent practicable.
(4) The enumeration of duties, functions and powers in this
section is not intended to be exclusive nor to limit the duties,
functions and powers imposed on the board by ORS 413.006 to
413.042, 413.101 and 741.340 and by other statutes.
(5) The board shall consult with the Department of Consumer and
Business Services in completing the tasks set forth in subsection
(1)(j) and (k)(A) of this section.
SECTION 45. ORS 413.032 is amended to read:
413.032. (1) The Oregon Health Authority is established. The
authority shall:
(a) Carry out policies adopted by the Oregon Health Policy
Board;
(b) Administer the Oregon Integrated and Coordinated Health
Care Delivery System established in ORS 414.620;
(c) Administer the Oregon Prescription Drug Program;
{ - (d) Administer the Family Health Insurance Assistance
Program; - }
{ - (e) - } { + (d) + } Develop the policies for and the
provision of publicly funded medical care and medical assistance
in this state;
{ - (f) - } { + (e) + } Develop the policies for and the
provision of mental health treatment and treatment of addictions;
{ - (g) - } { + (f) + } Assess, promote and protect the
health of the public as specified by state and federal law;
{ - (h) - } { + (g) + } Provide regular reports to the
board with respect to the performance of health services
Enrolled House Bill 2240 (HB 2240-B) Page 55
contractors serving recipients of medical assistance, including
reports of trends in health services and enrollee satisfaction;
{ - (i) - } { + (h) + } Guide and support, with the
authorization of the board, community-centered health initiatives
designed to address critical risk factors, especially those that
contribute to chronic disease;
{ - (j) - } { + (i) + } Be the state Medicaid agency for
the administration of funds from Titles XIX and XXI of the Social
Security Act and administer medical assistance under ORS chapter
414;
{ - (k) - } { + (j) + } In consultation with the Director
of the Department of Consumer and Business Services, periodically
review and recommend standards and methodologies to the
Legislative Assembly for:
(A) Review of administrative expenses of health insurers;
(B) Approval of rates; and
(C) Enforcement of rating rules adopted by the Department of
Consumer and Business Services;
{ - (L) - } { + (k) + } Structure reimbursement rates for
providers that serve recipients of medical assistance to reward
comprehensive management of diseases, quality outcomes and the
efficient use of resources and to promote cost-effective
procedures, services and programs including, without limitation,
preventive health, dental and primary care services, web-based
office visits, telephone consultations and telemedicine
consultations;
{ - (m) - } { + (L) + } Guide and support community
three-share agreements in which an employer, state or local
government and an individual all contribute a portion of a
premium for a community-centered health initiative or for
insurance coverage;
{ - (n) - } { + (m) + } Develop, in consultation with the
Department of Consumer and Business Services, one or more
products designed to provide more affordable options for the
small group market; and
{ - (o) - } { + (n) + } Implement policies and programs to
expand the skilled, diverse workforce as described in ORS 414.018
(4).
(2) The Oregon Health Authority is authorized to:
(a) Create an all-claims, all-payer database to collect health
care data and monitor and evaluate health care reform in Oregon
and to provide comparative cost and quality information to
consumers, providers and purchasers of health care about Oregon's
health care systems and health plan networks in order to provide
comparative information to consumers.
(b) Develop uniform contracting standards for the purchase of
health care, including the following:
(A) Uniform quality standards and performance measures;
(B) Evidence-based guidelines for major chronic disease
management and health care services with unexplained variations
in frequency or cost;
(C) Evidence-based effectiveness guidelines for select new
technologies and medical equipment; and
(D) A statewide drug formulary that may be used by publicly
funded health benefit plans.
(3) The enumeration of duties, functions and powers in this
section is not intended to be exclusive nor to limit the duties,
functions and powers imposed on or vested in the Oregon Health
Authority by ORS 413.006 to 413.042, 413.101 and 741.340 or by
other statutes.
Enrolled House Bill 2240 (HB 2240-B) Page 56
SECTION 46. ORS 413.201 is amended to read:
413.201. (1) The Oregon Health Authority is responsible for
statewide outreach and marketing of the Health Care for All
Oregon Children program established in ORS 414.231 and
administered by the authority { - and the Office of Private
Health Partnerships - } with the goal of enrolling in those
programs all eligible children residing in this state.
(2) To maximize the enrollment and retention of eligible
children in the Health Care for All Oregon Children program, the
authority shall develop and administer a grant program to provide
funding to organizations and community based groups to deliver
culturally specific and targeted outreach and direct application
assistance to:
(a) Members of racial, ethnic and language minority
communities;
(b) Children living in geographic isolation; and
(c) Children and family members with additional barriers to
accessing health care, such as cognitive, mental health or
sensory disorders, physical disabilities or chemical dependency,
and children experiencing homelessness.
SECTION 47. ORS 414.041 is amended to read:
414.041. (1) The Oregon Health Authority, under the direction
of the Oregon Health Policy Board and in collaboration with the
Department of Human Services, shall implement a streamlined and
simple application process for the medical assistance and premium
assistance programs administered by the Oregon Health Authority
{ - and the Office of Private Health Partnerships - } . The
process shall include, but not be limited to:
(a) An online application that may be submitted via the
Internet;
(b) Application forms that are readable at a sixth grade level
and that request the minimum amount of information necessary to
begin processing the application; and
(c) Application assistance from qualified staff to aid
individuals who have language, cognitive, physical or geographic
barriers to applying for medical assistance or premium
assistance.
(2) In developing the simplified application forms, the
department shall consult with persons not employed by the
department who have experience in serving vulnerable and
hard-to-reach populations.
(3) The Oregon Health Authority shall facilitate outreach and
enrollment efforts to connect eligible individuals with all
available publicly funded health programs { - , including but
not limited to the Family Health Insurance Assistance Program - }
.
SECTION 48. ORS 414.231, as amended by section 39 of this 2013
Act, is amended to read:
414.231. (1) As used in this section, 'child' means a person
under 19 years of age.
(2) The Health Care for All Oregon Children program is
established to make affordable, accessible health care available
to all of Oregon's children. The program is composed of:
(a) Medical assistance funded in whole or in part by Title XIX
of the Social Security Act, by the State Children's Health
Insurance Program under Title XXI of the Social Security Act and
by moneys appropriated or allocated for that purpose by the
Legislative Assembly; and
Enrolled House Bill 2240 (HB 2240-B) Page 57
(b) A private health option { - administered by the Office of
Private Health Partnerships under - } { + described in + } ORS
414.826.
(3) A child is eligible for medical assistance under either
subsection (2)(a) or (b) of this section if the child is lawfully
present in this state and the income of the child's family is at
or below 300 percent of the federal poverty guidelines. There is
no asset limit to qualify for the program. The Department of
Human Services or the Oregon Health Authority may prescribe by
rule additional eligibility criteria for medical assistance
described in subsection (2)(a) and (b) of this section consistent
with federal requirements for receiving federal financial
participation in the costs of the program and consistent with
this section.
(4)(a) A child receiving medical assistance through the Health
Care for All Oregon Children program is continuously eligible for
a minimum period of 12 months or until the child reaches 19 years
of age, whichever comes first.
(b) The department or the authority shall reenroll a child for
successive 12-month periods of enrollment as long as the child is
eligible for medical assistance on the date of reenrollment and
the child has not yet reached 19 years of age.
(c) A child may not be required to submit a new application as
a condition of reenrollment under paragraph (b) of this
subsection, and the department or the authority must determine
the child's eligibility for medical assistance using information
and sources available to the department or the authority or
documentation that is readily available to the child or the
child's caretaker.
{ - (5) Except for medical assistance funded by Title XIX of
the Social Security Act, the department or the authority may
prescribe by rule a period of uninsurance prior to enrollment in
the program. - }
SECTION 49. ORS 414.826 is amended to read:
414.826. (1) As used in this section:
(a) 'Child' means a person under 19 years of age who is
lawfully present in this state.
(b) 'Dental plan' { - has the meaning given that term in ORS
414.841 - } { + means a policy or certificate of group or
individual health insurance, as defined in ORS 731.162, providing
payment or reimbursement only for the expenses of dental
care + }.
(c) 'Health benefit plan' has the meaning given that term in
ORS { - 414.841 - } { + 743.730 + }.
(2) The { - Office of Private Health Partnerships - } { +
Oregon Health Authority + } shall administer a private health
option to expand access to private health insurance for Oregon's
children.
(3) The { - office - } { + authority + } shall adopt by
rule criteria for health benefit plans to qualify for premium
assistance under the private health option. The criteria may
include, but are not limited to, the following:
{ - (a) The health benefit plan meets or exceeds the
requirements for a basic benchmark health benefit plan under ORS
414.856. - }
{ - (b) - } { + (a) + } The health benefit plan offers a
benefit package comparable to the health services provided to
children receiving medical assistance, including mental health,
vision and dental services, and without any exclusion of or delay
of coverage for preexisting conditions.
Enrolled House Bill 2240 (HB 2240-B) Page 58
{ - (c) - } { + (b) + } The health benefit plan imposes
copayments or other cost sharing that is based upon a family's
ability to pay.
{ - (d) - } { + (c) + } Expenditures for the health benefit
plan qualify for federal financial participation.
(4) To qualify for premium assistance under the private health
option:
(a) A dental plan must provide coverage of dental services
necessary to prevent disease and promote oral health, restore
oral structures to health and function and treat emergency
conditions.
(b) Expenditures for the dental plan must qualify for federal
financial participation.
(5) The amount of premium assistance provided under this
section shall be:
(a) Equal to the full cost of the premiums for a health benefit
plan and a dental plan for children whose family income is at or
below 200 percent of the federal poverty guidelines and who have
access to employer sponsored health insurance; and
(b) Based on a sliding scale under criteria established by the
{ - office - } { + authority + } by rule for children whose
family income is above 200 percent but at or below 300 percent of
the federal poverty guidelines, regardless of whether the child
has access to coverage under an employer sponsored health benefit
plan or dental plan.
{ - (6) A child whose family income is more than 300 percent
of the federal poverty guidelines shall be offered the
opportunity to purchase a health benefit plan or dental plan
through the private health option but may not receive premium
assistance. - }
{ + (6) Premium assistance may be available under this
section to a child described in subsection (5)(b) of this section
for a health benefit plan purchased through the Oregon Health
Insurance Exchange. + }
SECTION 50. ORS 414.828 is amended to read:
414.828. Notwithstanding eligibility criteria and premium
assistance amounts determined pursuant to ORS 414.826, the
{ - Office of Private Health Partnerships - } { + Oregon
Health Authority + } shall provide premium assistance under the
private health option to eligible children to the extent the
Legislative Assembly appropriates funds for that purpose or
establishes expenditure limitations to provide such premium
assistance.
SECTION 51. ORS 414.839 is amended to read:
414.839. Subject to funds available, the Oregon Health
Authority may provide medical assistance in the form of premium
assistance for the purchase of health insurance coverage provided
by public programs or private insurance, including but not
limited to:
{ - (1) The Family Health Insurance Assistance Program; - }
{ - (2) - } { + (1) + } Medical assistance described in ORS
414.115; and
{ - (3) - } { + (2) + } The Health Care for All Oregon
Children program established in ORS 414.231.
SECTION 52. ORS 433.443 is amended to read:
433.443. (1) As used in this section:
(a) 'Covered entity' means:
(A) The Children's Health Insurance Program;
{ - (B) The Family Health Insurance Assistance Program
established under ORS 414.842; - }
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{ - (C) - } { + (B) + } A health insurer that is an insurer
as defined in ORS 731.106 and that issues health insurance as
defined in ORS 731.162;
{ - (D) - } { + (C) + } The state medical assistance
program; and
{ - (E) - } { + (D) + } A health care provider.
(b) 'Health care provider' includes but is not limited to:
(A) A psychologist, occupational therapist, regulated social
worker, professional counselor or marriage and family therapist
licensed or otherwise authorized to practice under ORS chapter
675 or an employee of the psychologist, occupational therapist,
regulated social worker, professional counselor or marriage and
family therapist;
(B) A physician, podiatric physician and surgeon, physician
assistant or acupuncturist licensed under ORS chapter 677 or an
employee of the physician, podiatric physician and surgeon,
physician assistant or acupuncturist;
(C) A nurse or nursing home administrator licensed under ORS
chapter 678 or an employee of the nurse or nursing home
administrator;
(D) A dentist licensed under ORS chapter 679 or an employee of
the dentist;
(E) A dental hygienist or denturist licensed under ORS chapter
680 or an employee of the dental hygienist or denturist;
(F) A speech-language pathologist or audiologist licensed under
ORS chapter 681 or an employee of the speech-language pathologist
or audiologist;
(G) An emergency medical services provider licensed under ORS
chapter 682;
(H) An optometrist licensed under ORS chapter 683 or an
employee of the optometrist;
(I) A chiropractic physician licensed under ORS chapter 684 or
an employee of the chiropractic physician;
(J) A naturopathic physician licensed under ORS chapter 685 or
an employee of the naturopathic physician;
(K) A massage therapist licensed under ORS 687.011 to 687.250
or an employee of the massage therapist;
(L) A direct entry midwife licensed under ORS 687.405 to
687.495 or an employee of the direct entry midwife;
(M) A physical therapist licensed under ORS 688.010 to 688.201
or an employee of the physical therapist;
(N) A medical imaging licensee under ORS 688.405 to 688.605 or
an employee of the medical imaging licensee;
(O) A respiratory care practitioner licensed under ORS 688.815
or an employee of the respiratory care practitioner;
(P) A polysomnographic technologist licensed under ORS 688.819
or an employee of the polysomnographic technologist;
(Q) A pharmacist licensed under ORS chapter 689 or an employee
of the pharmacist;
(R) A dietitian licensed under ORS 691.405 to 691.485 or an
employee of the dietitian;
(S) A funeral service practitioner licensed under ORS chapter
692 or an employee of the funeral service practitioner;
(T) A health care facility as defined in ORS 442.015;
(U) A home health agency as defined in ORS 443.005;
(V) A hospice program as defined in ORS 443.850;
(W) A clinical laboratory as defined in ORS 438.010;
(X) A pharmacy as defined in ORS 689.005;
(Y) A diabetes self-management program as defined in ORS
743A.184; and
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(Z) Any other person or entity that furnishes, bills for or is
paid for health care in the normal course of business.
(c) 'Individual' means a natural person.
(d) 'Individually identifiable health information' means any
oral or written health information in any form or medium that is:
(A) Created or received by a covered entity, an employer or a
health care provider that is not a covered entity; and
(B) Identifiable to an individual, including demographic
information that identifies the individual, or for which there is
a reasonable basis to believe the information can be used to
identify an individual, and that relates to:
(i) The past, present or future physical or mental health or
condition of an individual;
(ii) The provision of health care to an individual; or
(iii) The past, present or future payment for the provision of
health care to an individual.
(e) 'Legal representative' means attorney at law, person
holding a general power of attorney, guardian, conservator or any
person appointed by a court to manage the personal or financial
affairs of a person, or agency legally responsible for the
welfare or support of a person.
(2)(a) During a public health emergency declared under ORS
433.441, the Public Health Director may, as necessary to
appropriately respond to the public health emergency:
(A) Adopt reporting requirements for and provide notice of
those requirements to health care providers, institutions and
facilities for the purpose of obtaining information directly
related to the public health emergency;
(B) After consultation with appropriate medical experts, create
and require the use of diagnostic and treatment protocols to
respond to the public health emergency and provide notice of
those protocols to health care providers, institutions and
facilities;
(C) Order, or authorize local public health administrators to
order, public health measures appropriate to the public health
threat presented;
(D) Upon approval of the Governor, take other actions necessary
to address the public health emergency and provide notice of
those actions to health care providers, institutions and
facilities, including public health actions authorized by ORS
431.264;
(E) Take any enforcement action authorized by ORS 431.262,
including the imposition of civil penalties of up to $500 per day
against individuals, institutions or facilities that knowingly
fail to comply with requirements resulting from actions taken in
accordance with the powers granted to the Public Health Director
under subparagraphs (A), (B) and (D) of this paragraph; and
(F) The authority granted to the Public Health Director under
this section:
(i) Supersedes any authority granted to a local public health
authority if the local public health authority acts in a manner
inconsistent with guidelines established or rules adopted by the
director under this section; and
(ii) Does not supersede the general authority granted to a
local public health authority or a local public health
administrator except as authorized by law or necessary to respond
to a public health emergency.
(b) The authority of the Public Health Director to take
administrative action, and the effectiveness of any action taken,
under paragraph (a)(A), (B), (D), (E) and (F) of this subsection
Enrolled House Bill 2240 (HB 2240-B) Page 61
terminates upon the expiration of the { - proclaimed - } { +
declared + } state of public health emergency, unless the actions
are continued under other applicable law.
(3) Civil penalties under subsection (2) of this section shall
be imposed in the manner provided in ORS 183.745. The Public
Health Director must establish that the individual, institution
or facility subject to the civil penalty had actual notice of the
action taken that is the basis for the penalty. The maximum
aggregate total for penalties that may be imposed against an
individual, institution or facility under subsection (2) of this
section is $500 for each day of violation, regardless of the
number of violations of subsection (2) of this section that
occurred on each day of violation.
(4)(a) During a { - proclaimed - } { + declared + } state
of public health emergency, the Public Health Director and local
public health administrators shall be given immediate access to
individually identifiable health information necessary to:
(A) Determine the causes of an illness related to the public
health emergency;
(B) Identify persons at risk;
(C) Identify patterns of transmission;
(D) Provide treatment; and
(E) Take steps to control the disease.
(b) Individually identifiable health information accessed as
provided by paragraph (a) of this subsection may not be used for
conducting nonemergency epidemiologic research or to identify
persons at risk for post-traumatic mental health problems, or for
any other purpose except the purposes listed in paragraph (a) of
this subsection.
(c) Individually identifiable health information obtained by
the Public Health Director or local public health administrators
under this subsection may not be disclosed without written
authorization of the identified individual except:
(A) Directly to the individual who is the subject of the
information or to the legal representative of that individual;
(B) To state, local or federal agencies authorized to receive
such information by state or federal law;
(C) To identify or to determine the cause or manner of death of
a deceased individual; or
(D) Directly to a health care provider for the evaluation or
treatment of a condition that is the subject of a proclamation of
a state of public health emergency issued under ORS 433.441.
(d) Upon expiration of the state of public health emergency,
the Public Health Director or local public health administrators
may not use or disclose any individually identifiable health
information that has been obtained under this section. If a state
of emergency that is related to the state of public health
emergency has been declared under ORS 401.165, the Public Health
Director and local public health administrators may continue to
use any individually identifiable information obtained as
provided under this section until termination of the state of
emergency.
(5) All civil penalties recovered under this section shall be
paid into the State Treasury and credited to the General Fund and
are available for general governmental expenses.
(6) The Public Health Director may request assistance in
enforcing orders issued pursuant to this section from state or
local law enforcement authorities. If so requested by the Public
Health Director, state and local law enforcement authorities, to
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the extent resources are available, shall assist in enforcing
orders issued pursuant to this section.
(7) If the Oregon Health Authority adopts temporary rules to
implement the provisions of this section, the rules adopted are
not subject to the provisions of ORS 183.335 (6)(a). The
authority may amend temporary rules adopted pursuant to this
subsection as often as necessary to respond to the public health
emergency.
SECTION 53. Section 1, chapter 867, Oregon Laws 2009, as
amended by section 46, chapter 828, Oregon Laws 2009, section 2,
chapter 73, Oregon Laws 2010, and section 31, chapter 602, Oregon
Laws 2011, is amended to read:
{ + Sec. 1. + } (1) The Health System Fund is established in
the State Treasury, separate and distinct from the General Fund.
Interest earned by the Health System Fund shall be credited to
the fund.
(2) Amounts in the Health System Fund are continuously
appropriated to the Oregon Health Authority for the purpose of
funding the Health Care for All Oregon Children program
established in ORS 414.231, health services described in ORS
414.025 (8)(a) to (j) and other health services. Moneys in the
fund may also be used by the authority to:
(a) Provide grants to community health centers and safety net
clinics under ORS 413.225.
(b) Pay refunds due under section 41, chapter 736, Oregon Laws
2003, and under section 11, chapter 867, Oregon Laws 2009.
(c) Pay administrative costs incurred by the authority to
administer the assessment in section 9, chapter 867, Oregon Laws
2009.
(d) Provide health services described in ORS 414.025 (8) to
individuals described in ORS 414.025 (3)(f)(B).
{ - (3) The authority shall develop a system for
reimbursement by the authority to the Office of Private Health
Partnerships out of the Health System Fund for costs associated
with administering the private health option pursuant to ORS
414.826. - }
{ +
CONFORMING AMENDMENTS + }
SECTION 54. ORS 731.036 is amended to read:
731.036. Except as provided in ORS 743.061 or as specifically
provided by law, the Insurance Code does not apply to any of the
following to the extent of the subject matter of the exemption:
(1) A bail bondsman, other than a corporate surety and its
agents.
(2) A fraternal benefit society that has maintained lodges in
this state and other states for 50 years prior to January 1,
1961, and for which a certificate of authority was not required
on that date.
(3) A religious organization providing insurance benefits only
to its employees, if the organization is in existence and exempt
from taxation under section 501(c)(3) of the federal Internal
Revenue Code on September 13, 1975.
(4) Public bodies, as defined in ORS 30.260, that either
individually or jointly establish a self-insurance program for
tort liability in accordance with ORS 30.282.
(5) Public bodies, as defined in ORS 30.260, that either
individually or jointly establish a self-insurance program for
property damage in accordance with ORS 30.282.
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(6) Cities, counties, school districts, community college
districts, community college service districts or districts, as
defined in ORS 198.010 and 198.180, that either individually or
jointly insure for health insurance coverage, excluding
disability insurance, their employees or retired employees, or
their dependents, or students engaged in school activities, or
combination of employees and dependents, with or without employee
or student contributions, if all of the following conditions are
met:
(a) The individual or jointly self-insured program meets the
following minimum requirements:
(A) In the case of a school district, community college
district or community college service district, the number of
covered employees and dependents and retired employees and
dependents aggregates at least 500 individuals;
(B) In the case of an individual public body program other than
a school district, community college district or community
college service district, the number of covered employees and
dependents and retired employees and dependents aggregates at
least 500 individuals; and
(C) In the case of a joint program of two or more public
bodies, the number of covered employees and dependents and
retired employees and dependents aggregates at least 1,000
individuals;
(b) The individual or jointly self-insured health insurance
program includes all coverages and benefits required of group
health insurance policies under ORS chapters 743 and 743A;
(c) The individual or jointly self-insured program must have
program documents that define program benefits and
administration;
(d) Enrollees must be provided copies of summary plan
descriptions including:
(A) Written general information about services provided, access
to services, charges and scheduling applicable to each enrollee's
coverage;
(B) The program's grievance and appeal process; and
(C) Other group health plan enrollee rights, disclosure or
written procedure requirements established under ORS chapters 743
and 743A;
(e) The financial administration of an individual or jointly
self-insured program must include the following requirements:
(A) Program contributions and reserves must be held in separate
accounts and used for the exclusive benefit of the program;
(B) The program must maintain adequate reserves. Reserves may
be invested in accordance with the provisions of ORS chapter 293.
Reserve adequacy must be calculated annually with proper
actuarial calculations including the following:
(i) Known claims, paid and outstanding;
(ii) A history of incurred but not reported claims;
(iii) Claims handling expenses;
(iv) Unearned contributions; and
(v) A claims trend factor; and
(C) The program must maintain adequate reinsurance against the
risk of economic loss in accordance with the provisions of ORS
742.065 unless the program has received written approval for an
alternative arrangement for protection against economic loss from
the Director of the Department of Consumer and Business Services;
(f) The individual or jointly self-insured program must have
sufficient personnel to service the employee benefit program or
must contract with a third party administrator licensed under ORS
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chapter 744 as a third party administrator to provide such
services;
(g) The individual or jointly self-insured program shall be
subject to assessment in accordance with ORS 735.614 { - and
former enrollees shall be eligible for portability coverage in
accordance with ORS 735.616 - } ;
(h) The public body, or the program administrator in the case
of a joint insurance program of two or more public bodies, files
with the Director of the Department of Consumer and Business
Services copies of all documents creating and governing the
program, all forms used to communicate the coverage to
beneficiaries, the schedule of payments established to support
the program and, annually, a financial report showing the total
incurred cost of the program for the preceding year. A copy of
the annual audit required by ORS 297.425 may be used to satisfy
the financial report filing requirement; and
(i) Each public body in a joint insurance program is liable
only to its own employees and no others for benefits under the
program in the event, and to the extent, that no further funds,
including funds from insurance policies obtained by the pool, are
available in the joint insurance pool.
(7) All ambulance services.
(8) A person providing any of the services described in this
subsection. The exemption under this subsection does not apply to
an authorized insurer providing such services under an insurance
policy. This subsection applies to the following services:
(a) Towing service.
(b) Emergency road service, which means adjustment, repair or
replacement of the equipment, tires or mechanical parts of a
motor vehicle in order to permit the motor vehicle to be operated
under its own power.
(c) Transportation and arrangements for the transportation of
human remains, including all necessary and appropriate
preparations for and actual transportation provided to return a
decedent's remains from the decedent's place of death to a
location designated by a person with valid legal authority under
ORS 97.130.
(9)(a) A person described in this subsection who, in an
agreement to lease or to finance the purchase of a motor vehicle,
agrees to waive for no additional charge the amount specified in
paragraph (b) of this subsection upon total loss of the motor
vehicle because of physical damage, theft or other occurrence, as
specified in the agreement. The exemption established in this
subsection applies to the following persons:
(A) The seller of the motor vehicle, if the sale is made
pursuant to a motor vehicle retail installment contract.
(B) The lessor of the motor vehicle.
(C) The lender who finances the purchase of the motor vehicle.
(D) The assignee of a person described in this paragraph.
(b) The amount waived pursuant to the agreement shall be the
difference, or portion thereof, between the amount received by
the seller, lessor, lender or assignee, as applicable, that
represents the actual cash value of the motor vehicle at the date
of loss, and the amount owed under the agreement.
(10) A self-insurance program for tort liability or property
damage that is established by two or more affordable housing
entities and that complies with the same requirements that public
bodies must meet under ORS 30.282 (6). As used in this
subsection:
Enrolled House Bill 2240 (HB 2240-B) Page 65
(a) 'Affordable housing' means housing projects in which some
of the dwelling units may be purchased or rented, with or without
government assistance, on a basis that is affordable to
individuals of low income.
(b) 'Affordable housing entity' means any of the following:
(A) A housing authority created under the laws of this state or
another jurisdiction and any agency or instrumentality of a
housing authority, including but not limited to a legal entity
created to conduct a self-insurance program for housing
authorities that complies with ORS 30.282 (6).
(B) A nonprofit corporation that is engaged in providing
affordable housing.
(C) A partnership or limited liability company that is engaged
in providing affordable housing and that is affiliated with a
housing authority described in subparagraph (A) of this paragraph
or a nonprofit corporation described in subparagraph (B) of this
paragraph if the housing authority or nonprofit corporation:
(i) Has, or has the right to acquire, a financial or ownership
interest in the partnership or limited liability company;
(ii) Has the power to direct the management or policies of the
partnership or limited liability company;
(iii) Has entered into a contract to lease, manage or operate
the affordable housing owned by the partnership or limited
liability company; or
(iv) Has any other material relationship with the partnership
or limited liability company.
(11) A community-based health care initiative approved by the
Administrator of the Office for Oregon Health Policy and Research
under ORS 735.723 operating a community-based health care
improvement program approved by the administrator.
(12) Except as provided in ORS 735.500 and 735.510, a person
certified by the Department of Consumer and Business Services to
operate a retainer medical practice.
SECTION 55. ORS 735.625 is amended to read:
735.625. (1) Except as provided in subsection (3)(c) of this
section, the Oregon Medical Insurance Pool Board shall offer
major medical expense coverage to every eligible person.
(2) The coverage to be issued by the board, its schedule of
benefits, exclusions and other limitations, shall be established
through rules adopted by the board, taking into consideration the
advice and recommendations of the pool members. In the absence of
such rules, the pool shall adopt by rule the minimum benefits
prescribed by section 6 (Alternative 1) of the Model Health
Insurance Pooling Mechanism Act of the National Association of
Insurance Commissioners (1984).
(3)(a) In establishing portability coverage under the pool, the
board shall consider the levels of medical insurance provided in
this state and medical economic factors identified by the board.
The board may adopt rules to establish benefit levels,
deductibles, coinsurance factors, exclusions and limitations that
the board determines are equivalent to the portability health
benefit plans established under ORS 743.760.
(b) In establishing medical insurance coverage under the pool,
the board shall consider the levels of medical insurance provided
in this state and medical economic factors identified by the
board. The board may adopt rules to establish benefit levels,
deductibles, coinsurance factors, exclusions and limitations that
the board determines are equivalent to those found in the
commercial group or employer-based medical insurance market.
Enrolled House Bill 2240 (HB 2240-B) Page 66
(c) The board may provide a separate Medicare supplement policy
for individuals under the age of 65 who are receiving Medicare
disability benefits. The board shall adopt rules to establish
benefits, deductibles, coinsurance, exclusions and limitations,
premiums and eligibility requirements for the Medicare supplement
policy.
(d) In establishing medical insurance coverage for persons
eligible for coverage under ORS 735.615 (1)(d), the board shall
consider the levels of medical insurance provided in this state
and medical economic factors identified by the board. The board
may adopt rules to establish benefit levels, deductibles,
coinsurance factors, exclusions and limitations to create benefit
plans that qualify the person for the credit for health insurance
costs under section 35 of the federal Internal Revenue Code, as
amended and in effect on December 31, 2004.
(4)(a) Premiums charged for coverages issued by the board may
not be unreasonable in relation to the benefits provided, the
risk experience and the reasonable expenses of providing the
coverage.
(b) Separate schedules of premium rates based on age and
geographical location may apply for individual risks.
(c) The board shall determine the applicable medical and
portability risk rates either by calculating the average rate
charged by insurers offering coverages in the state comparable to
the pool coverage or by using reasonable actuarial techniques.
The risk rates shall reflect anticipated experience and expenses
for such coverage. Rates for pool coverage may not be more than
125 percent of rates established as applicable for medically
eligible individuals or for persons eligible for pool coverage
under ORS 735.615 (1)(d), or 100 percent of rates established as
applicable for portability eligible individuals.
(d) The board shall annually determine adjusted benefits and
premiums. The adjustments shall be in keeping with the purposes
of ORS 735.600 to 735.650, subject to a limitation of keeping
pool losses under one percent of the total of all medical
insurance premiums, subscriber contract charges and 110 percent
of all benefits paid by member self-insurance arrangements. The
board may determine the total number of persons that may be
enrolled for coverage at any time and may permit and prohibit
enrollment in order to maintain the number authorized. Nothing in
this paragraph authorizes the board to prohibit enrollment for
any reason other than to control the number of persons in the
pool.
(5)(a) The board may apply:
(A) A waiting period of not more than 90 days during which the
person has no available coverage; or
(B) Except as provided in paragraph (c) of this subsection, a
preexisting conditions provision of not more than six months from
the effective date of coverage under the pool.
(b) In determining whether a preexisting conditions provision
applies to an eligible enrollee, except as provided in this
subsection, the board shall credit the time the eligible enrollee
was covered under a previous health benefit plan if the previous
health benefit plan was continuous to a date not more than 63
days prior to the effective date of the new coverage under the
Oregon Medical Insurance Pool, exclusive of any applicable
waiting period. The Oregon Medical Insurance Pool Board need not
credit the time for previous coverage to which the insured or
dependent is otherwise entitled under this subsection with
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respect to benefits and services covered in the pool coverage
that were not covered in the previous coverage.
(c) The board may adopt rules applying a preexisting conditions
provision to a person who is eligible for coverage under ORS
735.615 (1)(d).
(d) For purposes of this subsection, a 'preexisting conditions
provision' means a provision that excludes coverage for services,
charges or expenses incurred during a specified period not to
exceed six months following the insured's effective date of
coverage, for a condition for which medical advice, diagnosis,
care or treatment was recommended or received during the
six-month period immediately preceding the insured's effective
date of coverage.
(6)(a) Benefits otherwise payable under pool coverage shall be
reduced by all amounts paid or payable through any other health
insurance, or self-insurance arrangement, and by all hospital and
medical expense benefits paid or payable under any workers'
compensation coverage, automobile medical payment or liability
insurance whether provided on the basis of fault or nonfault, and
by any hospital or medical benefits paid or payable under or
provided pursuant to any state or federal law or program except
the Medicaid portion of the medical assistance program offering a
level of health services described in ORS 414.707.
(b) The board shall have a cause of action against an eligible
person for the recovery of the amount of benefits paid which are
not for covered expenses. Benefits due from the pool may be
reduced or refused as a setoff against any amount recoverable
under this paragraph.
(7) { - Except as provided in ORS 735.616, - } No mandated
benefit statutes apply to pool coverage under ORS 735.600 to
735.650.
(8) Pool coverage may be furnished through a health care
service contractor or such alternative delivery system as will
contain costs while maintaining quality of care.
SECTION 56. ORS 743.526 is amended to read:
743.526. (1) An insurer may not offer a policy of group health
insurance described in { - ORS 743.522 (1)(c) - } { + section
7 (3) of this 2013 Act + } that insures persons in this state or
offer coverage under such a policy, whether the policy is to be
issued in this or another state, unless the Director of the
Department of Consumer and Business Services determines that the
requirements of this section and { - ORS 743.522 (1)(c) - }
{ + section 7 (3) of this 2013 Act + } are satisfied.
(2) The director shall determine with respect to a policy
whether the trustees are the policyholder. If the director
determines that the trustees are the policyholder and if the
policy is issued or proposed to be issued in this state, the
policy is subject to the Insurance Code. If the director
determines that the trustees are not the policyholder, the
evidence of coverage that is issued or proposed to be issued in
this state to a participating employer, labor union or
association shall be deemed to be a group health insurance policy
subject to the provisions of the Insurance Code. The director may
determine that the trustees are not the policyholder if:
(a) The evidence of coverage issued or proposed to be issued to
a participating employer, labor union or association is in fact
the primary statement of coverage for the employer, labor union
or association; and
(b) The trust arrangement is under the actual control of the
insurer.
Enrolled House Bill 2240 (HB 2240-B) Page 68
(3) An insurer shall submit evidence to the director showing
that the requirements of subsection (2) of this section and
{ - ORS 743.522 (1)(c) - } { + section 7 (3) of this 2013
Act + } are satisfied. The director shall review the evidence and
may request additional evidence as needed.
(4) An insurer shall submit to the director any changes in the
evidence submitted under subsection (3) of this section.
(5) The director may adopt rules to carry out this section.
SECTION 57. ORS 743.528 is amended to read:
743.528. A group health insurance policy shall contain in
substance the following provisions:
(1) A provision that, in the absence of fraud, all statements
made by applicants, the policyholder or an insured person shall
be deemed representations and not warranties, and that no
statement made for the purpose of effecting insurance shall avoid
the insurance or reduce benefits unless contained in a written
instrument signed by the policyholder or the insured person, a
copy of which has been furnished to the policyholder or to the
person or the beneficiary of the person.
(2) A provision that the insurer will furnish to the
policyholder for delivery to each employee or member of the
insured group a statement in summary form of the essential
features of the insurance coverage of the employee or member, to
whom the insurance benefits are payable, and the applicable
rights and conditions set forth in ORS 743.527, 743.529
{ - , - } { + and + } 743.600 to 743.610 { - and 743.760 - }
. If dependents are included in the coverage, only one statement
need be issued for each family unit.
(3) A provision that to the group originally insured may be
added from time to time eligible new employees or members or
dependents, as the case may be, in accordance with the terms of
the policy.
SECTION 58. ORS 743.560 is amended to read:
743.560. (1) A group health insurance policy shall contain a
provision allowing a minimum grace period of 10 days after the
premium due date for payment of premium.
(2) An insurer of a group health insurance policy providing
coverage for hospital or medical expenses, other than coverage
limited to expenses from accidents or specific diseases, that
seeks to terminate a policy for nonpayment of premium shall
notify the policyholder as described in ORS 743.565.
(3) An insurer of a group health insurance policy providing
coverage for hospital or medical expenses, other than coverage
limited to expenses from accidents or specific diseases, shall
notify the group policyholder when the policy is terminated and
the coverage is not replaced by the group policyholder. The
notice required under this subsection:
(a) Must be given on a form prescribed by the Department of
Consumer and Business Services;
(b) Must explain the rights of the certificate holders
regarding continuation of coverage provided by federal and state
law { - and portability coverage in accordance with ORS
743.760 - } ; and
(c) Must be given by mail and must be mailed not later than 10
working days after the date on which the group policy terminates
according to the terms of the policy.
(4) A group health insurance policy to which subsection (3) of
this section applies shall contain a provision requiring the
insurer to notify the group policyholder when the policy is
terminated and the coverage is not replaced by the group
Enrolled House Bill 2240 (HB 2240-B) Page 69
policyholder. Each certificate issued under the policy shall also
contain a statement of the provision required under this
subsection.
(5) If an insurer fails to give notice as required by this
section, the insurer shall continue the group health insurance
policy of the group policyholder in full force from the date
notice should have been provided until the date that the notice
is received by the policyholder and shall waive the premiums
owing for the period for which the coverage is continued under
this subsection. The time period within which the certificate
holder may exercise any right to continuation { - or
portability - } shall commence on the date that the policyholder
receives the notice.
(6) The insurer shall supply the employer holding the
terminated policy with the necessary information for the employer
to be able to notify properly the employee of the employee's
right to continuation of coverage under state and federal law
{ - and portability coverage in accordance with ORS 743.760 - }
.
SECTION 59. ORS 743.730, as amended by section 49, chapter 500,
Oregon Laws 2011, section 20, chapter 38, Oregon Laws 2012, and
section 17 of this 2013 Act, is amended to read:
743.730. For purposes of ORS 743.730 to 743.773:
(1) 'Actuarial certification' means a written statement by a
member of the American Academy of Actuaries or other individual
acceptable to the Director of the Department of Consumer and
Business Services that a carrier is in compliance with the
provisions of ORS 743.736 based upon the person's examination,
including a review of the appropriate records and of the
actuarial assumptions and methods used by the carrier in
establishing premium rates for small employer health benefit
plans.
(2) 'Affiliate' of, or person 'affiliated' with, a specified
person means any carrier who, directly or indirectly through one
or more intermediaries, controls or is controlled by or is under
common control with a specified person. For purposes of this
definition, 'control' has the meaning given that term in ORS
732.548.
(3) 'Affiliation period' means, under the terms of a group
health benefit plan issued by a health care service contractor, a
period:
(a) That is applied uniformly and without regard to any health
status related factors to an enrollee or late enrollee;
(b) That must expire before any coverage becomes effective
under the plan for the enrollee or late enrollee;
(c) During which no premium shall be charged to the enrollee or
late enrollee; and
(d) That begins on the enrollee's or late enrollee's first date
of eligibility for coverage and runs concurrently with any
eligibility waiting period under the plan.
(4) 'Bona fide association' means an association that:
(a) Has been in active existence for at least five years;
(b) Has been formed and maintained in good faith for purposes
other than obtaining insurance;
(c) Does not condition membership in the association on any
factor relating to the health status of an individual or the
individual's dependent or employee;
(d) Makes health insurance coverage that is offered through the
association available to all members of the association
Enrolled House Bill 2240 (HB 2240-B) Page 70
regardless of the health status of the member or individuals who
are eligible for coverage through the member;
(e) Does not make health insurance coverage that is offered
through the association available other than in connection with a
member of the association;
(f) Has a constitution and bylaws; and
(g) Is not owned or controlled by a carrier, producer or
affiliate of a carrier or producer.
(5) 'Carrier' means any person who provides health benefit
plans in this state, including:
(a) A licensed insurance company;
(b) A health care service contractor;
(c) A health maintenance organization;
(d) An association or group of employers that provides benefits
by means of a multiple employer welfare arrangement and that:
(A) Is subject to ORS 750.301 to 750.341; or
(B) Is fully insured and otherwise exempt under ORS 750.303 (4)
but elects to be governed by ORS 743.733 to 743.737; or
(e) Any other person or corporation responsible for the payment
of benefits or provision of services.
(6) 'Catastrophic plan' means a health benefit plan that meets
the requirements for a catastrophic plan under 42 U.S.C.
18022(e) and that is offered through the Oregon Health Insurance
Exchange.
(7) 'Creditable coverage' means prior health care coverage as
defined in 42 U.S.C. 300gg as amended and in effect on February
17, 2009, and includes coverage remaining in force at the time
the enrollee obtains new coverage.
(8) 'Dependent' means the spouse or child of an eligible
employee, subject to applicable terms of the health benefit plan
covering the employee.
(9) 'Eligible employee' means an employee who works on a
regularly scheduled basis, with a normal work week of 17.5 or
more hours. The employer may determine hours worked for
eligibility between 17.5 and 40 hours per week subject to rules
of the carrier. 'Eligible employee' does not include employees
who work on a temporary, seasonal or substitute basis. Employees
who have been employed by the employer for fewer than 90 days are
not eligible employees unless the employer so allows.
(10) 'Employee' means any individual employed by an employer.
(11) 'Enrollee' means an employee, dependent of the employee or
an individual otherwise eligible for a group or individual health
benefit plan who has enrolled for coverage under the terms of the
plan.
(12) 'Exchange' means the health insurance exchange
administered by the Oregon Health Insurance Exchange Corporation
in accordance with ORS 741.310.
(13) 'Exclusion period' means a period during which specified
treatments or services are excluded from coverage.
(14) 'Financial impairment' means that a carrier is not
insolvent and is:
(a) Considered by the director to be potentially unable to
fulfill its contractual obligations; or
(b) Placed under an order of rehabilitation or conservation by
a court of competent jurisdiction.
(15)(a) 'Geographic average rate' means the arithmetical
average of the lowest premium and the corresponding highest
premium to be charged by a carrier in a geographic area
established by the director for the carrier's:
(A) Group health benefit plans offered to small employers; or
Enrolled House Bill 2240 (HB 2240-B) Page 71
(B) Individual health benefit plans.
(b) 'Geographic average rate' does not include premium
differences that are due to differences in benefit design, age,
tobacco use or family composition.
(16) 'Grandfathered health plan' has the meaning prescribed by
the United States Secretaries of Labor, Health and Human Services
and the Treasury pursuant to 42 U.S.C. 18011(e).
(17) 'Group eligibility waiting period' means, with respect to
a group health benefit plan, the period of employment or
membership with the group that a prospective enrollee must
complete before plan coverage begins.
(18)(a) 'Health benefit plan' means any:
(A) Hospital expense, medical expense or hospital or medical
expense policy or certificate;
(B) Health care service contractor or health maintenance
organization subscriber contract; or
(C) Plan provided by a multiple employer welfare arrangement or
by another benefit arrangement defined in the federal Employee
Retirement Income Security Act of 1974, as amended, to the extent
that the plan is subject to state regulation.
(b) 'Health benefit plan' does not include:
(A) Coverage for accident only, specific disease or condition
only, credit or disability income;
(B) Coverage of Medicare services pursuant to contracts with
the federal government;
(C) Medicare supplement insurance policies;
(D) Coverage of TRICARE services pursuant to contracts with the
federal government;
(E) Benefits delivered through a flexible spending arrangement
established pursuant to section 125 of the Internal Revenue Code
of 1986, as amended, when the benefits are provided in addition
to a group health benefit plan;
(F) Separately offered long term care insurance, including, but
not limited to, coverage of nursing home care, home health care
and community-based care;
(G) Independent, noncoordinated, hospital-only indemnity
insurance or other fixed indemnity insurance;
(H) Short term health insurance policies that are in effect for
periods of 12 months or less, including the term of a renewal of
the policy;
(I) Dental only coverage;
(J) Vision only coverage;
(K) Stop-loss coverage that meets the requirements of ORS
742.065;
(L) Coverage issued as a supplement to liability insurance;
(M) Insurance arising out of a workers' compensation or similar
law;
(N) Automobile medical payment insurance or insurance under
which benefits are payable with or without regard to fault and
that is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance; or
(O) Any employee welfare benefit plan that is exempt from state
regulation because of the federal Employee Retirement Income
Security Act of 1974, as amended.
(c) For purposes of this subsection, renewal of a short term
health insurance policy includes the issuance of a new short term
health insurance policy by an insurer to a policyholder within 60
days after the expiration of a policy previously issued by the
insurer to the policyholder.
Enrolled House Bill 2240 (HB 2240-B) Page 72
(19) 'Individual coverage waiting period' means a period in an
individual health benefit plan during which no premiums may be
collected and health benefit plan coverage issued is not
effective.
(20) 'Individual health benefit plan' means a health benefit
plan:
(a) That is issued to an individual policyholder; or
(b) That provides individual coverage through a trust,
association or similar group, regardless of the situs of the
policy or contract.
(21) 'Initial enrollment period' means a period of at least 30
days following commencement of the first eligibility period for
an individual.
(22) 'Late enrollee' means an individual who enrolls in a group
health benefit plan subsequent to the initial enrollment period
during which the individual was eligible for coverage but
declined to enroll. However, an eligible individual shall not be
considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg or as prescribed by rule by the
Department of Consumer and Business Services;
(b) The individual applies for coverage during an open
enrollment period;
(c) A court issues an order that coverage be provided for a
spouse or minor child under an employee's employer sponsored
health benefit plan and request for enrollment is made within 30
days after issuance of the court order;
(d) The individual is employed by an employer that offers
multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period;
or
(e) The individual's coverage under Medicaid, Medicare,
TRICARE, Indian Health Service or a publicly sponsored or
subsidized health plan, including, but not limited to, the
medical assistance program under ORS chapter 414, has been
involuntarily terminated within 63 days after applying for
coverage in a group health benefit plan.
(23) 'Minimal essential coverage' has the meaning given that
term in section 5000A(f) of the Internal Revenue Code.
(24) 'Multiple employer welfare arrangement' means a multiple
employer welfare arrangement as defined in section 3 of the
federal Employee Retirement Income Security Act of 1974, as
amended, 29 U.S.C. 1002, that is subject to ORS 750.301 to
750.341.
(25) 'Oregon Medical Insurance Pool' means the pool created
under ORS 735.610.
(26) 'Preexisting condition exclusion' means:
(a) Except for a grandfathered health plan, a limitation or
exclusion of benefits or a denial of coverage based on a medical
condition being present before the effective date of coverage or
before the date coverage is denied, whether or not any medical
advice, diagnosis, care or treatment was recommended or received
for the condition before the date of coverage or denial of
coverage.
(b) With respect to a grandfathered health plan, a provision
applicable to an enrollee or late enrollee that excludes coverage
for services, charges or expenses incurred during a specified
period immediately following enrollment for a condition for which
medical advice, diagnosis, care or treatment was recommended or
received during a specified period immediately preceding
Enrolled House Bill 2240 (HB 2240-B) Page 73
enrollment. For purposes of this paragraph pregnancy and genetic
information do not constitute preexisting conditions.
(27) 'Premium' includes insurance premiums or other fees
charged for a health benefit plan, including the costs of
benefits paid or reimbursements made to or on behalf of enrollees
covered by the plan.
(28) 'Rating period' means the 12-month calendar period for
which premium rates established by a carrier are in effect, as
determined by the carrier.
(29) 'Representative' does not include an insurance producer or
an employee or authorized representative of an insurance producer
or carrier.
(30)(a) 'Small employer' means an employer that employed an
average of at least one but not more than { - 50 - } { +
100 + } employees on business days during the preceding calendar
year, the majority of whom are employed within this state, and
that employs at least one eligible employee on the first day of
the plan year.
(b) Any person that is treated as a single employer under
section 414 (b), (c), (m) or (o) of the Internal Revenue Code of
1986 shall be treated as one employer for purposes of this
subsection.
(c) The determination of whether an employer that was not in
existence throughout the preceding calendar year is a small
employer shall be based on the average number of employees that
it is reasonably expected the employer will employ on business
days in the current calendar year.
SECTION 60. ORS 743.757 is amended to read:
743.757. (1) As used in this section, 'guaranteed association'
means an association that:
(a) The Director of the Department of Consumer and Business
Services has determined under ORS 743.524 meets the requirements
described in { - ORS 743.522 (1)(b) - } { + section 7 (2) of
this 2013 Act + }; and
(b) Is a statewide nonprofit organization representing the
interests of individuals licensed under ORS chapter 696.
(2) A carrier may offer a health benefit plan to a guaranteed
association if the plan provides health benefits covering 500 or
more members or dependents of members of the association.
(3) When a carrier offers coverage to a guaranteed association
under subsection (2) of this section, the carrier shall offer
coverage to all members of the association and all dependents of
the members of the association without regard to the actual or
expected health status of any member or any dependent of a member
of the association.
(4) A carrier offering a health benefit plan under subsection
(2) of this section shall establish premium rates as follows:
(a) For the initial 12-month period of coverage, the carrier
shall submit to the director a certified statement that the
premium rates charged to the guaranteed association are
actuarially sound. The statement must be signed by an actuary
certifying the accuracy of the rating methodology as established
by the American Academy of Actuaries.
(b) For any subsequent 12-month period of coverage, according
to a rating methodology as established by the American Academy of
Actuaries.
(5) A member of a guaranteed association may apply for coverage
offered by a carrier under subsection (2) of this section only:
(a) If the member has been an active member of the association
for no less than 30 days;
Enrolled House Bill 2240 (HB 2240-B) Page 74
(b) During an annual open enrollment period offered by the
association; and
(c) After meeting any additional eligibility requirements
agreed upon by the association and the carrier.
(6) Notwithstanding subsection (5) of this section, if a member
or a dependent of a member of a guaranteed association terminates
coverage under the health benefit plan, the member or dependent
shall be excluded from coverage for 12 months from the date of
termination of coverage. The member may enroll for coverage of
the member or the dependent during an annual open enrollment
period following the expiration of the exclusion period.
SECTION 61. ORS 743.769 is amended to read:
743.769. (1) Each carrier shall actively market all individual
health benefit plans sold by the carrier { + that are not
grandfathered health plans + }.
(2) Except as provided in subsection (3) of this section, no
carrier or insurance producer shall, directly or indirectly,
discourage an individual from filing an application for coverage
because of the health status, claims experience, occupation or
geographic location of the individual.
(3) Subsection (2) of this section does not apply with respect
to information provided by a carrier to an individual regarding
the established geographic service area or a restricted network
provision of a carrier.
(4) Rejection by a carrier of an application for coverage shall
be in writing and shall state the reason or reasons for the
rejection.
(5) The Director of the Department of Consumer and Business
Services may establish by rule additional standards to provide
for the fair marketing and broad availability of individual
health benefit plans.
(6) A carrier that elects to discontinue offering all of its
individual health benefit plans under ORS 743.766
{ - (5)(c) - } { + (4)(c) + } or to discontinue offering and
renewing all such plans is prohibited from offering and renewing
health benefit plans in the individual market in this state for a
period of five years from the date of notice to the director
pursuant to ORS 743.766
{ - (5)(c) - } { + (4)(c) + } or, if such notice is not
provided, from the date on which the director provides notice to
the carrier that the director has determined that the carrier has
effectively discontinued offering individual health benefit plans
in this state. This subsection does not apply with respect to a
health benefit plan discontinued in a specified service area by a
carrier that covers services provided only by a particular
organization of health care providers or only by health care
providers who are under contract with the carrier.
SECTION 61a. ORS 743.801, as amended by section 5, chapter 24,
Oregon Laws 2012, is amended to read:
743.801. As used in this section and ORS 743.803, 743.804,
743.806, 743.807, 743.808, 743.811, 743.814, 743.817, 743.819,
743.821, 743.823, 743.827, 743.829, 743.831, 743.834, 743.837,
743.839, 743.854, 743.856, 743.857, 743.858, 743.859, 743.861,
743.862, 743.863, 743.864, 743.894, 743.911, 743.912, 743.913,
743.917 and 743.918:
(1) 'Adverse benefit determination' means an insurer's denial,
reduction or termination of a health care item or service, or an
insurer's failure or refusal to provide or to make a payment in
whole or in part for a health care item or service, that is based
on the insurer's:
Enrolled House Bill 2240 (HB 2240-B) Page 75
(a) Denial of eligibility for or termination of enrollment in a
health benefit plan;
(b) Rescission or cancellation of a policy or certificate;
(c) Imposition of a preexisting condition exclusion as defined
in ORS 743.730, source-of-injury exclusion, network exclusion,
annual benefit limit or other limitation on otherwise covered
items or services;
(d) Determination that a health care item or service is
experimental, investigational or not medically necessary,
effective or appropriate; or
(e) Determination that a course or plan of treatment that an
enrollee is undergoing is an active course of treatment for
purposes of continuity of care under ORS 743.854.
(2) 'Authorized representative' means an individual who by law
or by the consent of a person may act on behalf of the person.
(3) 'Enrollee' has the meaning given that term in ORS 743.730.
(4) 'Grievance' means:
(a) A communication from an enrollee or an authorized
representative of an enrollee expressing dissatisfaction with an
adverse benefit determination, without specifically declining any
right to appeal or review, that is:
(A) In writing, for an internal appeal or an external review;
or
(B) In writing or orally, for an expedited response described
in ORS 743.804 (2)(d) or an expedited external review; or
(b) A written complaint submitted by an enrollee or an
authorized representative of an enrollee regarding the:
(A) Availability, delivery or quality of a health care service;
(B) Claims payment, handling or reimbursement for health care
services and, unless the enrollee has not submitted a request for
an internal appeal, the complaint is not disputing an adverse
benefit determination; or
(C) Matters pertaining to the contractual relationship between
an enrollee and an insurer.
(5) 'Health benefit plan' has the meaning given that term in
ORS 743.730.
(6) 'Independent practice association' means a corporation
wholly owned by providers, or whose membership consists entirely
of providers, formed for the sole purpose of contracting with
insurers for the provision of health care services to enrollees,
or with employers for the provision of health care services to
employees, or with a group, as described in { - ORS 743.522 - }
{ + section 7 of this 2013 Act + }, to provide health care
services to group members.
(7) 'Insurer' includes a health care service contractor as
defined in ORS 750.005.
(8) 'Internal appeal' means a review by an insurer of an
adverse benefit determination made by the insurer.
(9) 'Managed health insurance' means any health benefit plan
that:
(a) Requires an enrollee to use a specified network or networks
of providers managed, owned, under contract with or employed by
the insurer in order to receive benefits under the plan, except
for emergency or other specified limited service; or
(b) In addition to the requirements of paragraph (a) of this
subsection, offers a point-of-service provision that allows an
enrollee to use providers outside of the specified network or
networks at the option of the enrollee and receive a reduced
level of benefits.
Enrolled House Bill 2240 (HB 2240-B) Page 76
(10) 'Medical services contract' means a contract between an
insurer and an independent practice association, between an
insurer and a provider, between an independent practice
association and a provider or organization of providers, between
medical or mental health clinics, and between a medical or mental
health clinic and a provider to provide medical or mental health
services. 'Medical services contract' does not include a contract
of employment or a contract creating legal entities and ownership
thereof that are authorized under ORS chapter 58, 60 or 70, or
other similar professional organizations permitted by statute.
(11)(a) 'Preferred provider organization insurance' means any
health benefit plan that:
(A) Specifies a preferred network of providers managed, owned
or under contract with or employed by an insurer;
(B) Does not require an enrollee to use the preferred network
of providers in order to receive benefits under the plan; and
(C) Creates financial incentives for an enrollee to use the
preferred network of providers by providing an increased level of
benefits.
(b) 'Preferred provider organization insurance' does not mean a
health benefit plan that has as its sole financial incentive a
hold harmless provision under which providers in the preferred
network agree to accept as payment in full the maximum allowable
amounts that are specified in the medical services contracts.
(12) 'Prior authorization' means a determination by an insurer
prior to provision of services that the insurer will provide
reimbursement for the services. 'Prior authorization ' does not
include referral approval for evaluation and management services
between providers.
(13) 'Provider' means a person licensed, certified or otherwise
authorized or permitted by laws of this state to administer
medical or mental health services in the ordinary course of
business or practice of a profession.
(14) 'Utilization review' means a set of formal techniques used
by an insurer or delegated by the insurer designed to monitor the
use of or evaluate the medical necessity, appropriateness,
efficacy or efficiency of health care services, procedures or
settings.
SECTION 62. ORS 743A.168 is amended to read:
743A.168. A group health insurance policy providing coverage
for hospital or medical expenses shall provide coverage for
expenses arising from treatment for chemical dependency,
including alcoholism, and for mental or nervous conditions at the
same level as, and subject to limitations no more restrictive
than, those imposed on coverage or reimbursement of expenses
arising from treatment for other medical conditions. The
following apply to coverage for chemical dependency and for
mental or nervous conditions:
(1) As used in this section:
(a) 'Chemical dependency' means the addictive relationship with
any drug or alcohol characterized by a physical or psychological
relationship, or both, that interferes on a recurring basis with
the individual's social, psychological or physical adjustment to
common problems. For purposes of this section, 'chemical
dependency' does not include addiction to, or dependency on,
tobacco, tobacco products or foods.
(b) 'Facility' means a corporate or governmental entity or
other provider of services for the treatment of chemical
dependency or for the treatment of mental or nervous conditions.
Enrolled House Bill 2240 (HB 2240-B) Page 77
(c) 'Group health insurer' means an insurer, a health
maintenance organization or a health care service contractor.
(d) 'Program' means a particular type or level of service that
is organizationally distinct within a facility.
(e) 'Provider' means a person that has met the credentialing
requirement of a group health insurer, is otherwise eligible to
receive reimbursement for coverage under the policy and is:
(A) A health care facility;
(B) A residential program or facility;
(C) A day or partial hospitalization program;
(D) An outpatient service; or
(E) An individual behavioral health or medical professional
authorized for reimbursement under Oregon law.
(2) The coverage may be made subject to provisions of the
policy that apply to other benefits under the policy, including
but not limited to provisions relating to deductibles and
coinsurance. Deductibles and coinsurance for treatment in health
care facilities or residential programs or facilities may not be
greater than those under the policy for expenses of
hospitalization in the treatment of other medical conditions.
Deductibles and coinsurance for outpatient treatment may not be
greater than those under the policy for expenses of outpatient
treatment of other medical conditions.
(3) The coverage may not be made subject to treatment
limitations, limits on total payments for treatment, limits on
duration of treatment or financial requirements unless similar
limitations or requirements are imposed on coverage of other
medical conditions. The coverage of eligible expenses may be
limited to treatment that is medically necessary as determined
under the policy for other medical conditions.
(4)(a) Nothing in this section requires coverage for:
(A) Educational or correctional services or sheltered living
provided by a school or halfway house;
(B) A long-term residential mental health program that lasts
longer than 45 days;
(C) Psychoanalysis or psychotherapy received as part of an
educational or training program, regardless of diagnosis or
symptoms that may be present;
(D) A court-ordered sex offender treatment program; or
(E) A screening interview or treatment program under ORS
813.021.
(b) Notwithstanding paragraph (a)(A) of this subsection, an
insured may receive covered outpatient services under the terms
of the insured's policy while the insured is living temporarily
in a sheltered living situation.
(5) A provider is eligible for reimbursement under this section
if:
(a) The provider is approved by the { - Department of Human
Services - } { + Oregon Health Authority + };
(b) The provider is accredited for the particular level of care
for which reimbursement is being requested by the Joint
Commission on Accreditation of Hospitals or the Commission on
Accreditation of Rehabilitation Facilities;
(c) The patient is staying overnight at the facility and is
involved in a structured program at least eight hours per day,
five days per week; or
(d) The provider is providing a covered benefit under the
policy.
(6) Payments may not be made under this section for support
groups.
Enrolled House Bill 2240 (HB 2240-B) Page 78
(7) If specified in the policy, outpatient coverage may include
follow-up in-home service or outpatient services. The policy may
limit coverage for in-home service to persons who are homebound
under the care of a physician.
(8) Nothing in this section prohibits a group health insurer
from managing the provision of benefits through common methods,
including but not limited to selectively contracted panels,
health plan benefit differential designs, preadmission screening,
prior authorization of services, utilization review or other
mechanisms designed to limit eligible expenses to those described
in subsection (3) of this section.
(9) The Legislative Assembly has found that health care cost
containment is necessary and intends to encourage insurance
policies designed to achieve cost containment by ensuring that
reimbursement is limited to appropriate utilization under
criteria incorporated into such policies, either directly or by
reference.
(10)(a) Subject to the patient or client confidentiality
provisions of ORS 40.235 relating to physicians, ORS 40.240
relating to nurse practitioners, ORS 40.230 relating to
psychologists, ORS 40.250 and 675.580 relating to licensed
clinical social workers and ORS 40.262 relating to licensed
professional counselors and licensed marriage and family
therapists, a group health insurer may provide for review for
level of treatment of admissions and continued stays for
treatment in health care facilities, residential programs or
facilities, day or partial hospitalization programs and
outpatient services by either group health insurer staff or
personnel under contract to the group health insurer, or by a
utilization review contractor, who shall have the authority to
certify for or deny level of payment.
(b) Review shall be made according to criteria made available
to providers in advance upon request.
(c) Review shall be performed by or under the direction of a
medical or osteopathic physician licensed by the Oregon Medical
Board, a psychologist licensed by the State Board of Psychologist
Examiners, a clinical social worker licensed by the State Board
of Licensed Social Workers or a professional counselor or
marriage and family therapist licensed by the Oregon Board of
Licensed Professional Counselors and Therapists, in accordance
with standards of the National Committee for Quality Assurance or
Medicare review standards of the Centers for Medicare and
Medicaid Services.
(d) Review may involve prior approval, concurrent review of the
continuation of treatment, post-treatment review or any
combination of these. However, if prior approval is required,
provision shall be made to allow for payment of urgent or
emergency admissions, subject to subsequent review. If prior
approval is not required, group health insurers shall permit
providers, policyholders or persons acting on their behalf to
make advance inquiries regarding the appropriateness of a
particular admission to a treatment program. Group health
insurers shall provide a timely response to such inquiries.
Noncontracting providers must cooperate with these procedures to
the same extent as contracting providers to be eligible for
reimbursement.
(11) Health maintenance organizations may limit the receipt of
covered services by enrollees to services provided by or upon
referral by providers contracting with the health maintenance
organization. Health maintenance organizations and health care
Enrolled House Bill 2240 (HB 2240-B) Page 79
service contractors may create substantive plan benefit and
reimbursement differentials at the same level as, and subject to
limitations no more restrictive than, those imposed on coverage
or reimbursement of expenses arising out of other medical
conditions and apply them to contracting and noncontracting
providers.
(12) Nothing in this section prevents a group health insurer
from contracting with providers of health care services to
furnish services to policyholders or certificate holders
according to ORS 743.531 or 750.005, subject to the following
conditions:
(a) A group health insurer is not required to contract with all
eligible providers.
(b) An insurer or health care service contractor shall, subject
to subsections (2) and (3) of this section, pay benefits toward
the covered charges of noncontracting providers of services for
the treatment of chemical dependency or mental or nervous
conditions. The insured shall, subject to subsections (2) and (3)
of this section, have the right to use the services of a
noncontracting provider of services for the treatment of chemical
dependency or mental or nervous conditions, whether or not the
services for chemical dependency or mental or nervous conditions
are provided by contracting or noncontracting providers.
(13) The intent of the Legislative Assembly in adopting this
section is to reserve benefits for different types of care to
encourage cost effective care and to ensure continuing access to
levels of care most appropriate for the insured's condition and
progress.
(14) The Director of the Department of Consumer and Business
Services, after notice and hearing, may adopt reasonable rules
not inconsistent with this section that are considered necessary
for the proper administration of these provisions.
{ +
CAPTIONS + }
SECTION 63. { + The unit captions used in this 2013 Act are
provided only for the convenience of the reader and do not become
part of the statutory law of this state or express any
legislative intent in the enactment of this 2013 Act. + }
{ +
REPEALS AND OPERATIVE AND EFFECTIVE DATES + }
SECTION 64. { + Sections 2 to 6 and 40 of this 2013 Act and
the amendments to ORS 192.556, 410.080, 413.011, 413.032,
413.201, 414.041, 414.231, 414.826, 414.828, 414.839, 433.443,
731.036, 735.625, 741.300, 743.018, 743.019, 743.405, 743.417,
743.420, 743.522, 743.524, 743.526, 743.528, 743.550, 743.552,
743.560, 743.610, 743.731, 743.733, 743.736, 743.737, 743.745,
743.748, 743.751, 743.752, 743.754, 743.757, 743.766, 743.767,
743.769, 743.777, 743.801, 743.804, 743.894, 743A.090, 743A.192,
746.015 and 746.045 and section 1, chapter 867, Oregon Laws 2009,
by sections 10 to 16, 18, 19, 21 to 30, 32 to 37, 42 to 58, 60,
61 and 61a of this 2013 Act become operative January 1, 2014. + }
SECTION 65. { + ORS 414.831, 414.841, 414.842, 414.844,
414.846, 414.848, 414.851, 414.852, 414.854, 414.856, 414.858,
414.861, 414.862, 414.864, 414.866, 414.868, 414.870, 414.872,
735.616, 735.700, 735.701, 735.702, 735.703, 735.705, 735.707,
Enrolled House Bill 2240 (HB 2240-B) Page 80
735.709, 735.710, 735.712, 743.549, 743.760 and 743.761 are
repealed January 1, 2014. + }
SECTION 66. { + (1)(a) The amendments to ORS 743.730 by
section 17 of this 2013 Act become operative January 2, 2014.
(b) The amendments to ORS 743.730 by section 59 of this 2013
Act become operative January 2, 2016.
(2) The amendments to ORS 731.146, 743.734 and 743.822 by
sections 9, 20 and 31 of this 2013 Act become operative January
2, 2014. + }
SECTION 67. { + This 2013 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2013 Act takes effect on
its passage. + }
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Passed by House May 28, 2013
.............................................................
Ramona J. Line, Chief Clerk of House
.............................................................
Tina Kotek, Speaker of House
Passed by Senate June 20, 2013
.............................................................
Peter Courtney, President of Senate
Enrolled House Bill 2240 (HB 2240-B) Page 81
Received by Governor:
......M.,............., 2013
Approved:
......M.,............., 2013
.............................................................
John Kitzhaber, Governor
Filed in Office of Secretary of State:
......M.,............., 2013
.............................................................
Kate Brown, Secretary of State
Enrolled House Bill 2240 (HB 2240-B) Page 82