Bill Text: OR HB2273 | 2013 | Regular Session | Introduced
Bill Title: Relating to prepaid managed care health services organizations.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Failed) 2013-07-08 - In committee upon adjournment. [HB2273 Detail]
Download: Oregon-2013-HB2273-Introduced.html
77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 1395
House Bill 2273
Sponsored by Representative FREEMAN (Presession filed.)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Requires Oregon Health Authority to continue to contract with
dental care organizations to serve medical assistance recipients.
A BILL FOR AN ACT
Relating to prepaid managed care health services organizations;
creating new provisions; amending ORS 192.493, 192.579,
414.018, 414.618, 414.631, 414.632, 414.645, 414.647, 416.510,
416.540, 741.300, 741.310, 743.061 and 743.847 and sections 14
and 64, chapter 602, Oregon Laws 2011.
Be It Enacted by the People of the State of Oregon:
SECTION 1. Section 14, chapter 602, Oregon Laws 2011, as
amended by section 2, chapter 8, Oregon Laws 2012, is amended to
read:
{ + Sec. 14. + } (1) Notwithstanding ORS 414.631 and 414.651,
in any area of the state where a coordinated care organization
has not been certified, the Oregon Health Authority shall
continue to contract with one or more prepaid managed care health
services organizations, as defined in ORS 414.736, that serve the
area and that are in compliance with contractual obligations owed
to the state or local government.
(2) Prepaid managed care health services organizations
contracting with the authority under this section are subject to
the applicable requirements for, and are permitted to exercise
the rights of, coordinated care organizations under ORS 414.153,
414.625, 414.635, 414.638, 414.651, 414.655, 414.679, 414.712,
414.728, 414.743, 414.746, 414.760, 416.510 to 416.610, 441.094,
442.464, 655.515, 659.830 and 743.847.
(3) The authority may amend contracts that are in place on July
1, 2011, to allow prepaid managed care health services
organizations that meet the criteria adopted by the authority
under ORS 414.625 to become coordinated care organizations.
(4) { + (a) + } The authority shall continue to renew the
contracts of prepaid managed care health services organizations
that have a contract with the authority on July 1, 2011,
until { + :
(A) For prepaid managed care health services organizations
other than dental care organizations, + } the earlier of the date
the prepaid managed care health services organization becomes a
coordinated care organization or July 1, 2014 { - . - } { + ;
and
(B) For dental care organizations, the date the dental care
organization enters into a contract with a coordinated care
organization.
(b) + } Contracts with prepaid managed care health services
organizations { + other than dental care organizations + } must
terminate no later than July 1, 2017.
(5) The authority shall continue to renew contracts or ensure
that counties renew contracts with providers of residential
chemical dependency treatment until the provider enters into a
contract with a coordinated care organization but no later than
July 1, 2013.
(6) Notwithstanding ORS 414.625 (2)(g) and 414.655 (2), the
authority shall allow for a period of transition to the full
adoption of health information technology by coordinated care
organizations and patient centered primary care homes. The
authority shall explore options for assisting providers and
coordinated care organizations in funding their use of health
information technology.
SECTION 2. ORS 414.018 is amended to read:
414.018. (1) It is the intention of the Legislative Assembly to
achieve the goals of universal access to an adequate level of
high quality health care at an affordable cost.
(2) The Legislative Assembly finds:
(a) A significant level of public and private funds is expended
each year for the provision of health care to Oregonians;
(b) The state has a strong interest in assisting Oregon
businesses and individuals to obtain reasonably available
insurance or other coverage of the costs of necessary basic
health care services;
(c) The lack of basic health care coverage is detrimental not
only to the health of individuals lacking coverage, but also to
the public welfare and the state's need to encourage employment
growth and economic development, and the lack results in
substantial expenditures for emergency and remedial health care
for all purchasers of health care including the state; and
(d) The use of integrated and coordinated health care systems
has significant potential to reduce the growth of health care
costs incurred by the people of this state.
(3) { + (a) + } The Legislative Assembly finds that achieving
its goals of improving health, increasing the quality,
reliability, availability and continuity of care and reducing the
cost of care requires an integrated and coordinated health care
system in which:
{ - (a) - } { + (A) + } Medical assistance recipients and
individuals who are dually eligible for both Medicare and
Medicaid participate.
{ - (b) - } { + (B) + } Health care services, other than
Medicaid-funded long term care services { + and dental services
delivered by dental care organizations + }, are delivered through
coordinated care contracts that use alternative payment
methodologies to focus on prevention, improving health equity and
reducing health disparities, utilizing patient centered primary
care homes, evidence-based practices and health information
technology to improve health and health care.
{ - (c) - } { + (C) + } High quality information is
collected and used to measure health outcomes, health care
quality and costs and clinical health information.
{ - (d) - } { + (D) + } Communities and regions are
accountable for improving the health of their communities and
regions, reducing avoidable health gaps among different cultural
groups and managing health care resources.
{ - (e) - } { + (E) + } Care and services emphasize
preventive services and services supporting individuals to live
independently at home or in their community.
{ - (f) - } { + (F) + } Services are person centered, and
provide choice, independence and dignity reflected in individual
plans and provide assistance in accessing care and services.
{ - (g) - } { + (G) + } Interactions between the Oregon
Health Authority and coordinated care organizations are done in a
transparent and public manner.
{ - (h) - } { + (H) + } Moneys provided by the federal
government for medical education are allocated to the
institutions that provide the education.
{ + (b) As used in this subsection:
(A) 'Community' means the groups within the geographic area
served by a coordinated care organization and includes groups
that identify themselves by age, ethnicity, race, economic
status, or other defining characteristic that may impact delivery
of health care services to the group, as well as the governing
body of each county located wholly or partially within the
coordinated care organization's service area.
(B) 'Region' means the geographical boundaries of the area
served by a coordinated care organization as well as the
governing body of each county that has jurisdiction over all or
part of the coordinated care organization's service area. + }
(4) The Legislative Assembly further finds that there is an
extreme need for a skilled, diverse workforce to meet the rapidly
growing demand for community-based health care. To meet that
need, this state must:
(a) Build on existing training programs; and
(b) Provide an opportunity for frontline care providers to have
a voice in their workplace in order to effectively advocate for
quality care.
{ - (5) As used in subsection (3) of this section: - }
{ - (a) 'Community' means the groups within the geographic
area served by a coordinated care organization and includes
groups that identify themselves by age, ethnicity, race, economic
status, or other defining characteristic that may impact delivery
of health care services to the group, as well as the governing
body of each county located wholly or partially within the
coordinated care organization's service area. - }
{ - (b) 'Region' means the geographical boundaries of the
area served by a coordinated care organization as well as the
governing body of each county that has jurisdiction over all or
part of the coordinated care organization's service area. - }
SECTION 3. ORS 414.618 is amended to read:
414.618. { - (1) In areas that are not served by a
coordinated care organization, the Oregon Health Authority may
execute prepaid capitated health service contracts for at least
hospital or physician medical care, or both, with hospital and
medical organizations, health maintenance organizations and any
other appropriate public or private persons. - }
{ - (2) - } { + (1) + } For purposes of ORS 279A.025,
279A.140, 414.145 and 414.610 to 414.620, instrumentalities and
political subdivisions of the state are authorized to enter into
{ - prepaid capitated health service - } { + dental care
organization + } contracts with the authority and shall not
thereby be considered to be transacting insurance.
{ - (3) In the event that there is an insufficient number of
qualified bids for coordinated care organizations or prepaid
capitated health services contracts for hospital or physician
medical care, or both, in some areas of the state, the authority
may continue a fee for service payment system. - }
{ - (4) - } { + (2) + } Payments to { - providers - }
{ + dental care organizations + } may be subject to contract
provisions requiring the retention of a specified percentage in
an incentive fund or to other contract provisions by which
adjustments to the payments are made based on utilization
efficiency.
{ - (5) - } { + (3) + } Contracts described in this section
are not subject to ORS chapters 279A and 279B, except that the
contracts are subject to ORS 279A.235 and 279A.250 to 279A.290.
SECTION 4. ORS 414.631 is amended to read:
414.631. (1) Except as provided in subsections (2), (3), (4)
and (5) of this section and ORS 414.632 (2), a person who is
eligible for or receiving health services must be enrolled in a
coordinated care organization to receive the health services for
which the person is eligible. For purposes of this subsection,
Medicaid-funded long term care services { + and dental services
provided by a dental care organization + } do not constitute
health services.
(2) Subsections (1) and (4) of this section do not apply to:
(a) A person who is a noncitizen and who is eligible only for
labor and delivery services and emergency treatment services;
(b) A person who is an American Indian and Alaskan Native
beneficiary;
(c) An individual described in ORS 414.632 (2) who is dually
eligible for Medicare and Medicaid and enrolled in a program of
all-inclusive care for the elderly; and
(d) A person whom the Oregon Health Authority may by rule
exempt from the mandatory enrollment requirement of subsection
(1) of this section, including but not limited to:
(A) A person who is also eligible for Medicare;
(B) A woman in her third trimester of pregnancy at the time of
enrollment;
(C) A person under 19 years of age who has been placed in
adoptive or foster care out of state;
(D) A person under 18 years of age who is medically fragile and
who has special health care needs;
(E) A person receiving services under the Medically Involved
Home-Care Program created by ORS 417.345 (1); and
(F) A person with major medical coverage.
(3) Subsection (1) of this section does not apply to a person
who resides in an area that is not served by a coordinated care
organization or where the organization's provider network is
inadequate.
(4) In any area that is not served by a coordinated care
organization but is served by a prepaid managed care health
services organization, a person must enroll with the prepaid
managed care health services organization to receive any of the
health services offered by the prepaid managed care health
services organization.
(5) As used in this section, 'American Indian and Alaskan
Native beneficiary' means:
(a) A member of a federally recognized Indian tribe;
(b) An individual who resides in an urban center and:
(A) Is a member of a tribe, band or other organized group of
Indians, including those tribes, bands or groups whose
recognition was terminated since 1940 and those recognized now or
in the future by the state in which the member resides, or who is
a descendant in the first or second degree of such a member;
(B) Is an Eskimo or Aleut or other Alaskan Native; or
(C) Is determined to be an Indian under regulations promulgated
by the United States Secretary of the Interior;
(c) A person who is considered by the United States Secretary
of the Interior to be an Indian for any purpose; or
(d) An individual who is considered by the United States
Secretary of Health and Human Services to be an Indian for
purposes of eligibility for Indian health care services,
including as a California Indian, Eskimo, Aleut or other Alaskan
Native.
SECTION 5. ORS 414.632, as amended by section 25, chapter 8,
Oregon Laws 2012, is amended to read:
414.632. (1) Subject to the Oregon Health Authority obtaining
any necessary authorization from the Centers for Medicare and
Medicaid Services, coordinated care organizations that meet the
criteria adopted under ORS 414.625 are responsible for providing
covered Medicare and Medicaid services, other than
Medicaid-funded long term care services { + and dental services
delivered by dental care organizations + }, to members who are
dually eligible for Medicare and Medicaid in addition to medical
assistance recipients.
(2) An individual who is dually eligible for Medicare and
Medicaid shall be permitted to enroll in and remain enrolled in
a:
(a) Program of all-inclusive care for the elderly, as defined
in 42 C.F.R. 460.6; and
(b) Medicare Advantage plan, as defined in 42 C.F.R. 422.2,
until the plan is fully integrated into a coordinated care
organization.
(3) Except for the enrollment in coordinated care organizations
of individuals who are dually eligible for Medicare and Medicaid,
the rights and benefits of Medicare beneficiaries under Title
XVIII of the Social Security Act shall be preserved.
SECTION 6. Section 64, chapter 602, Oregon Laws 2011, as
amended by section 70, chapter 602, Oregon Laws 2011, and section
23, chapter 8, Oregon Laws 2012, is amended to read:
{ + Sec. 64. + } (1) ORS 414.705 is repealed.
(2) Sections 13 and 17, chapter 602, Oregon Laws 2011, are
repealed January 2, 2014.
(3) ORS 414.610, { - 414.630, - } 414.640, 414.736, 414.738,
414.739 and 414.740 are repealed July 1, 2017.
(4) Section 14, chapter 602, Oregon Laws 2011, as amended by
section 2 { - of this 2012 Act - } { + , chapter 8, Oregon
Laws 2012 + }, is repealed July 1, 2017.
SECTION 7. ORS 192.493 is amended to read:
192.493. A record of an agency of the executive department as
defined in ORS 174.112 that contains the following information is
a public record subject to inspection under ORS 192.420 and is
not exempt from disclosure under ORS 192.501 or 192.502 except to
the extent that the record discloses information about an
individual's health or is proprietary to a person:
(1) The amounts determined by an independent actuary retained
by the agency to cover the costs of providing each of the
following health services under ORS 414.631, 414.651 and 414.688
to 414.750 for the six months preceding the report:
(a) Inpatient hospital services;
(b) Outpatient hospital services;
(c) Laboratory and X-ray services;
(d) Physician and other licensed practitioner services;
(e) Prescription drugs;
(f) Dental services;
(g) Vision services;
(h) Mental health services;
(i) Chemical dependency services;
(j) Durable medical equipment and supplies; and
(k) Other health services provided under a coordinated care
organization contract under ORS 414.651 or a contract with a
{ - prepaid managed care health services - } { + dental
care + } organization;
(2) The amounts the agency and each contractor have paid under
each coordinated care organization contract under ORS 414.651 or
{ - prepaid managed care health services - } { + dental
care + } organization contract for administrative costs and the
provision of each of the health services described in subsection
(1) of this section for the six months preceding the report;
(3) Any adjustments made to the amounts reported under this
section to account for geographic or other differences in
providing the health services; and
(4) The numbers of individuals served under each coordinated
care organization contract or { - prepaid managed care health
services - } { + dental care + } organization contract, listed
by category of individual.
SECTION 8. ORS 192.579 is amended to read:
192.579. (1) As used in this section, 'entity' means a health
care provider or a { - prepaid managed care health services - }
{ + dental care + } organization { - , as defined in ORS
414.736, - } that provides health care { + or dental care + }
to an individual, if the care is paid for by a state health plan.
(2) Notwithstanding ORS 179.505, an entity may disclose the
identity of an individual who receives health care { + or dental
care + } from the entity without obtaining an authorization from
the individual, or a personal representative of the individual,
to another entity for the purpose of coordinating the health care
{ + or dental care + } and treatment provided to the individual
by either entity.
SECTION 9. ORS 414.645 is amended to read:
414.645. (1) A { - prepaid managed care health services - }
{ + coordinated care organization and a dental care + }
organization that contracts with the Oregon Health Authority must
maintain a network of providers sufficient in numbers and areas
of practice and geographically distributed in a manner to ensure
that the health services provided under the contract are
reasonably accessible to enrollees.
(2) An enrollee may transfer from one organization to another
organization no more than once during each enrollment period.
SECTION 10. ORS 414.647 is amended to read:
414.647. (1) The Oregon Health Authority may approve the
transfer of 500 or more enrollees from one { - prepaid managed
care health services - } { + coordinated care organization or
dental care + } organization to another { - prepaid managed
care health services - } { + coordinated care organization or
dental care + } organization if:
(a) The enrollees' provider has contracted with the receiving
organization and has stopped accepting patients from or has
terminated providing services to enrollees in the transferring
organization; and
(b) Enrollees are offered the choice of remaining enrolled in
the transferring organization.
(2) Enrollees may not be transferred under this section until
the authority has evaluated the receiving organization and
determined that the organization meets criteria established by
the authority by rule, including but not limited to criteria that
ensure that the organization meets the requirements of ORS
414.645 (1).
(3) The authority shall provide notice of a transfer under this
section to enrollees that will be affected by the transfer at
least 90 days before the scheduled date of the transfer.
SECTION 11. ORS 416.510 is amended to read:
416.510. As used in ORS 416.510 to 416.610, unless the context
requires otherwise:
(1) 'Action' means an action, suit or proceeding.
(2) 'Alternative payment methodology' has the meaning given
that term in ORS 414.025.
(3) 'Applicant' means an applicant for assistance.
(4) 'Assistance' means moneys paid by the Department of Human
Services to persons directly and moneys paid by the Oregon Health
Authority or by a { - prepaid managed care health services - }
{ + dental care + } organization or a coordinated care
organization for services provided under contract pursuant to ORS
414.651 to others for the benefit of such persons.
(5) 'Authority' means the Oregon Health Authority.
(6) 'Claim' means a claim of a recipient of assistance for
damages for personal injuries against any person or public body,
agency or commission other than the State Accident Insurance Fund
Corporation or Workers' Compensation Board.
(7) 'Compromise' means a compromise between a recipient and any
person or public body, agency or commission against whom the
recipient has a claim.
(8) 'Coordinated care organization' means an organization that
meets the criteria adopted by the authority under ORS 414.625.
(9) 'Judgment' means a judgment in any action or proceeding
brought by a recipient to enforce the claim of the recipient.
{ - (10) 'Prepaid managed care health services organization '
means a managed health, dental or mental health care organization
that contracted with the authority on a prepaid capitated basis.
Prepaid managed care health services organizations may be dental
care organizations, fully capitated health plans, mental health
organizations or chemical dependency organizations. - }
{ - (11) - } { + (10) + } 'Recipient' means a recipient of
assistance.
{ - (12) - } { + (11) + } 'Settlement' means a settlement
between a recipient and any person or public body, agency or
commission against whom the recipient has a claim.
SECTION 12. ORS 416.540, as amended by section 27, chapter 8,
Oregon Laws 2012, is amended to read:
416.540. (1) Except as provided in subsection (2) of this
section and in ORS 416.590, the Department of Human Services and
the Oregon Health Authority shall have a lien upon the amount of
any judgment in favor of a recipient or amount payable to the
recipient under a settlement or compromise for all assistance
received by such recipient from the date of the injury of the
recipient to the date of satisfaction of such judgment or payment
under such settlement or compromise.
(2) The lien does not attach to the amount of any judgment,
settlement or compromise to the extent of attorney's fees, costs
and expenses incurred by a recipient in securing such judgment,
settlement or compromise and to the extent of medical, surgical
and hospital expenses incurred by the recipient on account of the
personal injuries for which the recipient had a claim.
(3) The authority may assign the lien described in subsection
(1) of this section to a { - prepaid managed care health
services - } { + dental care + } organization or a coordinated
care organization for medical costs incurred by a recipient:
(a) During a period for which the authority paid a capitation
or enrollment fee or a payment using a global payment
methodology; and
(b) On account of the personal injury for which the recipient
had a claim.
(4) A { - prepaid managed care health services - } { +
dental care + } organization or a coordinated care organization
to which the authority has assigned a lien shall notify the
authority no later than 10 days after filing notice of a lien.
(5) For the purposes of ORS 416.510 to 416.610, the authority
may designate the { - prepaid managed care health services - }
{ + dental care + } organization or the coordinated care
organization to which a lien is assigned as its designee.
(6) If the authority and a { - prepaid managed care health
services - } { + dental care + } organization or a coordinated
care organization both have filed a lien, the authority's lien
shall be satisfied first.
SECTION 13. 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 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.
(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 - } { + coordinated
care + } organization { + as defined in ORS 414.025 + }.
(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) - } { + (8) + } '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 14. ORS 741.310, as amended by section 12, chapter 415,
Oregon Laws 2011, section 11, chapter 38, Oregon Laws 2012, and
section 97, chapter 107, Oregon Laws 2012, is amended to read:
741.310. (1) The following individuals and groups may purchase
qualified health plans through the health insurance exchange:
(a) Individuals and families;
(b) Employers with no more than 100 employees; and
(c) Districts and eligible employees of districts that are
subject to ORS 243.886, unless their participation is precluded
by federal law.
(2)(a) Only individuals who purchase health plans through the
exchange may be eligible to receive premium tax credits under
section 36B of the Internal Revenue Code and reduced cost-sharing
under 42 U.S.C. 18071.
(b) Only employers that purchase health plans through the
exchange may be eligible to receive small employer health
insurance credits under section 45R of the Internal Revenue Code.
(3) Only an insurer that has a certificate of authority to
transact insurance in this state and that meets applicable
federal requirements for participating in the exchange may offer
a qualified health plan through the exchange. Any qualified
health plan must be certified under subsection (4) of this
section.
{ - Prepaid managed care health services organizations that do
not have a certificate of authority to transact insurance may
serve only medical assistance recipients through the exchange and
may not offer qualified health plans. - }
(4)(a) The Oregon Health Insurance Exchange Corporation shall
adopt by rule uniform requirements, standards and criteria for
the certification of qualified health plans, including
requirements that a qualified health plan provide, at a minimum,
essential health benefits and have acceptable consumer and
provider satisfaction ratings.
(b) The corporation may limit the number of qualified health
plans that may be offered through the exchange as long as the
same limit applies to all insurers.
(c) The corporation shall consult with stakeholders, including
but not limited to representatives of school administrators,
school board members and school employees, regarding the plans
that may be offered through the exchange to districts and
eligible employees of districts under subsection (1)(c) of this
section.
(5) Notwithstanding subsection (4) of this section, the
corporation shall certify as qualified a dental only health plan
as permitted by federal law.
(6) The corporation shall establish one streamlined and
seamless application and enrollment process for both the exchange
and the state medical assistance program.
(7) The corporation, in collaboration with the appropriate
state authorities, may establish risk mediation programs within
the exchange.
(8) The corporation shall establish by rule a process for
certifying insurance producers to facilitate the transaction of
insurance through the exchange, in accordance with federal
standards and policies.
(9) The corporation shall ensure, as required by federal laws,
that an insurer charges the same premiums for plans sold through
the exchange as for identical plans sold outside of the exchange.
(10) The corporation is authorized to enter into contracts for
the performance of duties, functions or operations of the
exchange, including but not limited to contracting with:
(a) Insurers that meet the requirements of subsections (3) and
(4) of this section, to offer qualified health plans through the
exchange; and
(b) Navigators certified by the corporation under ORS 741.002.
(11) The corporation is authorized to apply for and accept
federal grants, other federal funds and grants from
nongovernmental organizations for purposes of developing,
implementing and administering the exchange. Moneys received
under this subsection shall be deposited in an account
established under ORS 741.101.
SECTION 15. ORS 743.061 is amended to read:
743.061. (1) The Department of Consumer and Business Services
may adopt by rule uniform standards applicable to persons listed
in subsection (2) of this section for health care financial and
administrative transactions, including uniform standards for:
(a) Eligibility inquiry and response;
(b) Claim submission;
(c) Payment remittance advice;
(d) Claims payment or electronic funds transfer;
(e) Claims status inquiry and response;
(f) Claims attachments;
(g) Prior authorization;
(h) Provider credentialing; or
(i) Health care financial and administrative transactions
identified by the stakeholder work group described in ORS
743.062.
(2) Any uniform standards adopted under subsection (1) of this
section apply to:
(a) Health insurers.
{ - (b) Prepaid managed care health services organizations as
defined in ORS 414.736. - }
{ + (b) Dental care organizations. + }
(c) Third party administrators.
(d) Any person or public body that either individually or
jointly establishes a self-insurance plan, program or contract,
including but not limited to persons and public bodies that are
otherwise exempt from the Insurance Code under ORS 731.036.
(e) Health care clearinghouses or other entities that process
or facilitate the processing of health care financial and
administrative transactions from a nonstandard format to a
standard format.
(f) Any other person identified by the department that
processes health care financial and administrative transactions
between a health care provider and an entity described in this
subsection.
(3) In developing or updating any uniform standards adopted
under subsection (1) of this section, the department shall
consider recommendations from the Oregon Health Authority under
ORS 743.062.
SECTION 16. ORS 743.847 is amended to read:
743.847. (1) For the purposes of this section:
(a) 'Health insurer' or 'insurer' means an employee benefit
plan, self-insured plan, managed care organization or group
health plan, a third party administrator, fiscal intermediary or
pharmacy benefit manager of the plan or organization, or other
party that is by statute, contract or agreement legally
responsible for payment of a claim for a health care item or
service.
{ - (b) 'Medicaid' means medical assistance provided under 42
U.S.C. 1396a (section 1902 of the Social Security Act). - }
{ + (b) 'Medical assistance' has the meaning given that term
in ORS 414.025. + }
(2) A health insurer is prohibited from considering the
availability or eligibility for medical assistance in this
{ - or any other - } state { - under Medicaid - } { + or a
similar program of medical assistance in another state + } when
considering eligibility for coverage or making payments under its
group or individual plan for eligible enrollees, subscribers,
policyholders or certificate holders.
(3) To the extent that payment for covered expenses has been
made under the state { - Medicaid - } { + medical
assistance + } program for health care items or services
furnished to an individual, in any case when a third party has a
legal liability to make payments, the state is considered to have
acquired the rights of the individual to payment by any other
party for those health care items or services.
(4) An insurer may not deny a claim submitted by the
{ - state Medicaid agency, a prepaid managed care health
services - } { + Oregon Health Authority, the Department of
Human Services, a dental care + } organization or a coordinated
care organization described in ORS 414.651 under subsection (3)
of this section based on the date of submission of the claim, the
type or format of the claim form or a failure to present proper
documentation at the point of sale that is the basis of the claim
if:
(a) The claim is submitted by the { - agency - } { +
authority, the department + }, the { - prepaid managed care
health services - } { + dental care + } organization or the
coordinated care organization within the three-year period
beginning on the date on which the health care item or service
was furnished; and
(b) Any action by the { - agency - } { + authority, the
department + }, the
{ - prepaid managed care health services - } { + dental
care + } organization or the coordinated care organization to
enforce its rights with respect to the claim is commenced within
six years of the
{ - agency's or organization's - } submission of the claim.
(5) An insurer must provide to the { - state Medicaid
agency - } { + authority, the department + }, a { - prepaid
managed care health services - } { + dental care + }
organization or a coordinated care organization, upon request,
the following information:
(a) The period during which a { - Medicaid - } { + medical
assistance + } recipient, the spouse or dependents may be or may
have been covered by the plan;
(b) The nature of coverage that is or was provided by the plan;
and
(c) The name, address and identifying numbers of the plan.
(6) An insurer may not deny enrollment of a child under the
group or individual health plan of the child's parent on the
ground that:
(a) The child was born out of wedlock;
(b) The child is not claimed as a dependent on the parent's
federal tax return; or
(c) The child does not reside with the child's parent or in the
insurer's service area.
(7) When a child has group or individual health coverage
through an insurer of a noncustodial parent, the insurer must:
(a) Provide such information to the custodial parent as may be
necessary for the child to obtain benefits through that coverage;
(b) Permit the custodial parent or the provider, with the
custodial parent's approval, to submit claims for covered
services without the approval of the noncustodial parent; and
(c) Make payments on claims submitted in accordance with
paragraph (b) of this subsection directly to the custodial
parent, the provider or, if a claim is filed by the { - state
Medicaid agency - } { + authority, the department + }, a
{ - prepaid managed care health services - } { + dental
care + } organization or a coordinated care organization,
directly to the { - agency - } { + authority, the
department + } or the organization.
(8) When a parent is required by a court or administrative
order to provide health coverage for a child, and the parent is
eligible for family health coverage, the insurer must:
(a) Permit the parent to enroll, under the family coverage, a
child who is otherwise eligible for the coverage without regard
to any enrollment season restrictions;
(b) If the parent is enrolled but fails to make application to
obtain coverage for the child, enroll the child under family
coverage upon application of the child's other parent, the state
agency administering the Medicaid program or the state agency
administering 42 U.S.C. 651 to 669, the child support enforcement
program; and
(c) Not disenroll or eliminate coverage of the child unless the
insurer is provided satisfactory written evidence that:
(A) The court or administrative order is no longer in effect;
or
(B) The child is or will be enrolled in comparable health
coverage through another insurer which will take effect not later
than the effective date of disenrollment.
(9) An insurer may not impose requirements on a state agency
that has been assigned the rights of an individual eligible for
medical assistance { - under Medicaid - } and covered for
health benefits from the insurer if the requirements are
different from requirements applicable to an agent or assignee of
any other individual so covered.
(10) The provisions of ORS 743A.001 do not apply to this
section.
SECTION 17. { + The amendments to ORS 192.493, 192.579,
414.618, 414.645, 414.647, 416.510, 416.540, 741.300, 741.310,
743.061 and 743.847 by sections 3 and 7 to 16 of this 2013 Act
become operative July 1, 2017. + }
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