76th OREGON LEGISLATIVE ASSEMBLY--2012 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 19
A-Engrossed
House Bill 4127
Ordered by the House February 9
Including House Amendments dated February 9
Sponsored by Representatives HOYLE, WEIDNER; Representatives
BEYER, DEMBROW, DOHERTY, FREDERICK, GELSER, SCHAUFLER
(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.
Requires Oregon Health Authority to adopt standards and
procedures to certify specified mental health providers to
qualify for insurance reimbursement. { + Authorizes authority to
adopt fee for such certification and for applying for such
certification. + }
Declares emergency, effective on passage.
A BILL FOR AN ACT
Relating to certification of mental health providers; amending
ORS 743A.168; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. 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.
(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 { + as defined in ORS
430.010 + };
(B) A residential { - program or - } facility { + as
defined in ORS 430.010 + };
(C) A day or partial hospitalization program { + as defined in
ORS 430.010 + };
(D) An outpatient service { + as defined in ORS 430.010 + };
{ - or - }
(E) An individual behavioral health or medical professional
{ - authorized for reimbursement under Oregon law. - } { +
licensed or certified under Oregon law; or
(F) A provider organization certified by the Oregon Health
Authority under subsection (13) of this section. + }
(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 { + or certified + } by the
Department of Human Services { + or the 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.
(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
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 Oregon Health Authority shall establish a
process for the certification of an organization described in
subsection (1)(e)(F) of this section that:
(a) Is not otherwise subject to licensing or certification by
the authority; and
(b) Does not contract with the authority, a subcontractor of
the authority or a community mental health program.
(14) The Oregon Health Authority shall adopt by rule standards
for the certification provided under subsection (13) of this
section to ensure that a certified provider offers a distinct and
specialized program for the treatment of chemical dependency or
for mental or nervous conditions.
(15) The Oregon Health Authority may adopt by rule an
application fee or a certification fee, or both, to be imposed on
any provider organization that applies for certification under
subsection (13) of this section. Any fees collected shall be paid
into the Oregon Health Authority Fund established in ORS 413.101
and shall be used only for carrying out the provisions of
subsection (13) of this section. + }
{ - (13) - } { + (16) + } 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) - } { + (17) + } The Director of the Department of
Consumer and Business Services { + and the Oregon Health
Authority + }, after notice and hearing, may adopt reasonable
rules not inconsistent with this section that are considered
necessary for the proper administration of { - these
provisions - } { + this section + }.
SECTION 2. { + This 2012 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2012 Act takes effect on its
passage. + }
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