Bill Text: OR SB1523 | 2012 | Regular Session | Introduced
Bill Title: Relating to health insurance reimbursement.
Sponsorship: Unknown
Status: (Failed) 2012-03-05 - In committee upon adjournment. [SB1523 Detail]
Download: Oregon-2012-SB1523-Introduced.html
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 237
Senate Bill 1523
Printed pursuant to Senate Interim Rule 213.28 by order of the
President of the Senate in conformance with presession filing
rules, indicating neither advocacy nor opposition on the part
of the President (at the request of Senate Interim Committee on
General Government, Consumer and Small Business Protection for
the Oregon Ambulatory Surgery Center Association)
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 insurers to reimburse providers directly for health
care service provided to insureds if provider agrees that payment
constitutes payment in full for service other than amounts for
which insured is responsible. If provider does not agree to
accept payment as payment in full from insurer, insurer may, at
insurer's option and unless otherwise requested by insured, make
payment to insured or to provider.
A BILL FOR AN ACT
Relating to health insurance reimbursement; creating new
provisions; and amending ORS 743.435, 743.531, 743.543,
743.550, 743A.014, 743A.024 and 743A.048.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2012 Act is added to and made
a part of the Insurance Code. + }
SECTION 2. { + (1) As used in this section, 'indemnity payment
' means a payment equal to an insurer's allowable charge for a
service minus any copayment, deductible, coinsurance or other
amount that is the responsibility of the insured.
(2) An insurer shall pay indemnities for the cost of a
hospital, nursing, medical or surgical service under a
certificate or policy of health insurance to any provider of the
service that agrees to accept the insurer's indemnity payment as
payment in full from the insurer for the service.
(3) If a provider does not agree to accept an insurer's
indemnity payment as payment in full from the insurer for a
service and may seek additional reimbursement from the insured,
the insurer shall make the payment as requested by the
policyholder or insured or, if the policyholder or insured has
not made such a request, to the insured or to the provider at the
insurer's option. + }
SECTION 3. ORS 743.435 is amended to read:
743.435. (1) A health insurance policy shall contain a
provision as follows: 'PAYMENT OF CLAIMS: Indemnity for loss of
life will be payable in accordance with the beneficiary
designation and the provisions respecting such payment which may
be prescribed herein and effective at the time of payment. If no
such designation or provision is then effective, such indemnity
shall be payable to the estate of the insured. Any other accrued
indemnities unpaid at the insured's death may, at the option of
the insurer, be paid either to such beneficiary or to such
estate. All other indemnities will be payable to the insured. '
(2) The following provisions, or either of them, may be
included with the provision set forth in subsection (1) of this
section at the option of the insurer:
(a) 'If any indemnity of this policy shall be payable to the
estate of the insured, or to an insured or beneficiary who is a
minor or otherwise not competent to give a valid release, the
insurer may pay such indemnity, up to an amount not exceeding $__
(insert an amount which shall not exceed $1,000), to any relative
by blood or connection by marriage of the insured or beneficiary
who is deemed by the insurer to be equitably entitled thereto.
Any payment made by the insurer in good faith pursuant to this
provision shall fully discharge the insurer to the extent of such
payment. '
(b) ' { - Subject to any written direction of the insured in
the application or otherwise all or a portion of Any indemnities
provided by this policy on account of - } { + The insurer must
pay a provider directly for indemnities owed the provider for + }
hospital, nursing, medical or surgical services { + , other than
copayments, deductibles, coinsurance or other amounts that are
the responsibility of the insured, if the provider agrees to
accept the indemnity payment as payment in full from the insurer
for the services. If the provider does not agree to accept the
payment as payment in full from the insurer and may seek
additional reimbursement from the insured, the insurer + } may,
at the insurer's option and unless the insured requests otherwise
in writing not later than the time of filing proofs of such loss,
{ - be paid - } { + make payment to the insured or + }
directly to the hospital or person rendering such services; but
it is not required that the service be rendered by a particular
hospital or person. '
SECTION 4. ORS 743.531 is amended to read:
743.531. { - (1) A group health insurance policy may on
request by the group policyholder provide 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. - }
{ - (2) Nothing in this section is intended to authorize an
insurer to: - }
{ - (a) Furnish or provide directly services of hospitals or
physicians and surgeons; or - }
{ - (b) Direct, participate in or control the selection of
the specific hospital or physician and surgeon from whom the
insured secures services or who exercises medical or dental
professional judgment. - }
{ - (3) - } { + (1) + } { - Nothing in subsection (2) of
this section prevents an insurer from negotiating and
entering - } { + An insurer may negotiate and enter + } into
contracts for alternative rates of payment with providers { + to
provide services covered by a group health insurance policy + }
and { - offering - } { + may 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,
unless such services were requested by a member of such
organization or are rendered as the result of an emergency.
{ - (4) - } { + (2) + } { - Payment so made - }
{ + Benefits paid by an insurer to a provider under subsection
(1) of this section + } shall discharge the insurer's obligation
with respect to the amount of insurance so paid.
{ - (5) - } { + (3) + } Insurers shall provide group
policyholders with a current roster of institutional and
professional providers under contract to provide services at
alternative rates under their 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.
SECTION 5. ORS 743.543 is amended to read:
743.543. { + (1) Except as provided in subsection (2) of this
section, + } all benefits under a blanket health insurance policy
shall be payable to the person insured, or to the designated
beneficiary or beneficiaries of the person, or to the estate of
the person, except that if the person insured is a minor or
otherwise not competent to give a valid release, such benefits
may be made payable to the parent, guardian or other person
actually supporting the person. { - However, the - } { +
(2) A + } policy { - may - } { + must + } provide that all
or a portion of any indemnities provided by such policy on
account of hospital, nursing, medical or surgical
services { + , + } { - may, at the option of the insurer and
unless the insured requests otherwise in writing not later than
the time of filing proofs of such loss, - } { + other than
copayments, deductibles, coinsurance or other amounts that are
the responsibility of the insured, shall + } be paid directly to
the hospital or person rendering such services { + if the
hospital or person agrees to accept the indemnity payment as
payment in full from the insurer for the service. + } { - ;
but - } The policy may not require that the services be rendered
by a particular hospital or person. { + If the hospital or
person does not agree to accept the payment as payment in full
from the insurer for the service and may seek additional
reimbursement from the insured, the insurer may, at the insurer's
option and unless the insured requests otherwise in writing not
later than the time of filing proofs of such loss, make the
payment to the insured or to the hospital or person. Payments
made in accordance with this section + } { - Payment so
made - } shall discharge the obligation of the insurer with
respect to the amount of insurance so paid.
SECTION 6. 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, 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) - } { + (7) + } 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, unless such services were requested by a member of
such organization or are rendered as the result of an emergency.
{ - (9) - } { + (8) + } Payments made under subsection
{ - (8) - } { + (7) + } of this section shall discharge the
insurer's obligation with respect to the amount of insurance
paid.
{ - (10) - } { + (9) + } 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) - } { + (10) + } As used in this section, 'student
health insurance' 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.
SECTION 7. ORS 743A.014 is amended to read:
743A.014. Any insurance policy issued or issued for delivery in
this state that provides coverage for ambulance care and
transportation shall provide that payments will be made
{ - jointly - } { + directly + } to the provider of the
ambulance care and transportation
{ - and to the insured, unless the policy provides for direct
payment to the provider - } { + if the provider agrees to
accept the payment as payment in full from the insurer for the
ambulance care and transportation. If the provider does not agree
to accept the payment as payment in full for the service and may
seek additional reimbursement from the insured, other than
copayments, deductibles, coinsurance or other amounts that are
the responsibility of the insured, the payment shall be made
jointly to the provider of the ambulance care and transportation
and to the insured + }.
SECTION 8. ORS 743A.024 is amended to read:
743A.024. Whenever any individual or group health insurance
policy or blanket health insurance policy described in ORS
743.534 (3) provides for payment or reimbursement for any service
within the lawful scope of service of a clinical social worker
licensed under ORS 675.530:
(1) The insured under the policy shall be entitled to the
services of a clinical social worker licensed under ORS 675.530,
upon referral by a physician or psychologist.
(2) { - The insured under the policy shall be entitled to
have Payment or reimbursement made to the insured or on behalf of
the insured for the services performed. - } The payment or
reimbursement { + for the services of a clinical social
worker + } shall be in accordance with the benefits provided in
the policy and shall be computed in the same manner whether
performed by a physician, by a psychologist or by a clinical
social worker, according to the customary and usual fee of
clinical social workers in the area served.
SECTION 9. ORS 743A.048 is amended to read:
743A.048. Whenever any provision of any individual or group
health insurance policy or contract provides for payment or
reimbursement for any service which is within the lawful scope of
a psychologist licensed under ORS 675.010 to 675.150:
(1) The insured under such policy or contract shall be free to
select, and shall have direct access to, a psychologist licensed
under ORS 675.010 to 675.150, without supervision or referral by
a physician or another health practitioner, and wherever such
psychologist is authorized to practice.
(2) { - The insured under such policy or contract shall be
entitled to have payment or reimbursement made to the insured or
on the insured's behalf for the services performed. Such - }
{ + The + } payment or reimbursement { + for the services of
the psychologist + } shall be in accordance with the benefits
provided in the policy and shall be the same whether performed by
a physician or a psychologist licensed under ORS 675.010 to
675.150.
SECTION 10. { + Section 2 of this 2012 Act and the amendments
to ORS 743.435, 743.531, 743.543, 743.550, 743A.014, 743A.024 and
743A.048 by sections 3 to 9 of this 2012 Act apply to indemnities
paid on claims presented on or after the effective date of this
2012 Act. + }
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