Bill Text: OR SB211 | 2011 | Regular Session | Introduced
Bill Title: Relating to prepaid managed care health services organizations.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Failed) 2011-06-30 - In committee upon adjournment. [SB211 Detail]
Download: Oregon-2011-SB211-Introduced.html
76th OREGON LEGISLATIVE ASSEMBLY--2011 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 2674
Senate Bill 211
Sponsored by Senator BATES (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 give preference in
contracting to prepaid managed care health services organizations
that are community focused, have experience with medical
assistance recipients and have established relationships with
provider networks.
A BILL FOR AN ACT
Relating to prepaid managed care health services organizations;
creating new provisions; and amending ORS 414.725.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 414.725 is amended to read:
414.725. (1)(a) Pursuant to rules adopted by the Oregon Health
Authority, the authority shall execute prepaid managed care
health services contracts for health services funded by the
Legislative Assembly. The contract must require that all services
are provided to the extent and scope of the Health Services
Commission's report for each service provided under the contract.
The contracts are not subject to ORS chapters 279A and 279B,
except ORS 279A.250 to 279A.290 and 279B.235. Notwithstanding ORS
414.720 (8), the rules adopted by the authority shall establish
timelines for executing the contracts described in this
paragraph.
(b) { - It is the intent of ORS 414.705 to 414.750 that the
state use, - } To the greatest extent possible, { + the
authority shall contract with + } prepaid managed care health
services organizations to provide physical health, dental, mental
health and chemical dependency services under ORS 414.705 to
414.750. { + The authority shall give preference to prepaid
managed care health services organizations that:
(A) Are community focused;
(B) Have proven competency and success in serving the specific
needs of recipients of medical assistance;
(C) Have experience and an established relationship with the
networks of providers serving recipients of medical assistance;
and
(D) Have an infrastructure that adapts to changes in the needs
of a community. + }
(c) The authority shall solicit qualified providers or plans to
be reimbursed for providing the covered services. The contracts
may be with hospitals and medical organizations, health
maintenance organizations, managed health care plans and any
other qualified public or private prepaid managed care health
services organization. The authority may not discriminate against
any contractors that offer services within their providers'
lawful scopes of practice.
(d) The authority shall establish annual financial reporting
requirements for prepaid managed care health services
organizations. The authority shall prescribe a reporting
procedure that elicits sufficiently detailed information for the
authority to assess the financial condition of each prepaid
managed care health services organization and that includes
information on the three highest executive salary and benefit
packages of each prepaid managed care health services
organization.
(e) The authority shall require compliance with the provisions
of paragraph (d) of this subsection as a condition of entering
into a contract with a prepaid managed care health services
organization.
(f)(A) The authority shall adopt rules and procedures to ensure
that a rural health clinic that provides a health service to an
enrollee of a prepaid managed care health services organization
receives total aggregate payments from the organization, other
payers on the claim and the authority that are no less than the
amount the rural health clinic would receive in the authority's
fee-for-service payment system. The authority shall issue a
payment to the rural health clinic in accordance with this
subsection within 45 days of receipt by the authority of a
completed billing form.
(B) 'Rural health clinic,' as used in this paragraph, shall be
defined by the authority by rule and shall conform, as far as
practicable or applicable in this state, to the definition of
that term in 42 U.S.C. 1395x(aa)(2).
(2) The authority may institute a fee-for-service case
management system or a fee-for-service payment system for the
same physical health, dental, mental health or chemical
dependency services provided under the health services contracts
for persons eligible for health services under ORS 414.705 to
414.750 in designated areas of the state in which a prepaid
managed care health services organization is not able to assign
an enrollee to a person or entity that is primarily responsible
for coordinating the physical health, dental, mental health or
chemical dependency services provided to the enrollee. In
addition, the authority may make other special arrangements as
necessary to increase the interest of providers in participation
in the state's managed care system, including but not limited to
the provision of stop-loss insurance for providers wishing to
limit the amount of risk they wish to underwrite.
(3) As provided in subsections (1) and (2) of this section, the
aggregate expenditures by the authority for health services
provided pursuant to ORS 414.705 to 414.750 may not exceed the
total dollars appropriated for health services under ORS 414.705
to 414.750.
(4) Actions taken by providers, potential providers,
contractors and bidders in specific accordance with ORS 414.705
to 414.750 in forming consortiums or in otherwise entering into
contracts to provide health care services shall be performed
pursuant to state supervision and shall be considered to be
conducted at the direction of this state, shall be considered to
be lawful trade practices and may not be considered to be the
transaction of insurance for purposes of the Insurance Code.
(5) Health care providers contracting to provide services under
ORS 414.705 to 414.750 shall advise a patient of any service,
treatment or test that is medically necessary but not covered
under the contract if an ordinarily careful practitioner in the
same or similar community would do so under the same or similar
circumstances.
(6) A prepaid managed care health services organization shall
provide information on contacting available providers to an
enrollee in writing within 30 days of assignment to the health
services organization.
(7) Each prepaid managed care health services organization
shall provide upon the request of an enrollee or prospective
enrollee annual summaries of the organization's aggregate data
regarding:
(a) Grievances and appeals; and
(b) Availability and accessibility of services provided to
enrollees.
(8) A prepaid managed care health services organization may not
limit enrollment in a designated area based on the zip code of an
enrollee or prospective enrollee.
SECTION 2. { + The amendments to ORS 414.725 by section 1 of
this 2011 Act apply to contracts entered into or extended by the
Oregon Health Authority with prepaid managed care health services
organizations on or after the effective date of this 2011
Act. + }
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