Bill Text: OR SB214 | 2011 | Regular Session | Introduced
Bill Title: Relating to provider claims for health services to medical assistance recipients; declaring an emergency.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Failed) 2011-06-30 - In committee upon adjournment. [SB214 Detail]
Download: Oregon-2011-SB214-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 2677
Senate Bill 214
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 reconcile claims made by
and payments due to prepaid managed care health services
organizations no later than 90 days after effective date of Act
and to pay claims identified within 30 days. Requires authority
to adopt rules to ensure payment of all claims for health
services within 90 days of date claim is submitted.
Declares emergency, effective on passage.
A BILL FOR AN ACT
Relating to provider claims for health services to medical
assistance recipients; creating new provisions; amending ORS
414.065 and 414.736; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + (1) As used in this section:
(a) 'Health services' has the meaning given that term in ORS
414.705.
(b) 'Medical assistance recipient' includes any individual who:
(A) On the date a health service was provided, was shown in the
Medicaid management information system to be eligible for medical
assistance;
(B) On the date a health service was provided, a prepaid
managed care health services organization had been notified by
the Oregon Health Authority or the Department of Human Services
that the individual was eligible for medical assistance;
(C) Applied for medical assistance after the date that a health
service was provided to the individual, but was later determined
by the authority or the department to be eligible for medical
assistance retroactive to the date the service was provided; or
(D) Was eligible for medical assistance on the date the health
service was provided to the individual, but was later determined
by the authority or the department to be ineligible for medical
assistance on the date the service was provided.
(2) The Oregon Health Authority shall, no later than 90 days
after the effective date of this 2011 Act, reconcile all claims
made by and all payments due to a prepaid managed care health
services organization for health services or coverage provided by
the organization to a medical assistance recipient between
December 9, 2008, and the date that is 90 days after the
effective date of this 2011 Act. All claims and payments due
shall be paid no later than 30 days after the claims or payments
are identified in the reconciliation. The authority shall
contract with an independent auditor to certify the completeness
and accuracy of the reconciliation. + }
SECTION 2. ORS 414.065 is amended to read:
414.065. (1)(a) With respect to medical and remedial care and
services to be provided in medical assistance during any period,
and within the limits of funds available therefor, the Oregon
Health Authority shall determine, subject to such revisions as it
may make from time to time and with respect to the 'health
services' defined in ORS 414.705, subject to legislative funding
in response to the report of the Health Services Commission and
paragraph (b) of this subsection:
(A) The types and extent of medical and remedial care and
services to be provided to each eligible group of recipients of
medical assistance.
(B) Standards to be observed in the provision of medical and
remedial care and services.
(C) The number of days of medical and remedial care and
services toward the cost of which public assistance funds will be
expended in the care of any person.
(D) Reasonable fees, charges and daily rates to which public
assistance funds will be applied toward meeting the costs of
providing medical and remedial care and services to an applicant
or recipient.
(E) Reasonable fees for professional medical and dental
services which may be based on usual and customary fees in the
locality for similar services.
(F) The amount and application of any copayment or other
similar cost-sharing payment that the authority may require a
recipient to pay toward the cost of medical and remedial care or
services.
(b) { - Notwithstanding ORS 414.720 (8) - } { + Except as
provided in ORS 414.135 + }, the authority shall adopt rules
establishing timelines for payment of health services under
paragraph (a) of this subsection { + that ensure payment of all
claims no later than 90 days after the date a claim is
submitted + }.
(2) The types and extent of medical and remedial care and
services and the amounts to be paid in meeting the costs thereof,
as determined and fixed by the authority and within the limits of
funds available therefor, shall be the total available for
medical assistance and payments for such medical assistance shall
be the total amounts from public assistance funds available to
providers of medical and remedial care and services in meeting
the costs thereof.
(3) Except for payments under a cost-sharing plan, payments
made by the authority for medical assistance shall constitute
payment in full for all medical and remedial care and services
for which such payments of medical assistance were made.
(4) Medical benefits, standards and limits established pursuant
to subsection (1)(a)(A), (B) and (C) of this section for the
eligible medically needy, except for persons receiving assistance
under ORS 411.706, may be less than but may not exceed medical
benefits, standards and limits established for the eligible
categorically needy, except that, in the case of a research and
demonstration project entered into under ORS 411.135, medical
benefits, standards and limits for the eligible medically needy
may exceed those established for specific eligible groups of the
categorically needy.
SECTION 3. ORS 414.736 is amended to read:
414.736. As used in this section and ORS 414.725, 414.737,
414.738, 414.739, 414.740, 414.741 { - , 414.742 and 414.743 - }
{ + and 414.742 + } and section 9, chapter 867, Oregon Laws
2009 { + , and section 1 of this 2011 Act + }:
(1) 'Designated area' means a geographic area of the state
defined by the Oregon Health Authority by rule that is served by
a prepaid managed care health services organization.
(2) 'Fully capitated health plan' means an organization that
contracts with the Oregon Health Authority or the Oregon Health
Policy Board on a prepaid capitated basis under ORS 414.725 to
provide an adequate network of providers to ensure that the
health services provided under the contract are reasonably
accessible to enrollees.
(3) 'Physician care organization' means an organization that
contracts with the Oregon Health Authority or the Oregon Health
Policy Board on a prepaid capitated basis under ORS 414.725 to
provide an adequate network of providers to ensure that the
health services described in ORS 414.705 (1)(b), (c), (d), (e),
(g) and (j) are reasonably accessible to enrollees. A physician
care organization may also contract with the authority or the
board on a prepaid capitated basis to provide the health services
described in ORS 414.705 (1)(k) and (L).
(4) 'Prepaid managed care health services organization ' means
a managed physical health, dental, mental health or chemical
dependency organization that contracts with the authority or the
board on a prepaid capitated basis under ORS 414.725. A prepaid
managed care health services organization may be a dental care
organization, fully capitated health plan, physician care
organization, mental health organization or chemical dependency
organization.
SECTION 4. ORS 414.736, as amended by section 6, chapter 886,
Oregon Laws 2009, is amended to read:
414.736. As used in this section and ORS 414.725, 414.737,
414.738, 414.739, 414.740, 414.741 and 414.742 and section 9,
chapter 867, Oregon Laws 2009 { + , and section 1 of this 2011
Act + }:
(1) 'Designated area' means a geographic area of the state
defined by the Oregon Health Authority by rule that is served by
a prepaid managed care health services organization.
(2) 'Fully capitated health plan' means an organization that
contracts with the Oregon Health Authority or the Oregon Health
Policy Board on a prepaid capitated basis under ORS 414.725 to
provide an adequate network of providers to ensure that the
health services provided under the contract are reasonably
accessible to enrollees.
(3) 'Physician care organization' means an organization that
contracts with the Oregon Health Authority or the Oregon Health
Policy Board on a prepaid capitated basis under ORS 414.725 to
provide an adequate network of providers to ensure that the
health services described in ORS 414.705 (1)(b), (c), (d), (e),
(g) and (j) are reasonably accessible to enrollees. A physician
care organization may also contract with the authority or the
board on a prepaid capitated basis to provide the health services
described in ORS 414.705 (1)(k) and (L).
(4) 'Prepaid managed care health services organization ' means
a managed physical health, dental, mental health or chemical
dependency organization that contracts with the authority or the
board on a prepaid capitated basis under ORS 414.725. A prepaid
managed care health services organization may be a dental care
organization, fully capitated health plan, physician care
organization, mental health organization or chemical dependency
organization.
SECTION 5. { + This 2011 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2011 Act takes effect on its
passage. + }
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