Bill Text: OR SB382 | 2013 | Regular Session | Enrolled
Bill Title: Relating to prior authorization for prescription drugs; and declaring an emergency.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2013-07-03 - Effective date, July 1, 2013. [SB382 Detail]
Download: Oregon-2013-SB382-Enrolled.html
77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session
Enrolled
Senate Bill 382
Sponsored by Senator BATES (Presession filed.)
CHAPTER ................
AN ACT
Relating to prior authorization for prescription drugs; creating
new provisions; amending ORS 743.801; and declaring an
emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2013 Act is added to and made
a part of the Insurance Code. + }
SECTION 2. { + (1) The Department of Consumer and Business
Services, in consultation with the Oregon Health Authority, shall
develop by rule a form that providers in this state shall use to
request prior authorization for prescription drug benefits. The
form must:
(a) Be uniform for all providers;
(b) Not exceed two pages;
(c) Be electronically available and transmissible; and
(d) Include a provision under which additional information may
be requested and provided.
(2) If a person described in ORS 743.061 (2) requires prior
authorization for prescription drug benefits, the person must
allow the use of the form developed under subsection (1) of this
section.
(3) An insurer meets the requirement set forth in ORS 743.807
(2)(d) if the insurer answers a provider's request for prior
authorization within two business days of having received a
completed form developed under subsection (1) of this section and
all supporting documentation needed to process the request.
(4) The department may adopt rules to implement this
section. + }
SECTION 3. ORS 743.801, as amended by section 5, chapter 24,
Oregon Laws 2012, is amended to read:
743.801. As used in this section and ORS 743.803, 743.804,
743.806, 743.807, 743.808, 743.811, 743.814, 743.817, 743.819,
743.821, 743.823, 743.827, 743.829, 743.831, 743.834, 743.837,
743.839, 743.854, 743.856, 743.857, 743.858, 743.859, 743.861,
743.862, 743.863, 743.864, 743.894, 743.911, 743.912, 743.913,
743.917 and 743.918 { + and section 2 of this 2013 Act + }:
(1) 'Adverse benefit determination' means an insurer's denial,
reduction or termination of a health care item or service, or an
insurer's failure or refusal to provide or to make a payment in
whole or in part for a health care item or service, that is based
on the insurer's:
(a) Denial of eligibility for or termination of enrollment in a
health benefit plan;
Enrolled Senate Bill 382 (SB 382-B) Page 1
(b) Rescission or cancellation of a policy or certificate;
(c) Imposition of a preexisting condition exclusion as defined
in ORS 743.730, source-of-injury exclusion, network exclusion,
annual benefit limit or other limitation on otherwise covered
items or services;
(d) Determination that a health care item or service is
experimental, investigational or not medically necessary,
effective or appropriate; or
(e) Determination that a course or plan of treatment that an
enrollee is undergoing is an active course of treatment for
purposes of continuity of care under ORS 743.854.
(2) 'Authorized representative' means an individual who by law
or by the consent of a person may act on behalf of the person.
(3) 'Enrollee' has the meaning given that term in ORS 743.730.
(4) 'Grievance' means:
(a) A communication from an enrollee or an authorized
representative of an enrollee expressing dissatisfaction with an
adverse benefit determination, without specifically declining any
right to appeal or review, that is:
(A) In writing, for an internal appeal or an external review;
or
(B) In writing or orally, for an expedited response described
in ORS 743.804 (2)(d) or an expedited external review; or
(b) A written complaint submitted by an enrollee or an
authorized representative of an enrollee regarding the:
(A) Availability, delivery or quality of a health care service;
(B) Claims payment, handling or reimbursement for health care
services and, unless the enrollee has not submitted a request for
an internal appeal, the complaint is not disputing an adverse
benefit determination; or
(C) Matters pertaining to the contractual relationship between
an enrollee and an insurer.
(5) 'Health benefit plan' has the meaning given that term in
ORS 743.730.
(6) 'Independent practice association' means a corporation
wholly owned by providers, or whose membership consists entirely
of providers, formed for the sole purpose of contracting with
insurers for the provision of health care services to enrollees,
or with employers for the provision of health care services to
employees, or with a group, as described in ORS 743.522, to
provide health care services to group members.
(7) 'Insurer' includes a health care service contractor as
defined in ORS 750.005.
(8) 'Internal appeal' means a review by an insurer of an
adverse benefit determination made by the insurer.
(9) 'Managed health insurance' means any health benefit plan
that:
(a) Requires an enrollee to use a specified network or networks
of providers managed, owned, under contract with or employed by
the insurer in order to receive benefits under the plan, except
for emergency or other specified limited service; or
(b) In addition to the requirements of paragraph (a) of this
subsection, offers a point-of-service provision that allows an
enrollee to use providers outside of the specified network or
networks at the option of the enrollee and receive a reduced
level of benefits.
(10) 'Medical services contract' means a contract between an
insurer and an independent practice association, between an
insurer and a provider, between an independent practice
association and a provider or organization of providers, between
Enrolled Senate Bill 382 (SB 382-B) Page 2
medical or mental health clinics, and between a medical or mental
health clinic and a provider to provide medical or mental health
services. 'Medical services contract' does not include a contract
of employment or a contract creating legal entities and ownership
thereof that are authorized under ORS chapter 58, 60 or 70, or
other similar professional organizations permitted by statute.
(11)(a) 'Preferred provider organization insurance' means any
health benefit plan that:
(A) Specifies a preferred network of providers managed, owned
or under contract with or employed by an insurer;
(B) Does not require an enrollee to use the preferred network
of providers in order to receive benefits under the plan; and
(C) Creates financial incentives for an enrollee to use the
preferred network of providers by providing an increased level of
benefits.
(b) 'Preferred provider organization insurance' does not mean a
health benefit plan that has as its sole financial incentive a
hold harmless provision under which providers in the preferred
network agree to accept as payment in full the maximum allowable
amounts that are specified in the medical services contracts.
(12) 'Prior authorization' means a determination by an insurer
prior to provision of services that the insurer will provide
reimbursement for the services. 'Prior authorization ' does not
include referral approval for evaluation and management services
between providers.
(13) 'Provider' means a person licensed, certified or otherwise
authorized or permitted by laws of this state to administer
medical or mental health services in the ordinary course of
business or practice of a profession.
(14) 'Utilization review' means a set of formal techniques used
by an insurer or delegated by the insurer designed to monitor the
use of or evaluate the medical necessity, appropriateness,
efficacy or efficiency of health care services, procedures or
settings.
SECTION 4. { + (1) Section 2 of this 2013 Act and the
amendments to ORS 743.801 by section 3 of this 2013 Act become
operative on July 1, 2015.
(2) The Department of Consumer and Business Services and the
Oregon Health Authority may take any action before the operative
date specified in subsection (1) of this section that is
necessary to enable the department and the authority to exercise,
on and after the operative date specified in subsection (1) of
this section, all the duties, functions and powers conferred on
the department and the authority by section 2 of this 2013 Act
and the amendments to ORS 743.801 by section 3 of this 2013
Act. + }
SECTION 5. { + This 2013 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2013 Act takes effect on its
passage. + }
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Enrolled Senate Bill 382 (SB 382-B) Page 3
Passed by Senate June 19, 2013
.............................................................
Robert Taylor, Secretary of Senate
.............................................................
Peter Courtney, President of Senate
Passed by House June 24, 2013
.............................................................
Tina Kotek, Speaker of House
Enrolled Senate Bill 382 (SB 382-B) Page 4
Received by Governor:
......M.,............., 2013
Approved:
......M.,............., 2013
.............................................................
John Kitzhaber, Governor
Filed in Office of Secretary of State:
......M.,............., 2013
.............................................................
Kate Brown, Secretary of State
Enrolled Senate Bill 382 (SB 382-B) Page 5
