Bill Text: OR SB850 | 2011 | Regular Session | Introduced
Bill Title: Relating to primary care reimbursement rates.
Sponsorship: Committee Bill
Status: (Failed) 2011-06-30 - In committee upon adjournment. [SB850 Detail]
Download: Oregon-2011-SB850-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 1317
Senate Bill 850
Sponsored by COMMITTEE ON HEALTH CARE, HUMAN SERVICES AND RURAL
HEALTH POLICY
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.
Specifies minimum reimbursement rate for primary care
practitioner services provided under health benefit plan or to
medical assistance recipient.
A BILL FOR AN ACT
Relating to primary care reimbursement rates; creating new
provisions; and amending ORS 743.801.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2011 Act is added to and made
a part of the Insurance Code. + }
SECTION 2. { + (1) As used in this section:
(a) 'Primary care rate' means the rate established by the
Oregon Health Authority under section 3 of this 2011 Act.
(b) 'Relative value unit' means the value for a service that is
established by the Centers for Medicare and Medicaid Services
pursuant to 42 C.F.R. 414.22 and 414.24.
(2) All insurers offering a health benefit plan in this state
shall reimburse primary care practitioners at a rate no less than
the primary care rate multiplied by the relative value unit for
the service. + }
SECTION 3. { + (1) As used in this section:
(a) 'Relative value unit' means the value for a service that is
established by the Centers for Medicare and Medicaid Services
pursuant to 42 C.F.R. 414.22 and 414.24.
(b) 'Prepaid managed care health services organization' has the
meaning given that term in ORS 414.736.
(c) 'Primary care practitioner' means:
(A) A nurse practitioner who is certified by the Oregon State
Board of Nursing under ORS 678.375 and who is acting within the
scope of practice for a nurse practitioner;
(B) A naturopathic physician licensed under ORS 685.020 who is
acting within the scope of practice for a naturopathic physician;
or
(C) A physician licensed under ORS chapter 677 whose specialty
is family practice, general practice, internal medicine,
pediatrics or obstetrics and gynecology.
(2) All primary care practitioners that provide services to
medical assistance recipients and who are paid on a
fee-for-service basis by the Oregon Health Authority or by a
prepaid managed care health services organization shall be
reimbursed an amount no less than the relative value unit for the
service multiplied by 110 percent of the primary care rate.
(3) The primary care rate for 2012 is $75. Beginning in 2013,
the Oregon Health Authority shall adjust the primary care rate
annually using the increase or decrease in the cost of living for
the previous calendar year, based on changes in the
Portland-Salem, OR-WA Consumer Price Index for All Urban
Consumers for All Items as published by the Bureau of Labor
Statistics of the United States Department of Labor. + }
SECTION 4. { + Sections 2 and 3 of this 2011 Act apply to
payments for services rendered by primary care practitioners
under contracts or agreements with insurers or with the Oregon
Health Authority that are entered into on or after the effective
date of this 2011 Act. + }
SECTION 5. ORS 743.801 is amended to read:
743.801. As used in ORS 743.801, 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, 743.911, 743.912, 743.913, 743.917, 743.918 and
743A.012 { + and section 2 of this 2011 Act + }:
(1) 'Emergency medical condition' means a medical condition
that manifests itself by acute symptoms of sufficient severity,
including severe pain, that a prudent layperson possessing an
average knowledge of health and medicine would reasonably expect
that failure to receive immediate medical attention would place
the health of a person, or a fetus in the case of a pregnant
woman, in serious jeopardy.
(2) 'Emergency medical screening exam' means the medical
history, examination, ancillary tests and medical determinations
required to ascertain the nature and extent of an emergency
medical condition.
(3) 'Emergency services' means those health care items and
services furnished in an emergency department and all ancillary
services routinely available to an emergency department to the
extent they are required for the stabilization of a patient.
(4) 'Enrollee' has the meaning given that term in ORS 743.730.
(5) 'Grievance' means a written complaint submitted by or on
behalf of an enrollee regarding the:
(a) Availability, delivery or quality of health care services,
including a complaint regarding an adverse determination made
pursuant to utilization review;
(b) Claims payment, handling or reimbursement for health care
services; or
(c) Matters pertaining to the contractual relationship between
an enrollee and an insurer.
(6) 'Health benefit plan' has the meaning provided for that
term in ORS 743.730.
(7) '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.
(8) 'Insurer' has the meaning provided for that term in ORS
731.106. For purposes of ORS 743.801, 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, 743.911, 743.912, 743.913, 743.917, 743A.012,
750.055 and 750.333, 'insurer' also includes a health care
service contractor as defined in ORS 750.005.
(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
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) 'Primary care practitioner' means:
(a) A nurse practitioner who is certified by the Oregon State
Board of Nursing under ORS 678.375 and who is acting within the
scope of practice for a nurse practitioner;
(b) A naturopathic physician licensed under ORS 685.020 who is
acting within the scope of practice for a naturopathic physician;
or
(c) A physician licensed under ORS chapter 677 whose specialty
is family practice, general practice, internal medicine,
pediatrics or obstetrics and gynecology. + }
{ - (12) - } { + (13) + } '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) - } { + (14) + } '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) - } { + (15) + } 'Stabilization' means that,
within reasonable medical probability, no material deterioration
of an emergency medical condition is likely to occur.
{ - (15) - } { + (16) + } '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.
----------
