71st OREGON LEGISLATIVE ASSEMBLY--2001 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 2238
House Bill 2497
Sponsored by Representative KRUSE
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.
Creates three-year pilot program requiring recipients of
services under Oregon Health Plan to make copayments based on
federal regulations.
Prescribes operative dates.
A BILL FOR AN ACT
Relating to Oregon Health Plan; creating new provisions; and
amending ORS 414.065 and 414.115.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + (1) The Department of Human Services shall
adopt rules establishing copayments for primary care services
provided under the Oregon Health Plan. The schedule of copayments
shall range from 50 cents to $3 and be based upon federal
regulations. The rules establishing the copayments may allow
for:
(a) Waivers for certain recipients, including but not limited
to children and pregnant women;
(b) Copayment ceilings for recipients with disabilities or
chronic illnesses requiring multiple or frequent treatments; and
(c) Exemptions for certain types of services, including but not
limited to emergency services and prenatal care.
(2) The rules established under subsection (1) of this section
shall address whether a recipient is liable for the copayment
amount for each appointment made, other than an appointment
canceled with at least 24 hours' notice to the provider. + }
SECTION 2. { + (1) The Department of Human Services shall
apply to the federal Health Care Financing Administration for
permission to require a copayment for Oregon Health Plan primary
care services pursuant to section 1 of this 2001 Act.
Notwithstanding sections 1 and 6 of this 2001 Act and the
amendments to ORS 414.065 and 414.115 by sections 4 and 5 of this
2001 Act, the department shall not require a copayment pursuant
to section 1 of this 2001 Act unless the administration grants
permission to require the copayment.
(2) Notwithstanding sections 1 and 6 of this 2001 Act and the
amendments to ORS 414.065 and 414.115 by sections 4 and 5 of this
2001 Act, the department shall not require a copayment pursuant
to section 1 of this 2001 Act if the primary care services are
provided more than two years after the date that the
administration first grants permission to require a copayment as
described in subsection (1) of this section. + }
SECTION 3. { + The intent of the copayment requirement imposed
by section 1 of this 2001 Act is to reduce the burden on the
Oregon Health Plan resulting from overuse. The pilot program
created by sections 1 and 6 of this 2001 Act is intended to test
the hypothesis that a copayment will reduce unjustified medical
service requests but will not deter a recipient from seeking
justified medical services. + }
SECTION 4. ORS 414.065 is amended to read:
414.065. (1) 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 Department
of Human Services 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:
(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 - } { + the
required + } copayment { + under section 1 of this 2001 Act + }
or { + of any + } other similar cost-sharing payment that the
department may require a recipient to pay toward the cost of
medical and remedial care or services.
(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 department 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 department 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), (b) and (c) of this section for the
eligible medically needy, except for the aged served under ORS
chapter 413 and for the blind and disabled served under ORS
chapter 412, may be less but shall 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.
(5) Notwithstanding the provisions of this section, the
department shall cause Type A hospitals and Type B hospitals, as
defined in ORS 442.470, identified by the Office of Rural Health
as rural hospitals to be reimbursed for the cost of covered
services as follows:
(a) For services provided to persons entitled to receive
medical assistance, based on the Medicare determination of
reasonable cost as derived from the Hospital and Hospital Health
Care Complex Cost Report, referred to as the Medicare Report.
(b) In accordance with the terms of the agreement for services
provided to persons whose medical assistance benefits are
administered by the contracting health care provider under an
agreement between the hospital and a health care provider
contracting with the Department of Human Services under ORS
414.725 (1) for reimbursement other than that specified by ORS
414.727 (1). Hospitals reimbursed under the terms of this
paragraph are entitled to no additional reimbursement for
services provided.
(c) Hospitals that have been reimbursed by health care
providers contracting with the Department of Human Services under
ORS 414.725 (1) in accordance with ORS 414.727 (1), are entitled
to full reimbursement from the department for the cost of covered
services provided to persons whose medical assistance benefits
are administered by the contracting health care provider
according to paragraph (a) of this subsection.
SECTION 5. ORS 414.115 is amended to read:
414.115. (1) In lieu of providing one or more of the medical
and remedial care and services available under medical assistance
by direct payments to providers thereof and in lieu of providing
such medical and remedial care and services made available
pursuant to ORS 414.065, the Department of Human Services shall
use available medical assistance funds to purchase and pay
premiums on policies of insurance, or enter into and pay the
expenses on health care service contracts, or medical or hospital
service contracts that provide one or more of the medical and
remedial care and services available under medical assistance for
the benefit of the categorically needy or the medically needy, or
both. Notwithstanding other specific provisions, the use of
available medical assistance funds to purchase medical or
remedial care and services may provide the following insurance or
contract options:
(a) Differing services or levels of service among groups of
eligibles as defined by rules of the department; and
(b) Services and reimbursement for these services may vary
among contracts and need not be uniform { + except that all
copayment provisions shall comply with rules adopted pursuant to
section 1 of this 2001 Act + }.
(2) The policy of insurance or the contract by its terms, or
the insurer or contractor by written acknowledgment to the
department must guarantee:
(a) To provide medical and remedial care and services of the
type, within the extent and according to standards prescribed
under ORS 414.065;
(b) To pay providers of medical and remedial care and services
the amount due, based on the number of days of care and the fees,
charges and costs established under ORS 414.065, except as to
medical or hospital service contracts which employ a method of
accounting or payment on other than a fee-for-service basis;
(c) To provide medical and remedial care and services under
policies of insurance or contracts in compliance with all laws,
rules and regulations applicable thereto; and
(d) To provide such statistical data, records and reports
relating to the provision, administration and costs of providing
medical and remedial care and services to the department as may
be required by the department for its records, reports and
audits.
SECTION 6. { + The amendments to ORS 414.115 by section 5 of
this 2001 Act apply to contracts entered into or renewed on or
after the effective date of this 2001 Act. For services rendered
under contracts entered into prior to the effective date of this
2001 Act, the Department of Human Services shall bill recipients
for copayment amounts due under section 1 of this 2001 Act. + }
SECTION 7. { + Sections 1, 2, 3 and 6 of this 2001 Act are
repealed three years after the date that the federal Health Care
Financing Administration first grants permission to the
Department of Human Services to require a copayment for Oregon
Health Plan primary care services under section 2 of this 2001
Act. + }
SECTION 8. ORS 414.065, as amended by section 4 of this 2001
Act, is amended to read:
414.065. (1) 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 Department
of Human Services 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:
(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 + } { - the
required - } copayment { - under section 1 of this 2001 Act - }
or { - of any - } other similar cost-sharing payment that the
department may require a recipient to pay toward the cost of
medical and remedial care or services.
(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 department 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 department 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), (b) and (c) of this section for the
eligible medically needy, except for the aged served under ORS
chapter 413 and for the blind and disabled served under ORS
chapter 412, may be less but shall 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.
(5) Notwithstanding the provisions of this section, the
department shall cause Type A hospitals and Type B hospitals, as
defined in ORS 442.470, identified by the Office of Rural Health
as rural hospitals to be reimbursed for the cost of covered
services as follows:
(a) For services provided to persons entitled to receive
medical assistance, based on the Medicare determination of
reasonable cost as derived from the Hospital and Hospital Health
Care Complex Cost Report, referred to as the Medicare Report.
(b) In accordance with the terms of the agreement for services
provided to persons whose medical assistance benefits are
administered by the contracting health care provider under an
agreement between the hospital and a health care provider
contracting with the Department of Human Services under ORS
414.725 (1) for reimbursement other than that specified by ORS
414.727 (1). Hospitals reimbursed under the terms of this
paragraph are entitled to no additional reimbursement for
services provided.
(c) Hospitals that have been reimbursed by health care
providers contracting with the Department of Human Services under
ORS 414.725 (1) in accordance with ORS 414.727 (1), are entitled
to full reimbursement from the department for the cost of covered
services provided to persons whose medical assistance benefits
are administered by the contracting health care provider
according to paragraph (a) of this subsection.
SECTION 9. ORS 414.115, as amended by section 5 of this 2001
Act, is amended to read:
414.115. (1) In lieu of providing one or more of the medical
and remedial care and services available under medical assistance
by direct payments to providers thereof and in lieu of providing
such medical and remedial care and services made available
pursuant to ORS 414.065, the Department of Human Services shall
use available medical assistance funds to purchase and pay
premiums on policies of insurance, or enter into and pay the
expenses on health care service contracts, or medical or hospital
service contracts that provide one or more of the medical and
remedial care and services available under medical assistance for
the benefit of the categorically needy or the medically needy, or
both. Notwithstanding other specific provisions, the use of
available medical assistance funds to purchase medical or
remedial care and services may provide the following insurance or
contract options:
(a) Differing services or levels of service among groups of
eligibles as defined by rules of the department; and
(b) Services and reimbursement for these services may vary
among contracts and need not be uniform { - except that all
copayment provisions shall comply with rules adopted pursuant to
section 1 of this 2001 Act - } .
(2) The policy of insurance or the contract by its terms, or
the insurer or contractor by written acknowledgment to the
department must guarantee:
(a) To provide medical and remedial care and services of the
type, within the extent and according to standards prescribed
under ORS 414.065;
(b) To pay providers of medical and remedial care and services
the amount due, based on the number of days of care and the fees,
charges and costs established under ORS 414.065, except as to
medical or hospital service contracts which employ a method of
accounting or payment on other than a fee-for-service basis;
(c) To provide medical and remedial care and services under
policies of insurance or contracts in compliance with all laws,
rules and regulations applicable thereto; and
(d) To provide such statistical data, records and reports
relating to the provision, administration and costs of providing
medical and remedial care and services to the department as may
be required by the department for its records, reports and
audits.
SECTION 10. { + The amendments to ORS 414.065 and 414.115 by
sections 8 and 9 of this 2001 Act become operative three years
after the date that the federal Health Care Financing
Administration first grants permission to the Department of Human
Services to require a copayment for Oregon Health Plan primary
care services under section 2 of this 2001 Act. + }
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