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 2226
House Bill 2506
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.
Requires Oregon Health Plan participant to make copayment with
each medical visit. Provides exceptions for certain types of
visits. Prohibits payments for out-of-state medical assistance
received by participants. Provides exceptions. Requires 60 days'
written notice of change in rates or covered services to health
care providers contracting to provide services to Oregon Health
Plan participants.
A BILL FOR AN ACT
Relating to the Oregon Health Plan; creating new provisions; and
amending ORS 414.065, 414.115 and 414.630.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + The Department of Human Services shall apply to
the federal Health Care Financing Administration to obtain the
necessary waiver from federal regulations and statutes in order
to implement sections 2 and 8 of this 2001 Act and the amendments
to ORS 414.065, 414.115 and 414.630 by sections 3 to 5 of this
2001 Act. + }
SECTION 2. { + (1) A provider of medical assistance as defined
in ORS 414.025 shall require all persons seeking medical
assistance to make a copayment of $2 for each visit.
(2) Notwithstanding subsection (1) of this section, a copayment
may not be charged for:
(a) Emergency services provided in a hospital if a prudent
layperson possessing an average knowledge of health and medicine
would reasonably believe that the time required to seek
nonemergency services would place the health of the person, or a
fetus in the case of a pregnant woman, in serious jeopardy.
(b) Services provided under the Oregon Health Plan that are
preventive in nature including, but not limited to, health
screenings, immunizations and prenatal care.
(c) Prescription drugs that are medically necessary for regular
health maintenance.
(d) Services provided pursuant to a referral from a primary
care physician.
(e) Services to an individual eligible to receive state
assistance for services provided:
(A) By long term care facilities as described in ORS 442.015;
(B) By home and community-based services under waivers
authorized by section 1915(c) of the Social Security Act;
(C) By residential facilities as defined in ORS 443.400;
(D) By adult foster homes as defined in ORS 443.705; or
(E) To children under 21 years of age who are in the state's
care and custody or are receiving adoption or guardianship
assistance.
(3) The Department of Human Services shall randomly survey
fee-for-service providers and managed care health service
providers once per year to determine the total amount of moneys
collected in copayments. + }
SECTION 3. 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) { + Except for copayments required by section 2 of this
2001 Act, + } the amount and application of any copayment or
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 4. 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.
(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 { + ; and
(e) Not to reduce reimbursement or compensation rates to
providers for services provided to eligible persons as described
in ORS 414.025 due to a copayment required under section 2 of
this 2001 Act + }.
SECTION 5. ORS 414.630 is amended to read:
414.630. (1) The Department of Human Services shall execute
prepaid capitated health service contracts for at least hospital
or physician medical care, or both, with hospital and medical
organizations, health maintenance organizations and any other
appropriate public or private persons.
(2) For purposes of ORS 279.015, 279.712, 414.145 and 414.610
to 414.640, instrumentalities and political subdivisions of the
state are authorized to enter into prepaid capitated health
service contracts with the Department of Human Services and shall
not thereby be considered to be transacting insurance.
(3) In the event that there is an insufficient number of
qualified bids for prepaid capitated health services contracts
for hospital or physician medical care, or both, in some areas of
the state, the department may continue a fee for service payment
system.
(4) { + (a) + } Payments to providers may be subject to
contract provisions requiring the retention of a specified
percentage in an incentive fund or to other contract provisions
by which adjustments to the payments are made based on
utilization efficiency.
{ + (b) Payments to providers may not be reduced due to
copayments collected by the provider under section 2 of this 2001
Act. + }
SECTION 6. { + The amendments to ORS 414.065, 414.115 and
414.630 by sections 3 to 5 of this 2001 Act apply to contracts
entered into or renewed on or after the date that the Department
of Human Services receives the necessary waiver described in
section 1 of this 2001 Act from the federal Health Care Financing
Administration. + }
SECTION 7. { + The Office of Medical Assistance Programs shall
apply to the federal Health Care Financing Administration to
receive approval to require that, under Oregon Health Plan
administrative rules, participants must be enrolled with a
prepaid health provider for up to 12 months prior to requesting
disenrollment without cause. + }
SECTION 8. { + (1) Except for medical assistance rendered
pursuant to subsection (2) of this section, the Department of
Human Services, a department subcontractor or a managed care
health service provider under contract with the department may
not provide payment for out-of-state medical assistance received
by persons enrolled in the Oregon Health Plan.
(2) Persons enrolled in the Oregon Health Plan may seek
reimbursement from the department, a department subcontractor or
a managed care health service provider for medical assistance
rendered out of state if any of the following apply:
(a) The medical assistance was received out of state but was
received within the contiguous service area of the department, a
department subcontractor or the managed care health service
provider;
(b) The enrollee obtained prior authorization from the
department, a department subcontractor or the managed care health
service provider before obtaining the out-of-state medical
assistance;
(c) The medical assistance was provided to a person under 21
years of age who resides in an out-of-state facility under an
agreement with the Oregon Youth Authority or the State Office for
Services to Children and Families; or
(d) The medical assistance was obtained due to an emergency the
nature of which would cause a prudent layperson possessing an
average knowledge of health and medicine to reasonably believe
that the time required to seek nonemergency services would place
the health of the person, or a fetus in the case of a pregnant
woman, in serious jeopardy. + }
SECTION 9. { + Sections 2 and 8 of this 2001 Act and the
amendments to ORS 414.065, 414.115 and 414.630 by sections 3 to 5
of this 2001 Act become operative upon receipt by the Department
of Human Services of the necessary waiver described in section 1
of this 2001 Act from the federal Health Care Financing
Administration. + }
SECTION 10. { + (1) The Office of Medical Assistance Programs
shall provide 60 days' written notice to health care providers
contracting to provide services under ORS 414.705 to 414.750 of
any proposed change to reimbursement rates or covered services
under the contract providing medical services to the eligible
population under ORS 414.705 to 414.750.
(2) If a health care provider contracting to provide services
objects to the proposed change of reimbursement rates or covered
services, the provider may appeal the change to the Director of
Human Services.
(3) Once a decision has been made by the director under
subsection (2) of this section, the health care provider
contracting to provide services may appeal the decision of the
director as a contested case under ORS 183.310 to 183.550.
(4) If a health care provider contracting to provide services
that receives notice of a proposed change to reimbursement rates
or covered services fails to appeal the change to the director,
the change shall take effect upon the expiration of the 60-day
notice period.
(5) Notwithstanding the notice requirement of subsection (1) of
this section, the Office of Medical Assistance Programs may
implement contract changes without a notice and appeal process if
the changes are required by federal law. + }
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