71st OREGON LEGISLATIVE ASSEMBLY--2001 Regular Session
 
HA to HB 3040
 
LC 3018/HB 3040-2
 
                       HOUSE AMENDMENTS TO
                         HOUSE BILL 3040
 
           By COMMITTEE ON HEALTH AND PUBLIC ADVOCACY
 
                            March 21
 
  On page 2 of the printed bill, line 7, delete 'only' and insert
'a specified network or networks of'.
  In line 8, after 'insurer' insert 'in order to receive benefits
under the plan, except for emergency or other specified limited
service'.
  In line 10, delete 'Creates financial or other in-'.
  Delete lines 11 and 12 and insert '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.'.
  After line 19, insert:
  ' (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.'.
  In line 20, delete '(11)' and insert '(12)'.
  In line 23, delete '(12)' and insert '(13)'.
  In line 26, delete '(13)' and insert '(14)'.
  In line 28, delete '(14)' and insert '(15)'.
  Delete lines 40 through 45 and insert:
  ' (2) An insurer offering managed health insurance or preferred
provider organization insurance in this state shall provide
continuity of care to an enrollee under a health benefit plan if:
  ' (a) A medical services contract or other contract for an
individual provider's services is terminated;
  ' (b) The provider no longer participates in the provider
network; and
  ' (c) The insurer does not cover services when services are
provided to enrollees by the individual provider or covers
services at a benefit level below the benefit level specified in
the plan for out-of-network providers.'.
  On page 3, line 8, after 'insurer' insert 'described in
subsection (2) of this section'.
  In line 12, after 'insurer' insert 'described in subsection (2)
of this section'.
  Delete line 18 and insert:
  ' (C) No longer holds an active license;'.
  On page 4, line 18, delete 'to deliver the notice' and insert
'that the provider group may do so'.
  On page 6, line 21, after the period delete the rest of the
line and lines 22 and 23 and insert 'If the plan does not have a
network provider available to give a second medical opinion or
consultation, the plan must allow the enrollee to obtain the
opinion or consultation from a similarly qualified physician who
is not a network provider.'.
  In line 24, delete 'a network provider.'.
  In line 34, after 'insurance' insert 'or preferred provider
organization insurance'.
  In line 39, after 'insurance' insert 'or preferred provider
organization insurance'.
  In line 44, after 'insurance' insert 'or preferred provider
organization insurance'.
  In line 45, after 'plan' insert 'or preferred provider
organization insurance'.
  On page 7, line 36, after 'insurance' insert 'or preferred
provider organization insurance'.
  In line 42, delete '10, 11 and' and insert '10 and 11'.
  In line 43, delete '14'.
  On page 8, line 45, delete 'Costs of' and insert 'Fees for'.
  On page 9, line 5, after 'insurer' delete the rest of the line
and line 6 and insert 'only one opportunity to reject the
assignment of an independent review organization to a particular
case.'.
  Delete lines 7 through 11 and insert:
  '  { +  SECTION 10. + } (1) An insurer of a health benefit plan
shall include in the plan the following statements, in boldfaced
type or otherwise emphasized:
  ' (a) A statement of the right of enrollees to apply for
external review by an independent review organization; and
  ' (b) A statement of whether the insurer agrees to be bound by
decisions of independent review organizations.'.
  In line 13, after 'is' insert 'not'.
  In line 14, after 'disclose' delete the rest of the line and
lines 15 and 16 and insert 'that:
  ' (a) The insurer is not bound by the decisions of independent
review organizations;
  ' (b) The insurer may follow nonetheless a decision by an
independent review organization; and
  ' (c) If the insurer does not follow a decision of an
independent review organization, the enrollee has the right to
sue the insurer.'.
  On page 10, line 7, before 'decision' insert 'adverse ' and
after 'insurer' delete the rest of the line and line 8 and insert
'under section 8 (1) of this 2001 Act and issue the decision in
writing.'.
  Delete line 19 and insert 'not later than the third day after
the date on which the enrollee applies to the insurer for an
expedited review.'.
  Delete lines 21 and 22 and insert 'decision not later than the
30th day after the enrollee applies to the insurer for a
review.'.
  In line 25, after 'confidential' insert ', that is otherwise
exempt from disclosure under ORS 192.501 and 192.502 or that may
otherwise allow identification of an enrollee.'.
  Delete lines 32 through 36.
  In line 37, delete '(3)' and insert '(2)'.
  After line 39, insert:
  ' (3) The sanctions under subsection (1) of this section and
the remedies under subsection (2) of this section are in addition
to and not in lieu of other sanctions, rights and remedies
provided by law or contract.'.
  Delete lines 40 through 45 and insert:
  '  { +  SECTION 14. + }  { + (1) An enrollee who is the subject
of a decision of an independent review organization has a private
right of action against the insurer for damages arising from an
adverse decision by the insurer that is subject to external
review if:
  ' (a) The insurer states in the health benefit plan in which
the enrollee is enrolled that the insurer is not bound by the
decisions of an independent review organization; and
  ' (b) The insurer fails to comply with the decision.
  ' (2) The Legislative Assembly intends that there is no private
right of action under subsection (1) of this section if a court
finds either subsection (1)(a) or (b) of this section to be
unconstitutional or otherwise void. + } ' .
  On page 11, line 27, delete '9, 10, 11, 12 and 13' and insert
'10 and 11'.
  On page 12, line 21, delete '9, 10, 11, 12 and 13' and insert
'10 and 11'.
  On page 13, line 17, delete '9, 10, 11, 12 and 13' and insert
'10 and 11'.
  On page 14, line 5, delete '13' and insert '14'.
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