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 3616
House Bill 3553
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.
Modifies medical assistance program in Department of Human
Services to provide medical assistance only. Modifies
responsibilities of Insurance Pool Governing Board to provide
health services to children and adults not eligible for medical
assistance. Renames Family Health Insurance Assistance Program as
Oregon Child and Family Health Insurance Program. Changes
membership on Insurance Pool Governing Board. Abolishes Health
Services Commission. Abolishes Medicaid Advisory Committee.
Abolishes Drug Use Review Board. Abolishes Oregon Health Care
Cost Containment System. Abolishes Office for Oregon Health Plan
Policy and Research Advisory Committee.
Declares emergency, effective July 1, 2001.
A BILL FOR AN ACT
Relating to health care; creating new provisions; amending ORS
414.018, 414.021, 414.022, 414.024, 414.025, 414.033, 414.036,
414.042, 414.065, 414.115, 414.125, 414.135, 414.145, 414.150,
414.152, 414.325, 414.610, 414.630, 414.640, 414.660, 414.710,
414.712, 414.727, 414.750, 442.588, 653.705, 653.715, 653.725,
653.735, 653.745, 653.747, 653.800, 653.805, 653.810, 653.815,
653.820, 653.825, 653.830, 653.835, 653.840, 653.850, 743.730
and 743.736 and section 3, chapter 385, Oregon Laws 1995;
repealing ORS 414.019, 414.107, 414.151, 414.153, 414.211,
414.221, 414.225, 414.350, 414.355, 414.360, 414.365, 414.370,
414.375, 414.380, 414.385, 414.390, 414.395, 414.400, 414.410,
414.415, 414.620, 414.630, 414.670, 414.705, 414.715, 414.720,
414.725, 414.730, 414.735, 414.745, 414.751 and 653.845 and
section 6a, chapter 916, Oregon Laws 1991, and section 34,
chapter 683, Oregon Laws 1997; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 414.018 is amended to read:
414.018. (1) It is the intention of the Legislative Assembly to
achieve the goals of universal access to an adequate level of
high quality health care at an affordable cost.
(2) The Legislative Assembly finds:
(a) A significant { + and growing + } level of public and
private funds is expended each year for the provision of health
care to Oregonians;
(b) The state has a strong interest in assisting Oregon
businesses and individuals to obtain reasonably available
insurance or other coverage of the costs of necessary basic
health care services;
(c) The lack of basic health care coverage is detrimental not
only to the health of individuals lacking coverage, but also to
the public welfare and the state's need to encourage employment
growth and economic development, and the lack results in
substantial expenditures for emergency and remedial health care
for all { + private and public + } purchasers of health care
{ - including the state - } ; and
(d) The use of managed health care systems has { + made
possible + } significant { - potential - } { + expansion in
Oregon of public and private coverage while helping + } to reduce
the growth of health care costs incurred by the people of this
state.
SECTION 2. ORS 414.025 is amended to read:
414.025. As used in this chapter, unless the context or a
specially applicable statutory definition requires otherwise:
(1) 'Category of aid' means old-age assistance, aid to the
blind, aid to the disabled, temporary assistance for needy
families or Supplemental Security Income payment of the federal
government.
(2) 'Categorically needy' means, insofar as funds are available
for the category, a person who is a resident of this state and
who:
(a) Is receiving a category of aid.
{ - (b) Would be eligible for, but is not receiving a
category of aid. - }
{ - (c) - } { + (b) + } Is in a medical facility and, if
the person left such facility, would be eligible for a category
of aid.
{ - (d) - } { + (c) + } Is under the age of 21 years and
would be a dependent child under the program for temporary
assistance for needy families except for age and regular
attendance in school or in a course of professional or technical
training.
{ - (e) - } { + (d) + } Is a caretaker relative named in
ORS 418.035 (1)(a)(C) who cares for a dependent child who would
be a dependent child under the program for temporary assistance
for needy families except for age and regular attendance in
school or in a course of professional or technical training; or
is the spouse of such caretaker relative and fulfills the
requirements of ORS 418.035 (2).
{ - (f) - } { + (e) + } Is under the age of 21 years, is in
a foster family home or licensed child-caring agency or
institution under a purchase of care agreement and is one for
whom a public agency of this state is assuming financial
responsibility, in whole or in part.
{ - (g) - } { + (f) + } Is a spouse of an individual
receiving a category of aid and who is living with the recipient
of a category of aid, whose needs and income are taken into
account in determining the cash needs of the recipient of a
category of aid, and who is determined by the Department of Human
Services to be essential to the well-being of the recipient of a
category of aid.
{ - (h) - } { + (g) + } Is a caretaker relative named in
ORS 418.035 (1)(a)(C) who cares for a dependent child receiving
temporary assistance for needy families or is the spouse of such
caretaker relative and fulfills the requirements of ORS 418.035
(2).
{ - (i) - } { + (h) + } Is under the age of 21 years, is in
a youth care center and is one for whom a public agency of this
state is assuming financial responsibility, in whole or in part.
{ - (j) - } { + (i) + } Is under the age of 21 years and is
in an intermediate care facility which includes institutions for
the mentally retarded; or is under the age of 22 years and is in
a psychiatric hospital.
{ - (k) - } { + (j) + } Is under the age of 21 years and is
in an independent living situation with all or part of the
maintenance cost paid by the State Office for Services to
Children and Families.
{ - (L) - } { + (k) + } Is a member of a family that
received temporary assistance for needy families in at least
three of the six months immediately preceding the month in which
such family became ineligible for such assistance because of
increased hours of or increased income from employment. As long
as the member of the family is employed, such families will
continue to be eligible for medical assistance for a period of at
least six calendar months beginning with the month in which such
family became ineligible for assistance because of increased
hours of employment or increased earnings.
{ - (m) - } { + (L) + } Is an adopted person under 21 years
of age for whom a public agency is assuming financial
responsibility in whole or in part.
{ - (n) - } { + (m) + } Is an individual or is a member of
a group who is required by federal law to be included in the
state's medical assistance program in order for that program to
qualify for federal funds.
{ - (o) - } { + (n) + }Is an individual or member of a
group who, subject to the rules of the office and within
available funds, may optionally be included in the state's
medical assistance program under federal law and regulations
concerning the availability of federal funds for the expenses of
that individual or group.
{ - (p) - } { + (o) + } Is a pregnant woman who would be
eligible for temporary assistance for needy families including
such aid based on the unemployment of a parent, whether or not
the woman is eligible for cash assistance.
{ - (q) - } { + (p) + } Would be eligible for temporary
assistance for needy families pursuant to 42 U.S.C. 607 based
upon the unemployment of a parent, whether or not the state
provides cash assistance.
{ - (r) - } { + (q) + } Except as otherwise provided in
this section and to the extent of available funds, is a pregnant
woman or child for whom federal financial participation is
available under Title XIX of the federal Social Security Act.
{ - (s) Is not otherwise categorically needy and is not
eligible for care under Title XVIII of the federal Social
Security Act or is not a full-time student in a post-secondary
education program as defined by the Department of Human Services
by rule, but whose family income is less than the federal poverty
level and whose family investments and savings equal less than
the investments and savings limit established by the department
by rule. - }
(3) 'Income' means income as defined in ORS 413.005 (3).
(4) 'Investments and savings' means cash, securities as defined
in ORS 59.015, negotiable instruments as defined in ORS 73.0104
and such similar investments or savings as the Department of
Human Services may establish by rule that are available to the
applicant or recipient to contribute toward meeting the needs of
the applicant or recipient.
(5) 'Medical assistance' means so much of the following medical
and remedial care and services as may be prescribed by the
Department of Human Services according to the standards
established pursuant to ORS 414.065, including payments made for
services provided under an insurance or other contractual
arrangement and money paid directly to the recipient for the
purchase of medical care:
(a) Inpatient hospital services, other than services in an
institution for mental diseases;
(b) Outpatient hospital services;
(c) Other laboratory and X-ray services;
(d) Skilled nursing facility services, other than services in
an institution for mental diseases;
(e) Physicians' services, whether furnished in the office, the
patient's home, a hospital, a skilled nursing facility or
elsewhere;
(f) Medical care { - , or any other type of remedial care
recognized under state law, - } furnished by licensed
practitioners within the scope of their practice as defined by
state law;
(g) Home health care services;
(h) Private duty nursing services;
(i) Clinic services;
(j) Dental services;
(k) Physical therapy and related services;
(L) Prescribed drugs, including those dispensed and
administered as provided under ORS chapter 689;
(m) Dentures and prosthetic devices; and eyeglasses prescribed
by a physician skilled in diseases of the eye or by an
optometrist, whichever the individual may select;
(n) Other diagnostic, screening, preventive and rehabilitative
services;
(o) Inpatient hospital services, skilled nursing facility
services and intermediate care facility services for individuals
65 years of age or over in an institution for mental diseases;
(p) Any other medical care, and any other type of remedial care
recognized under state law;
(q) Periodic screening and diagnosis of individuals under the
age of 21 years to ascertain their physical or mental defects,
and such health care, treatment and other measures to correct or
ameliorate defects and chronic conditions discovered thereby;
(r) Inpatient hospital services for individuals under 22 years
of age in an institution for mental diseases; and
(s) Hospice services.
(6) 'Medical assistance' includes any care or services for any
individual who is a patient in a medical institution or any care
or services for any individual who has attained 65 years of age
or is under 22 years of age, and who is a patient in a private or
public institution for mental diseases. 'Medical assistance '
{ - includes - } { + does not include + } 'health services'
as defined in ORS
{ - 414.705 - } { + 414.660 + }. 'Medical assistance' does
not include care or services for an inmate in a nonmedical public
institution.
(7) 'Medically needy' means a person who is a resident of this
state and who is considered eligible under federal law for
medically needy assistance.
(8) 'Resources' means resources as defined in ORS 413.005 (4).
For eligibility purposes, 'resources' shall not include
charitable contributions raised by a community to assist with
medical expenses.
SECTION 3. ORS 414.033 is amended to read:
414.033. The Department of Human Services { + and the
Insurance Pool Governing Board + } may:
(1) Subject to the allotment system provided for in ORS 291.234
to 291.260, expend such sums as are required to be expended in
this state to provide medical assistance. Expenditures for
medical assistance include, but are not limited to, expenditures
for deductions, cost sharing, enrollment fees, premiums or
similar charges imposed with respect to hospital insurance
benefits or supplementary health insurance benefits, as
established by federal law.
(2) Enter into agreements with, join with or accept grants
from, the federal government for cooperative research and
demonstration projects for public welfare purposes, including,
but not limited to, any project which determines the cost of
providing medical assistance to the medically needy and evaluates
service delivery systems.
SECTION 4. ORS 414.036 is amended to read:
414.036. (1) The Legislative Assembly finds that:
(a) Hundreds of thousands of Oregonians have no health
insurance or other coverage and lack the income and resources
needed to obtain health care;
(b) The number of persons without access to health services
increases dramatically during periods of high unemployment;
(c) Without health coverage, persons { - who lack access to
health services - } may receive treatment, but through costly,
inefficient, acute care;
(d) The unpaid cost of health services for such persons is
shifted to paying patients, driving up the cost of
hospitalization and health insurance for all Oregonians; and
(e) The state's medical assistance program is increasingly
unable to fund the health care needs of low-income citizens.
(2) In order to provide access to health services for those in
need, to contain rising health services costs through appropriate
incentives to providers, payers and consumers, to reduce or
eliminate cost shifting and to promote the stability of the
health services delivery system and the health and well-being of
all Oregonians, it is the policy of the State of Oregon to
provide medical assistance { + or facilitate accessibility to
health services + } to those individuals in need whose family
income is below the federal poverty level and who are eligible
for services under the programs authorized by this chapter.
SECTION 5. ORS 414.042 is amended to read:
414.042. (1) The need for and the amount of medical assistance
to be made available for each eligible group of recipients of
medical assistance shall be determined, in accordance with the
rules of the Department of Human Services, taking into account:
(a) The requirements and needs of the person, the spouse and
other dependents;
(b) The income, resources and maintenance available to the
person { - but, except as provided in ORS 414.025 (2)(s),
resources shall be disregarded for those eligible by reason of
having income below the federal poverty level and who are
eligible for medical assistance only because of the enactment of
chapter 836, Oregon Laws 1989 - } ; { + and + }
(c) The responsibility of the spouse and, with respect to a
person who is blind or is permanently and totally disabled or is
under 21 years of age, the responsibility of the parents { - ;
and - } { + . + }
{ - (d) The report of the Health Services Commission as
funded by the Legislative Assembly and such other programs as the
Legislative Assembly may authorize. However, medical assistance,
including health services, shall not be provided to persons
described in ORS 414.025 (2)(s) unless the Legislative Assembly
specifically appropriates funds to provide such assistance. - }
(2) Such amounts of income and resources may be disregarded as
the department may prescribe by rules, except that the department
may not require any needy person over 65 years of age, as a
condition of entering or remaining in a hospital, nursing home or
other congregate care facility, to sell any real property
normally used as such person's home. Any rule of the department
inconsistent with this section is to that extent invalid. The
amounts to be disregarded shall be within the limits required or
permitted by federal law, rules or orders applicable thereto.
(3) In the determination of the amount of medical assistance
available to a medically needy person, all income and resources
available to the person in excess of the amounts prescribed in
ORS 414.038, within limits prescribed by the department, shall be
applied first to costs of needed medical and remedial care and
services not available under the medical assistance program and
then to the costs of benefits under the medical assistance
program.
SECTION 6. 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 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 - } { + entities under contract + } 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 7. 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 - } { + in conjunction with the Insurance Pool
Governing Board may + } 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.
SECTION 8. ORS 414.125 is amended to read:
414.125. (1) Any payment of available medical assistance funds
for policies of insurance or service contracts shall be according
to { - such - } { + the + } uniform area-wide rates
{ - as - } { + that + } the Department of Human Services
{ - shall - } { + and the Insurance Pool Governing Board + }
have established and { - which it - } { + that they
collaboratively + } may revise from time to time as may be
necessary or practical, except that, in the case of a research
and demonstration project entered into under ORS 411.135 special
rates may be established.
(2) No premium or other periodic charge on any policy of
insurance, health care service contract, or medical or hospital
service contract shall be paid from available medical assistance
funds unless the insurer or contractor issuing such policy or
contract is by law authorized to transact business as an
insurance company, health care service contractor or hospital
association in this state.
SECTION 9. ORS 414.135 is amended to read:
414.135. The Department of Human Services { + and the
Insurance Pool Governing Board + } may enter into nonexclusive
contracts under which funds available for medical assistance may
be administered and disbursed by the contractor to direct
providers of medical and remedial care and services available
under medical assistance in consideration of services rendered
and supplies furnished by them in accordance with the provisions
of this chapter. Payment shall be made according to the rules of
the department pursuant to the number of days and the fees,
charges and costs established under ORS 414.065. The contractor
must guarantee the department by written acknowledgment:
(1) To make all payments under this chapter promptly but not
later than 30 days after receipt of the proper evidence
establishing the validity of the provider's claim.
(2) To provide such data, records and reports to the department
as may be required by the department.
SECTION 10. ORS 414.145 is amended to read:
414.145. (1) The provisions of ORS 414.115, 414.125 or 414.135
{ - shall - } { + may + } be implemented whenever it appears
to the Department of Human Services that such implementation will
provide comparable benefits at equal or less cost than provision
thereof by direct payments by the department to the providers of
medical assistance, but in no case greater than the legislatively
approved budgeted cost per eligible recipient at the time of
contracting.
(2) When determining comparable benefits at equal or less cost
as provided in subsection (1) of this section, the department
must take into consideration the recipients' need for reasonable
access to preventive and remedial care, and the contractor's
ability to assure continuous quality delivery of both routine and
emergency services.
SECTION 11. ORS 414.325 is amended to read:
414.325. (1) As used in this section, 'legend drug' means any
drug requiring a prescription by a { + prescribing + }
practitioner, as defined in ORS 689.005.
(2) A licensed { + prescribing + } practitioner may prescribe
such drugs under this chapter as the practitioner in the exercise
of professional judgment considers appropriate for the diagnosis
or treatment of the patient in the practitioner's care and within
the scope of practice. Prescriptions shall be dispensed in the
generic form pursuant to ORS 689.515 { - , - } { + and + }
689.854 { - and 689.857 - } and pursuant to rules of the
{ - division - } { + Department of Human Services + } unless
the practitioner prescribes otherwise { - and an exception is
granted by the division - } .
(3) Except as provided in subsections (4) and (5) of this
section, the { - division - } { + department + } shall place
no limit on the type of legend drug that may be prescribed by a
practitioner, but shall pay only for drugs in the generic form
unless an exception has been granted by the { - division - }
{ + department + }.
(4) Notwithstanding subsection (3) of this section, an
exception must be applied for and granted before the
{ - division - } { + department + } is required to pay for
minor tranquilizers and amphetamines and amphetamine derivatives,
as defined by rule of the { - division - } { +
department + }.
(5)(a) Notwithstanding subsections (1) to (4) of this section
and except as provided in paragraph (b) of this subsection, the
{ - division - } { + department + } is authorized to:
(A) Withhold payment for a legend drug when federal financial
participation is not available; and
(B) Require prior authorization of payment for drugs
{ - which - } { + that + } the { - division - }
{ + department by rule + } has determined should be limited to
those conditions generally recognized as appropriate by the
medical profession.
(b) The { - division - } { + department + } may not require
prior authorization for therapeutic classes of nonsedating
antihistamines and nasal inhalers, as defined by rule by the
{ - division - } { + department + }, when prescribed by an
allergist for treatment of any of the following conditions { - ,
as described by the Health Services Commission on the funded
portion of its prioritized list of services - } :
(A) Asthma;
(B) Sinusitis;
(C) Rhinitis; or
(D) Allergies.
SECTION 12. ORS 414.610 is amended to read:
414.610. It is the intent of the Legislative Assembly to
develop and implement new strategies for persons eligible to
receive medical assistance { + or health services + } that
promote and change the incentive structure in the delivery and
financing of medical care, that encourage cost consciousness on
the part of the users and providers while maintaining quality
medical care and that strive to make state payments for such
medical care sufficient to compensate providers adequately for
the reasonable costs of such care in order to minimize
inappropriate cost shifts onto other health care payers.
SECTION 13. 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 - } { + and + } 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 - } { + and + } physician medical care
{ - , or both, - } in some areas of the state, the department
may continue a fee for service payment system.
(4) 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.
SECTION 14. ORS 414.640 is amended to read:
414.640. (1) Eligible persons shall select, to the extent
practicable as determined by the Department of Human Services,
from among available providers participating in the program.
(2) The department { - by rule shall define the circumstances
under which it may choose to - } { + may not + } reimburse
{ + a provider + } for any medical services not covered under
the prepaid capitation or costs of related services provided by
or under referral from any physician participating in the program
in which the eligible person is enrolled.
(3) The department shall establish requirements as to the
minimum time period that an eligible person is assigned to
specific providers in the system.
(4) Actions taken by providers, potential providers,
contractors and bidders in specific accordance with this chapter
in forming consortiums or in otherwise entering into contracts to
provide medical care shall be considered to be conducted at the
direction of this state, shall be considered to be lawful trade
practices and shall not be considered to be the transaction of
insurance for purposes of ORS 279.015, 279.712, 414.145 and
414.610 to 414.640.
SECTION 15. Section 3, chapter 385, Oregon Laws 1995, as
amended by section 1, chapter 589, Oregon Laws 1997, and section
10, chapter 1077, Oregon Laws 1999, is amended to read:
{ + Sec. 3. + } (1) Notwithstanding ORS 323.030 (2) and in
addition to and not in lieu of any other tax, every distributor,
as defined in ORS 323.015, shall pay a tax upon distributions of
cigarettes at the rate of five mills for the distribution of each
cigarette in this state occurring prior to January 1, 2002.
(2) Any cigarette with respect to which a tax has once been
imposed under ORS 323.005 to 323.455 and 323.990 and this section
shall not be subject upon a subsequent distribution to the taxes
imposed by ORS 323.005 to 323.455 and 323.990 and this section.
(3) The moneys received under this section shall be paid over
and credited to the General Fund and shall be used exclusively to
fund the Oregon Health Plan { - as described under ORS
414.019 - } .
SECTION 16. ORS 414.021 is amended to read:
414.021. (1) The Administrator of the Office for Oregon Health
Plan Policy and Research shall be responsible for analyzing and
reporting on the implementation of the elements of the Oregon
Health Plan that are assigned to various state agencies,
including but not limited to the Department of Human Services and
the Department of Consumer and Business Services, and shall
administer
{ - the Health Services Commission, - } the Health Resources
Commission and the Oregon Health Council. Pursuant to the
responsibilities described in this subsection, the administrator
may review and monitor the progress of the various activities
that comprise Oregon's efforts to reform health care through
state-funded and employer-based coverage. Except for
administration of { - the Health Services Commission, - } the
Health Resources Commission and the Oregon Health Council and as
specifically authorized in ORS 414.018 to 414.024, 414.042,
{ - 414.107, - } 414.710 { - , 414.720 - } and 653.747, the
administrator shall not be responsible for the day-to-day
operations of the Oregon Health Plan, but shall exercise such
oversight responsibilities as are necessary to further the Oregon
Health Plan's goals.
(2) The administrator shall be responsible for the activities
necessary to implement the plans and programs described in
sections 4 and 7, chapter 815, Oregon Laws 1993, that are
intended to expand voluntary health care coverage to Oregonians.
(3) The administrator shall employ such staff or utilize such
state agency personnel as are necessary to fulfill the
responsibilities and duties of the administrator. In addition,
the administrator may contract with third parties for technical
and administrative services necessary to carry out Oregon Health
Plan activities where contracting promotes economy, avoids
duplication of effort and makes best use of available expertise.
The administrator may call upon other state agencies to provide
available information as necessary to assist the administrator in
meeting the responsibilities under ORS 414.018 to 414.024,
414.042, { - 414.107, - } 414.710 { - , 414.720 - } and
653.747. The information shall be supplied as promptly as
circumstances permit.
(4) The Oregon Health Council shall serve as the primary
advisory committee to the administrator, the Governor and the
Legislative Assembly. The administrator also may appoint other
technical or advisory committees to assist the Oregon Health
Council in formulating its advice. Individuals appointed to any
technical or other advisory committee shall serve without
compensation for their services as members, but may be reimbursed
for their travel expenses pursuant to ORS 292.495.
(5) The administrator may apply for, receive and accept grants,
gifts and other payments, including property and services, from
any governmental or other public or private entity or person and
may make arrangements for the use of these receipts, including
the undertaking of special studies and other projects relating to
health care costs and access to health care.
(6) The directors of the Departments of Human Services and
Consumer and Business Services and other state agency personnel
responsible for implementing elements of the Oregon Health Plan
shall cooperate fully with the administrator in carrying out
their responsibilities under the Oregon Health Plan.
(7) All health policy advisory committees reporting to the
Office for Oregon Health Plan Policy and Research and all
advisory task forces on health policy appointed by the
administrator shall report directly to the Oregon Health Council.
SECTION 17. ORS 414.022 is amended to read:
414.022. Mental health services shall be provided by the
Department of Human Services, in collaboration with the Mental
Health and Developmental Disability Services Division { - , - }
{ + and + } the Office of Medical Assistance Programs { - and
the Health Services Commission, - } for the purpose of
determining how best to serve the range of mental health
conditions statewide utilizing a capitated managed care system.
The services shall begin as soon as feasible following receipt of
the necessary waiver in anticipation that the services are to be
available not later than January 1, 1995, and shall cover up to
25 percent of state-funded mental health services until July 1,
1997. After July 1, 1997, the services shall cover all of the
state-funded eligible mental health services. The provision of
services under this section shall support and be consistent with
community mental health and developmental disabilities programs
established and operated or contracted for under ORS chapter 430.
The goals and criteria are:
(1) Test actuarial assumptions used to project costs and
utilization rates, and revise estimates of cost for statewide
implementation.
(2) Compare current medical assistance fee for service with
capitated managed care mental health system, using state
determined quality assurance standards to evaluate capacity,
diagnosis, utilization and treatment:
(a) Including components for testing full integration of
physical medicine and mental health services and measuring the
impact of mental health services on utilization of physical
health services.
(b) Comparing current medical assistance fee for service with
capitated managed care system for utilization and length of stay
in private and public hospitals, and in nonhospital residential
care facilities.
(c) Comparing for specific conditions, treatment configuration,
effectiveness and disposition rates.
(3) Design the services to assure geographic coverage of urban
and rural areas including significant population bases, and areas
with and without existing capacity to provide fully capitated
managed care services including:
(a) Requiring providers to maintain and report information
about clients by type and amount of services in a predetermined
uniform format for comparison with state established quality
assurance standards.
(b) Within the geographic areas in which services are provided,
requiring providers to serve the full range of mental health
populations and conditions.
(c) Requiring providers to have the full range of eligible
mental health services available including, but not limited to,
assessment, case management, outpatient treatment and
hospitalization.
(4) The department shall report to the Emergency Board and
other appropriate interim legislative committees and task forces
by October 1, 1996, on the implementation of the services.
SECTION 18. ORS 414.024 is amended to read:
414.024. In the selection of any area of the state for the
initial operation of the programs authorized by ORS 414.018 to
414.024, 414.042, { - 414.107, - } 414.710 { - , 414.720 - }
and 653.747, the Administrator of the Office for Oregon Health
Plan Policy and Research shall take into account the levels and
rates of unemployment in different areas of the state, the need
to provide basic health care coverage to a population reasonably
representative of the portion of the state's population that
lacks such coverage and the need for geographic, demographic and
economic diversity.
SECTION 19. ORS 414.712 is amended to read:
414.712. { + (1) + } Within six months after obtaining the
necessary federal waivers or { + on + } January 1,
{ - 1995 - } { + 2002 + }, whichever is later, the
{ - Department of Human Services - } { + Insurance Pool
Governing Board + } shall provide { + health services to
children and adults not eligible for + } medical assistance under
ORS 414.705 to 414.750 { - to - } { + including + } eligible
persons who are aged and described in ORS chapter 413 or who are
blind or disabled and described in ORS chapter 412 and to
children described in ORS 414.025 { - (2)(f), (i), (j), (k) and
(m) - } { + (2)(e), (h), (i), (j) and (L) + }, 418.001 to
418.034, 418.187 to 418.970 and 657A.020 to 657A.530 { - and
those mental health and chemical dependency services recommended
according to standards of medical assistance set pursuant to
chapter 836, Oregon Laws 1989, and according to the schedule of
implementation established by the Legislative Assembly - } .
{ + (2) + } In providing medical assistance services
described in ORS 414.018 to 414.024, 414.042, { - 414.107, - }
414.710 { - , 414.720 - } and 653.747, the Department of Human
Services shall also provide the following:
{ - (1) - } { + (a) + } Ombudsman services for eligible
persons who are aged and described in ORS chapter 413 or who are
blind or disabled and described in ORS chapter 412. An ombudsman
shall serve as a patient's advocate whenever the patient or a
physician or other medical personnel serving the patient is
reasonably concerned about access to, quality of or limitations
on the care being provided by a health care provider. Patients
shall be informed of the availability of an ombudsman.
{ - (2) - } { + (b) + } Case management services in each
health care provider organization for those eligible persons who
are aged and described in ORS chapter 413 or who are blind or
disabled and described in ORS chapter 412. Case managers shall be
trained in and shall exhibit skills in communication with and
sensitivity to the unique health care needs of people who are
elderly and those with disabilities. Case managers shall be
reasonably available to assist patients served by the
organization with the coordination of the patient's health care
services at the reasonable request of the patient or a physician
or other medical personnel serving the patient. Patients shall be
informed of the availability of case managers.
{ - (3) - } { + (c) + } A mechanism, established by rule,
for soliciting consumer opinions and concerns regarding
accessibility to and quality of the services of each health care
provider.
{ - (4) - } { + (d) + } A choice of available medical plans
and, within those plans, choice of a primary care provider.
{ - (5) - } { + (e) + } Due process procedures for any
individual whose request for medical assistance coverage for any
treatment or service is denied or is not acted upon with
reasonable promptness. These procedures shall include an
expedited process for cases in which a patient's medical needs
require swift resolution of a dispute.
SECTION 20. ORS 414.712, as amended by section 53, chapter
1084, Oregon Laws 1999, is amended to read:
414.712. { + (1) + } Within six months after obtaining the
necessary federal waivers or { + on + } January 1,
{ - 1995 - } { + 2002 + }, whichever is later, the
{ - Department of Human Services - } { + Insurance Pool
Governing Board + } shall provide { + health services to
children and adults not eligible for + } medical assistance under
ORS 414.705 to 414.750 { - to - } { + including + } eligible
persons who are aged and described in ORS chapter 413 or who are
blind or disabled and described in ORS chapter 412 and to
children described in ORS 414.025 { - (2)(f), (i), (j), (k) and
(m) - } { + (2)(e), (h), (i), (j) and (L) + }, 418.001 to
418.034, 418.189 to 418.970 and 657A.020 to 657A.530 { - and
those mental health and chemical dependency services recommended
according to standards of medical assistance set pursuant to
chapter 836, Oregon Laws 1989, and according to the schedule of
implementation established by the Legislative Assembly - } .
{ + (2) + } In providing medical assistance services
described in ORS 414.018 to 414.024, 414.042, { - 414.107, - }
414.710 { - , 414.720 - } and 653.747, the Department of Human
Services shall also provide the following:
{ - (1) - } { + (a) + } Ombudsman services for eligible
persons who are aged and described in ORS chapter 413 or who are
blind or disabled and described in ORS chapter 412. An ombudsman
shall serve as a patient's advocate whenever the patient or a
physician or other medical personnel serving the patient is
reasonably concerned about access to, quality of or limitations
on the care being provided by a health care provider. Patients
shall be informed of the availability of an ombudsman.
{ - (2) - } { + (b) + } Case management services in each
health care provider organization for those eligible persons who
are aged and described in ORS chapter 413 or who are blind or
disabled and described in ORS chapter 412. Case managers shall be
trained in and shall exhibit skills in communication with and
sensitivity to the unique health care needs of people who are
elderly and those with disabilities. Case managers shall be
reasonably available to assist patients served by the
organization with the coordination of the patient's health care
services at the reasonable request of the patient or a physician
or other medical personnel serving the patient. Patients shall be
informed of the availability of case managers.
{ - (3) - } { + (c) + } A mechanism, established by rule,
for soliciting consumer opinions and concerns regarding
accessibility to and quality of the services of each health care
provider.
{ - (4) - } { + (d) + } A choice of available medical plans
and, within those plans, choice of a primary care provider.
{ - (5) - } { + (e) + } Due process procedures for any
individual whose request for medical assistance coverage for any
treatment or service is denied or is not acted upon with
reasonable promptness. These procedures shall include an
expedited process for cases in which a patient's medical needs
require swift resolution of a dispute.
SECTION 21. ORS 414.150 is amended to read:
414.150. It is the purpose of ORS 414.150 { - to 414.153 - }
{ + and 414.152 + } to take advantage of opportunities to:
(1) Enhance the state and local public health partnership;
(2) Improve the access to care and health status of women and
children; and
(3) Strengthen public health programs and services at the
county health department level.
SECTION 22. ORS 414.152 is amended to read:
414.152. To capitalize on the successful public health programs
provided by county health departments and the sizable investment
by state and local governments in the public health system, state
agencies shall encourage agreements that allow county health
departments and other publicly supported programs to continue to
be the providers of those prevention and health promotion
services now available, plus other maternal and child health
services such as prenatal outreach and care, child health
services and family planning services to women and children who
become eligible for poverty level medical assistance program
{ - benefits pursuant to ORS 414.153 - } .
SECTION 23. ORS 414.660 is amended to read:
414.660. { + (1) + } The { - Department of Human
Services - } { + Insurance Pool Governing Board + } shall
pursue demonstration projects for
{ - medical service contracts - } { + health service
coverage + } in at least { + each of + } the { - four
standard metropolitan statistical areas - } { + five
congressional districts + } in this state and is authorized to
seek the necessary federal waivers in order to accomplish such
{ - contracts - } { + projects, + } including but not limited
to:
{ - (1) - } { + (a) + } Limiting the scope of the system to
selected geographic areas;
{ - (2) - } { + (b) + } Allowing participating health plans
to offer benefit enhancements;
{ - (3) - } { + (c) + } Limiting the choice of eligible
persons to those providers affiliated with a participating health
plan;
{ - (4) - } { + (d) + } Allowing primary care providers
access to data concerning clients' utilization of service from
other providers; and
{ - (5) - } { + (e) + } Allowing the { - department - }
{ + board + } the reimbursement flexibility necessary to
implement a prospective reimbursement system for hospital care.
{ + (2) As used in this section, 'health services' means at
least so much of each of the following as are approved and funded
by the Legislative Assembly for the Oregon Child and Family
Health Insurance Program established under ORS 653.805:
(a) Provider services and supplies;
(b) Outpatient services;
(c) Inpatient hospital services; and
(d) Health promotion and disease prevention services. + }
SECTION 24. ORS 414.710 is amended to read:
414.710. The following services are available to persons
eligible for services under ORS 414.025, 414.036, 414.042
{ - , - } { + and + } 414.065 { - and 414.705 to 414.750 but
such services are not subject to ORS 414.720 - } :
(1) Nursing facilities and home- and community-based waivered
services funded through the Senior and Disabled Services
Division;
(2) Medical assistance to eligible persons who are aged and
described in ORS chapter 413 or who are blind or disabled and
described in ORS chapter 412 or to children described in ORS
414.025 { - (2)(f), (i), (j), (k) and (m) - } { + (2)(e),
(h), (i), (j) and (L) + }, 418.001 to 418.034, 418.187 to 418.970
and 657A.020 to 657A.530;
(3) Institutional, home- and community-based waivered services
or community mental health program care for the mentally retarded
or developmentally disabled, for the chronically mentally ill or
emotionally disturbed and for the treatment of alcohol and drug
dependent persons; and
(4) Services to children who are wards of the State Office for
Services to Children and Families by order of the juvenile court
and services to children and families for health care or mental
health care through the office.
SECTION 25. ORS 414.710, as amended by section 52, chapter
1084, Oregon Laws 1999, is amended to read:
414.710. The following services are available to persons
eligible for services under ORS 414.025, 414.036, 414.042
{ - , - } { + and + } 414.065 { - and 414.705 to 414.750 but
such services are not subject to ORS 414.720 - } :
(1) Nursing facilities and home- and community-based waivered
services funded through the Senior and Disabled Services
Division;
(2) Medical assistance to eligible persons who are aged and
described in ORS chapter 413 or who are blind or disabled and
described in ORS chapter 412 or to children described in ORS
414.025 { - (2)(f), (i), (j), (k) and (m) - } { + (2)(e),
(h), (i), (j) and (L) + }, 418.001 to 418.034, 418.189 to 418.970
and 657A.020 to 657A.530;
(3) Institutional, home- and community-based waivered services
or community mental health program care for the mentally retarded
or developmentally disabled, for the chronically mentally ill or
emotionally disturbed and for the treatment of alcohol and drug
dependent persons; and
(4) Services to children who are wards of the State Office for
Services to Children and Families by order of the juvenile court
and services to children and families for health care or mental
health care through the office.
SECTION 26. ORS 414.727 is amended to read:
414.727. (1) { - A health care provider that contracts
with - } The Department of Human Services { - under ORS
414.725 (1) to provide prepaid managed care health services - }
shall reimburse Type A and Type B hospitals, as defined in ORS
442.470 and identified by the Office of Rural Health as rural
hospitals, fully for the cost of covered services based on the
cost-to-charge ratio used for each hospital in setting the
capitation rates paid to the contracting health care provider for
the contract period.
(2) Nothing in this section shall be construed to prohibit a
health care provider and hospital from mutually agreeing to
reimbursement other than the reimbursement specified in
subsection (1) of this section.
SECTION 27. ORS 414.750 is amended to read:
414.750. Nothing in ORS 414.036 { - and 414.705 to
414.750 - } { + and 414.712 + } is intended to limit the
authority of the Legislative Assembly to authorize services for
persons whose income exceeds 100 percent of the federal poverty
level for whom federal medical assistance matching funds are
available if state funds are available therefor.
SECTION 28. ORS 653.705 is amended to read:
653.705. As used in ORS 653.705 to 653.850, unless the context
requires otherwise:
(1) 'Board' means the Insurance Pool Governing Board
established under ORS 653.725.
(2) 'Carrier' means an insurance company or health care service
contractor holding a valid certificate of authority from the
Director of the Department of Consumer and Business Services, or
two or more companies or contractors acting together pursuant to
a joint venture, partnership or other joint means of operation.
(3) 'Class of employee' means an employee classed as either
management or nonmanagement employee.
(4) 'Eligible employee' means an employee of an employer who is
employed by the employer for an average of at least 17.5 hours
per week who elects to participate in one of the group benefit
plans provided through board action, and sole proprietors,
business partners, and limited partners. The term does not
include individuals:
(a) Engaged as independent contractors.
(b) Whose periods of employment are on an intermittent or
irregular basis.
(c) Who have been employed by the employer for fewer than 90
days.
(5) 'Family member' means an eligible employee's spouse and any
unmarried child or stepchild within age limits and other
conditions imposed by the board with regard to unmarried children
or stepchildren.
(6) 'Health benefit plan' means a contract for group { + or
individual + } medical, surgical, hospital or any other remedial
care recognized by state law and related services and supplies.
(7) 'Premium' means the monthly or other periodic charge for a
health benefit plan.
SECTION 29. ORS 653.715 is amended to read:
653.715. It is the intent of the Legislative Assembly by
enactment of ORS 653.705 to 653.850 to increase access to health
insurance and health care by providing:
(1) Information about health benefit plans and the premiums
charged for those plans to { - self-employed - } individuals
and { - small - } employers in Oregon;
(2) Direct assistance to health insurance agents and health
insurance consumers regarding health benefit plans; and
(3) A central source for information about resources for health
care and health insurance.
SECTION 30. ORS 653.725 is amended to read:
653.725. (1) There is established an Insurance Pool Governing
Board consisting of { - seven - } { + eight + } voting
members { - six of whom shall be - } appointed by the
Governor. { - Of the members appointed by the Governor, two - }
{ + Five + } shall be employers { + , + } { - and - } one
shall be an employee representing organized labor { + , one shall
be a consumer representative and one shall be a physician + }.
{ - At least - } { + No more than + } two { + members + }
shall be knowledgeable about insurance { - but who are not - }
{ + based on their being + } officers or employees of a carrier
{ - and not - } { + or + } consultants to a carrier or
contractor. { - The Director of the Department of Consumer and
Business Services shall appoint a consumer representative who
shall serve as a voting member. - }
(2) The term of office of each member is three years, but a
voting member serves at the pleasure of the appointing authority.
Before the expiration of the term of a member, the appointing
authority shall appoint a successor whose term begins on July 1
next following. A member is eligible for reappointment. If there
is a vacancy for any cause, the appointing authority shall make
an appointment to become immediately effective for the unexpired
term.
(3) The appointing authority shall not allow any position on
the board to remain vacant for more than 60 days after the
vacancy occurs.
SECTION 31. ORS 653.735 is amended to read:
653.735. (1) A member of the Insurance Pool Governing Board
shall not be compensated but is entitled to reimbursement for
expenses as provided in ORS 292.495 (2).
(2) The board shall select one of its { - voting - } members
as chairperson and one of its { - voting or nonvoting - }
members as vice chairperson, for such terms and with duties and
powers necessary for the performance of the functions of such
offices as the board determines.
(3) A majority of the members of the board constitutes a quorum
for the transaction of business.
(4) The board shall meet at least once every three months at a
place, day and hour determined by the board. The board also shall
meet at other times and places specified by the call of the
chairperson or of a majority of the members of the board.
(5) In accordance with applicable provisions of ORS 183.310 to
183.550, the board may adopt rules necessary for the
administration of the laws that the board is charged with
administering.
SECTION 32. ORS 653.745 is amended to read:
653.745. (1) In carrying out its duties under ORS 653.705 to
653.850, the Insurance Pool Governing Board shall:
(a) Enter into contracts for administration of ORS 653.705 to
653.850 including collection of premiums and paying carriers.
(b) Retain consultants and employ staff.
{ + (c) Perform other duties to provide low-cost insurance
plans of types likely to be purchased by individuals or
employers.
(d) Notwithstanding any other benefit plan contracted for and
offered by the board, the board shall contract for a health
benefit plan or plans best designed to meet the needs of both
individual and employers for affordable coverage. + }
(2) The board may employ whatever means are reasonably
necessary to carry out the purposes of ORS 653.705 to 653.850.
Such authority includes but is not limited to authority to seek
clarification, amendment, modification, suspension or termination
of any agreement or contract { - which - } { + that + } in
the board's judgment requires such action.
{ + (3) If the board requests less service than is otherwise
required by state law, a carrier is not required to offer such
service. + }
SECTION 33. ORS 653.747 is amended to read:
653.747. (1) The Insurance Pool Governing Board shall encourage
increased health insurance coverage among { - small - }
{ + individuals and + } employers:
(a) By providing information, benefit comparisons, premium
comparisons and technical assistance on obtaining
{ - employee - } { + health + } benefits and on incentives
including, but not limited to, information on the pretax health
benefit options allowed under section 125 of the United States
Internal Revenue Code { + or similar provisions of federal
law + }; and
(b) By using other means necessary to market health benefit
plan coverage to { - small - } { + individuals and + }
employers.
(2) The Insurance Pool Governing Board shall provide
information about other resources for accessing health care and
shall assist consumers in accessing those resources.
SECTION 34. { + Sections 35 to 38 of this 2001 Act are added
to and made a part of ORS 653.705 to 653.850. + }
SECTION 35. { + (1) The monthly contribution of each
individual enrolled for health benefit plan coverage shall be the
total cost per month of the benefit coverage afforded under the
plan or plans for the plan or plans picked by the individual,
including the administrative expenses therefor less the portion
thereof, if any, contributed by the employer. An individual may
enroll in more than one plan at a time as long as the plans do
not offer overlapping services.
(2) The contribution shall be the amount necessary to pay the
cost of the health benefit plan covering the individual, as
described in section 37 of this 2001 Act, and other plans
selected by a covered individual, including the administrative
expenses.
(3) Payroll deductions for the costs that are not payable by
the employer shall be made by the employer upon receipt of a
signed authorization from the employee indicating an election to
participate in the plan covering the employee or the employee's
immediate family. + }
SECTION 36. { + (1) In order to be eligible to participate in
the programs authorized by ORS 653.705 to 653.850, an employer
shall make a contribution to be set by the Insurance Pool
Governing Board toward the premium incurred on behalf of a
covered employee or other individual.
(2) An employer may elect to cover fewer than the total number
of employees as long as its covered class includes all employees
in the class. + }
SECTION 37. { + (1) Part I coverage applies to eligible
covered individuals only.
(2) The plan shall have a stop loss to ensure that no
individual is required to pay the costs of a major accident or
illness, beyond the costs of the deductible and other reasonable
cost-sharing requirements, and that Part I coverage can be
obtained at a low enough cost to ensure accessibility.
(3) All covered eligible individuals shall participate in and
be covered by at least Part I coverage. An employer may require a
minimum employee contribution of not to exceed 25 percent of the
premium for only Part I coverage described in this section.
(4) Part I coverage shall include at least those health care
services defined in ORS 414.660. + }
SECTION 38. { + (1) Part II coverage shall consist of a
variety of additional benefit packages that an individual or
employer may purchase. All packages shall contain incentives to
encourage the covered individual to intelligently utilize
services in a cost-effective way and disincentives to discourage
non-cost-effective use of services.
(2) Packages shall be available to extend coverage to the
employee or the employee's family members.
(3) In general, Part II packages shall not provide benefits
provided by Part I coverage. Employers may contribute toward the
cost of Part II coverage.
(4) The Insurance Pool Governing Board may establish by rule
that certain packages shall not be available to an employee who
is not covered by a certain other package or packages. + }
SECTION 39. ORS 653.800 is amended to read:
653.800. For purposes of ORS 653.800 to 653.850:
(1) 'Eligible individual' means an individual who:
(a) Is a resident of the State of Oregon;
(b) Is not eligible for Medicare;
(c) Either has been without health benefit plan coverage for a
period of time established by the Insurance Pool Governing Board,
or meets exception criteria established by the board;
(d) Except as otherwise provided by the board, has family
income less than 200 percent of the federal poverty level;
(e) Has investments and savings less than the limit established
by the board; and
(f) Meets other eligibility criteria established by the board.
(2) 'Family' means:
(a) { - A single - } { + An + } individual who is not
claimed as a dependent for state income tax purposes;
(b) An adult and the adult's spouse;
(c) An adult and the adult's spouse and all unmarried,
dependent children under 23 years of age, including adopted
children and children placed for adoption; or
(d) An adult and the adult's unmarried, dependent children
under 23 years of age, including adopted children and children
placed for adoption.
(3)(a) 'Health benefit plan' means a policy or certificate of
group or individual health insurance, as defined in ORS 731.162,
providing payment or reimbursement for hospital, medical and
surgical expenses. 'Health benefit plan' includes a medical
savings account, health care service contractor or health
maintenance organization subscriber contract, the Oregon Medical
Insurance Pool and any plan provided by a less than fully insured
multiple employer welfare arrangement or by another benefit
arrangement defined in the federal Employee Retirement Income
Security Act of 1974, as amended.
(b) 'Health benefit plan' does not include coverage for
accident only, specific disease or condition only, credit,
disability income, coverage of Medicare services pursuant to
contracts with the federal government, Medicare supplement
insurance, student accident and health insurance, long term care
insurance, hospital indemnity only, dental only, vision only,
coverage issued as a supplement to liability insurance, insurance
arising out of a workers' compensation or similar law, automobile
medical payment insurance or insurance under which the benefits
are payable with or without regard to fault and that is legally
required to be contained in any liability insurance policy or
equivalent self-insurance.
(4) 'Income' means gross income in cash or kind available to
the applicant or recipient.
(5) 'Investment and savings' means cash, securities as defined
in ORS 59.015, negotiable instruments as defined in ORS 73.0104
and such similar investments or savings as the board may
establish that are available to the applicant or recipient to
contribute toward meeting the needs of an applicant or eligible
individual.
(6) 'Medicaid' means medical assistance provided under 42
U.S.C. section 396a (section 1902 of the Social Security Act).
(7) 'Medical savings account' means a trust that is created
exclusively for the purpose of paying qualified medical expenses
of the account holder and that qualifies for tax deduction under
section 220 of the Internal Revenue Code. 'Medical savings
account' includes an associated high deductible health benefit
plan.
(8) 'Resident' means an individual who demonstrates to the
Insurance Pool Governing Board that the individual is lawfully
residing in Oregon and intends to reside in Oregon permanently.
(9) 'Subsidy' means payment or reimbursement to an eligible
individual toward the purchase of a health benefit plan, and may
include a net billing arrangement with insurance carriers or a
prospective or retrospective payment for health benefit plan
premiums and eligible copayments or deductible expenses directly
related to the eligible individual.
(10) 'Third-party administrator' means any insurance company or
other entity licensed under the Insurance Code to administer
health insurance benefit programs.
SECTION 40. ORS 653.805 is amended to read:
653.805. (1) There is established the { + Oregon Child and + }
Family Health Insurance { - Assistance - } Program in the
Insurance Pool Governing Board. The purpose of the program is to
remove economic barriers to health insurance coverage for
residents of the State of Oregon with family income less than 200
percent of the federal poverty level, and investment and savings
less than the limit established by the board, while encouraging
individual responsibility, promoting health benefit plan coverage
of children, building on the private sector health benefit plan
system and encouraging employer and employee participation in
employer sponsored health benefit plan coverage.
(2) The Insurance Pool Governing Board shall be responsible for
the implementation and operation of the { + Oregon Child and + }
Family Health Insurance { - Assistance - } Program. { - The
Administrator of the Office for Oregon Health Plan Policy and
Research, in consultation with the Oregon Health Council, shall
make recommendations to the board regarding program policy,
including but not limited to eligibility requirements, assistance
levels, benefit criteria and insurance carrier participation. The
board shall adopt all policy recommendations made by the
Administrator of the Office for Oregon Health Plan Policy and
Research pursuant to this subsection. - }
(3) The board { - shall - } { + may + } enter into a
contract with a third-party administrator to administer the
{ + Oregon Child and + } Family Health Insurance
{ - Assistance - } Program. Duties of the third-party
administrator may include but are not limited to:
(a) Eligibility determination;
(b) Data collection;
(c) Assistance payments;
(d) Financial tracking and reporting; and
(e) Such other services as the board may deem necessary for the
administration of the program.
(4) In entering into a contract with a third-party
administrator pursuant to subsection (3) of this section, the
board shall engage in competitive bidding. The board shall
evaluate bids according to criteria established by the board,
including but not limited to:
(a) The applicant's proven ability to administer a program of
the size of the { + Oregon Child and + } Family Health Insurance
{ - Assistance - } Program;
(b) The efficiency of the applicant's payment procedures;
(c) The estimate provided of the total charges necessary to
administer the program; and
(d) The applicant's ability to operate the program in a
cost-effective manner.
SECTION 41. { + (1) The amendments to ORS 653.805 by section
40 of this 2001 Act are intended to change the name of the Family
Health Insurance Assistance Program to the Oregon Child and
Family Health Insurance Program.
(2) For the purpose of harmonizing and clarifying statute
sections published in Oregon Revised Statutes, the Legislative
Counsel may substitute for words designating the Family Health
Insurance Assistance Program, wherever they occur in Oregon
Revised Statutes, other words designating the Oregon Child and
Family Health Insurance Program. + }
SECTION 42. ORS 653.810 is amended to read:
653.810. (1) To enroll in the { + Oregon Child and + } Family
Health Insurance { - Assistance - } Program established in ORS
653.800 to 653.850, an applicant shall submit a written
application to the Insurance Pool Governing Board or to the
third-party administrator contracted by the board to administer
the program pursuant to ORS 653.805 in the form and manner
prescribed by the board. Except as provided in ORS 653.820, if
the applicant qualifies as an eligible individual, the applicant
shall either be enrolled in the program or placed on a waiting
list for enrollment.
(2) After an eligible individual has enrolled in the program,
the individual shall remain eligible for enrollment for the
period of time established by the board.
(3) After an eligible individual has enrolled in the program,
the board or third-party administrator shall issue subsidies in
an amount determined pursuant to ORS 653.815 to either the
eligible individual or to the health insurance carrier designated
by the eligible individual, subject to the following
restrictions:
(a) Subsidies may not be issued to an adult unless all
children, if any, in the adult's family are covered under a
health benefit plan or Medicaid.
(b) Subsidies may not be used to subsidize premiums on a health
benefit plan whose premiums are wholly paid by the eligible
individual's employer without contribution from the employee.
(c) Such other restrictions as the board may adopt.
(4) The board may issue subsidies to an eligible individual in
advance of a purchase of a health benefit plan.
(5) To remain eligible for a subsidy, an eligible individual
must enroll in a group health benefit plan if a plan is available
to the eligible individual through the individual's employment
and the employer makes a monetary contribution toward the cost of
the plan, unless the board implements specific cost or benefit
structure criteria that make enrollment in an individual health
insurance plan more advantageous for the eligible individual.
SECTION 43. ORS 653.815 is amended to read:
653.815. (1) The Insurance Pool Governing Board shall determine
the level of assistance to be granted under ORS 653.810 based on
a sliding scale that considers:
(a) Family size;
(b) Family income;
(c) The number of members of a family who will receive health
benefit plan coverage subsidized through the { + Oregon Child
and + } Family Health Insurance { - Assistance - } Program;
and
(d) Such other factors as the board may establish.
(2) Notwithstanding the sliding scale established in subsection
(1) of this section, the board may establish different assistance
levels for otherwise similarly situated eligible individuals
based on factors including but not limited to whether the
individual is enrolled in an employer-sponsored group health
benefit plan or an individual health benefit plan.
SECTION 44. ORS 653.820 is amended to read:
653.820. (1) Notwithstanding eligibility criteria and subsidy
amounts established pursuant to ORS 653.800 to 653.850, subsidies
shall be provided only to the extent the Legislative Assembly
specifically appropriates funds to provide such assistance.
(2) The Insurance Pool Governing Board shall prohibit or limit
enrollment in the { + Oregon Child and + } Family Health
Insurance
{ - Assistance - } Program to ensure that program expenditures
are within legislatively appropriated amounts. Prohibitions or
limitations allowed under this section may include but are not
limited to:
(a) Lowering the allowable income level necessary to qualify as
an eligible individual; and
(b) Establishing a waiting list of eligible individuals who
shall receive subsidies only when sufficient funds are available.
SECTION 45. ORS 653.825 is amended to read:
653.825. The Insurance Pool Governing Board may { - , based on
the recommendation of the Administrator of the Office for Oregon
Health Plan Policy and Research, - } establish minimum benefit
requirements for individual health benefit plans subject to
subsidy pursuant to the { + Oregon Child and + } Family Health
Insurance
{ - Assistance - } Program, including but not limited to the
type of services covered and the amount of cost-sharing to be
allowed.
SECTION 46. ORS 653.830 is amended to read:
653.830. (1) Except as otherwise provided in this section,
information provided to the Insurance Pool Governing Board as
part of an application for enrollment in the { + Oregon Child
and + } Family Health Insurance { - Assistance - } Program
shall remain confidential.
(2) The board may exchange information provided to the board
with other state and federal agencies for the purposes of
verifying eligibility for the program, improving provision of
services and identifying economic trends relevant to
administration of the program.
(3) In accordance with applicable state and federal law, the
board may require applicants to provide their Social Security
numbers and use those numbers in the administration of the
program.
SECTION 47. ORS 653.835 is amended to read:
653.835. The Insurance Pool Governing Board { - , in
consultation with the Administrator of the Office for Oregon
Health Plan Policy and Research, - } shall adopt all rules
necessary for the implementation and operation of the { + Oregon
Child and + } Family Health Insurance { - Assistance - }
Program.
SECTION 48. ORS 653.840 is amended to read:
653.840. There is established in the State Treasury the { +
Oregon Child and + } Family Health Insurance { - Assistance - }
Program Account, which shall consist of moneys appropriated to
the account by the Legislative Assembly and interest earnings
from the investment of moneys in the account. All moneys in the
{ + Oregon Child and + } Family Health Insurance
{ - Assistance - } Program Account are continuously
appropriated to the Insurance Pool Governing Board to carry out
the provisions of ORS 653.800 to 653.850.
SECTION 49. ORS 653.850 is amended to read:
653.850. (1) The Insurance Pool Governing Board may impose
sanctions against an individual who violates any provision of ORS
653.800 to 653.850 or rules adopted thereto, including but not
limited to suspension or termination from the { + Oregon Child
and + } Family Health Insurance { - Assistance - } Program and
repayment of any subsidy amounts paid due to the fraudulent
misrepresentation of an applicant or enrolled individual.
Sanctions allowed under this subsection shall be imposed in the
manner prescribed in ORS 183.310 to 183.550.
(2) In addition to the sanctions available pursuant to
subsection (1) of this section, the board may impose a civil
penalty not to exceed $1,000 against any individual who violates
any provision of ORS 653.800 to 653.850 or rules adopted pursuant
thereto. Civil penalties imposed pursuant to this section shall
be imposed pursuant to ORS 183.090.
SECTION 50. ORS 442.588 is amended to read:
442.588. Nothing in ORS { - 414.720, - } 431.120, 442.120,
442.575, 442.583 and 442.588 is intended to limit the authority
of the Health Resources Commission { - and Health Services
Commission - } to appoint { - their - } { + its + } own
employees.
SECTION 51. ORS 743.730 is amended to read:
743.730. As used in ORS 743.730 to 743.773:
(1) 'Actuarial certification' means a written statement by a
member of the American Academy of Actuaries or other individual
acceptable to the Director of the Department of Consumer and
Business Services that a carrier is in compliance with the
provisions of ORS 743.736, 743.760 or 743.761, based upon the
person's examination, including a review of the appropriate
records and of the actuarial assumptions and methods used by the
carrier in establishing premium rates for small employer and
portability health benefit plans.
(2) 'Affiliate' of, or person 'affiliated' with, a specified
person means any carrier who, directly or indirectly through one
or more intermediaries, controls or is controlled by or is under
common control with a specified person. For purposes of this
definition, 'control' has the meaning given that term in ORS
732.548.
(3) 'Affiliation period' means, under the terms of a group
health benefit plan issued by a health care service contractor, a
period:
(a) That is applied uniformly and without regard to any health
status related factors to an enrollee or late enrollee in lieu of
a preexisting conditions provision;
(b) That must expire before any coverage becomes effective
under the plan for the enrollee or late enrollee;
(c) During which no premium shall be charged to the enrollee or
late enrollee; and
(d) That begins on the enrollee's or late enrollee's first date
of eligibility for coverage and runs concurrently with any
eligibility waiting period under the plan.
(4) 'Basic health benefit plan' means a health benefit plan for
small employers that is required to be offered by all small
employer carriers and approved by the Director of the Department
of Consumer and Business Services in accordance with ORS 743.736.
(5) 'Bona fide association' means an association that meets the
requirements of 42 U.S.C. 300gg-11 as amended and in effect on
July 1, 1997.
(6) 'Carrier' means any person who provides health benefit
plans in this state, including a licensed insurance company, a
health care service contractor, a health maintenance
organization, an association or group of employers that provides
benefits by means of a multiple employer welfare arrangement or
any other person or corporation responsible for the payment of
benefits or provision of services.
(7) 'Committee' means the Health Insurance Reform Advisory
Committee created under ORS 743.745.
(8) 'Creditable coverage' means prior health care coverage as
defined in 42 U.S.C. 300gg as amended and in effect on July 1,
1997, and includes coverage remaining in force at the time the
enrollee obtains new coverage.
(9) 'Department' means the Department of Consumer and Business
Services.
(10) 'Dependent' means the spouse or child of an eligible
employee, subject to applicable terms of the health benefit plan
covering the employee.
(11) 'Director' means the Director of the Department of
Consumer and Business Services.
(12) 'Eligible employee' means an employee of a small employer
who works on a regularly scheduled basis, with a normal work week
of 17.5 or more hours. The employer may determine hours worked
for eligibility between 17.5 and 40 hours per week subject to
rules of the carrier. The term includes sole proprietors,
partners of a partnership or independent contractors if they are
included as employees under a health benefit plan of a small
employer but does not include employees who work on a temporary,
seasonal or substitute basis. Employees who have been employed by
the small employer for fewer than 90 days are not eligible
employees unless the small employer so allows.
(13) 'Enrollee' means an employee, dependent of the employee or
an individual otherwise eligible for a group, individual or
portability health benefit plan who has enrolled for coverage
under the terms of the plan.
(14) 'Exclusion period' means a period during which specified
treatments or services are excluded from coverage.
(15) 'Financially impaired' means a member that is not
insolvent and is:
(a) Considered by the Director of the Department of Consumer
and Business Services to be potentially unable to fulfill its
contractual obligations; or
(b) Placed under an order of rehabilitation or conservation by
a court of competent jurisdiction.
(16)(a) 'Geographic average rate' means the arithmetical
average of the lowest premium and the corresponding highest
premium to be charged by a carrier in a geographic area
established by the director for the carrier's:
(A) Small employer group health benefit plans;
(B) Individual health benefit plans; or
(C) Portability health benefit plans.
(b) 'Geographic average rate' does not include premium
differences that are due to differences in benefit design or
family composition.
(17) 'Group eligibility waiting period' means, with respect to
a group health benefit plan, the period of employment or
membership with the group that a prospective enrollee must
complete before plan coverage begins.
(18)(a) 'Health benefit plan' means any hospital expense,
medical expense or hospital or medical expense policy or
certificate, health care service contractor or health maintenance
organization subscriber contract, any plan provided by a multiple
employer welfare arrangement or by another benefit arrangement
defined in the federal Employee Retirement Income Security Act of
1974, as amended.
(b) 'Health benefit plan' does not include coverage for
accident only, specific disease or condition only, credit,
disability income, coverage of Medicare services pursuant to
contracts with the federal government, Medicare supplement
insurance policies, coverage of CHAMPUS services pursuant to
contracts with the federal government, benefits delivered through
a flexible spending arrangement established pursuant to section
125 of the Internal Revenue Code of 1986, as amended, when the
benefits are provided in addition to a group health benefit plan,
long term care insurance, hospital indemnity only, short term
health insurance policies (the duration of which does not exceed
six months including renewals), student accident and health
insurance policies, dental only, vision only, a policy of
stop-loss coverage that meets the requirements of ORS 742.065,
coverage issued as a supplement to liability insurance, insurance
arising out of a workers' compensation or similar law, automobile
medical payment insurance or insurance under which benefits are
payable with or without regard to fault and that is statutorily
required to be contained in any liability insurance policy or
equivalent self-insurance.
(c) Nothing in this subsection shall be construed to regulate
any employee welfare benefit plan that is exempt from state
regulation because of the federal Employee Retirement Income
Security Act of 1974, as amended.
(19) 'Health statement' means any information that is intended
to inform the carrier or agent of the health status of an
enrollee or prospective enrollee in a health benefit plan. '
Health statement' includes the standard health statement
developed by the Health Insurance Reform Advisory Committee.
{ - (20) 'Implementation of chapter 836, Oregon Laws 1989 '
means that the Health Services Commission has prepared a priority
list, the Legislative Assembly has enacted funding of the list
and all necessary federal approval, including waivers, has been
obtained. - }
{ - (21) - } { + (20) + } 'Individual coverage waiting
period' means a period in an individual health benefit plan
during which no premiums may be collected and health benefit plan
coverage issued is not effective.
{ - (22) - } { + (21) + } 'Initial enrollment period' means
a period of at least 30 days following commencement of the first
eligibility period for an individual.
{ - (23) - } { + (22) + } 'Insurance Pool Governing Board'
means the Insurance Pool Governing Board established by ORS
653.725.
{ - (24) - } { + (23) + } 'Late enrollee' means an
individual who enrolls in a group health benefit plan subsequent
to the initial enrollment period during which the individual was
eligible for coverage but declined to enroll. However, an
eligible individual shall not be considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg as amended and in effect on July
1, 1997;
(b) The individual applies for coverage during an open
enrollment period;
(c) A court has ordered that coverage be provided for a spouse
or minor child under a covered employee's health benefit plan and
request for enrollment is made within 30 days after issuance of
the court order;
(d) The individual is employed by an employer who offers
multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period;
or
(e) The individual's coverage under Medicaid, Medicare,
CHAMPUS, Indian Health Service or a publicly sponsored or
subsidized health plan, including but not limited to the Oregon
Health Plan, has been involuntarily terminated within 63 days of
applying for coverage in a group health benefit plan.
{ - (25) - } { + (24) + } 'Multiple employer welfare
arrangement' means a multiple employer welfare arrangement as
defined in section 3 of the federal Employee Retirement Income
Security Act of 1974, as amended, 29 U.S.C. 1002, that is subject
to ORS 750.301 to 750.341.
{ - (26) - } { + (25) + } 'Oregon Medical Insurance Pool'
means the pool created under ORS 735.610.
{ - (27) - } { + (26) + } 'Preexisting conditions
provision' means a health benefit plan provision applicable to an
enrollee or late enrollee that excludes coverage for services,
charges or expenses incurred during a specified period
immediately following enrollment for a condition for which
medical advice, diagnosis, care or treatment was recommended or
received during a specified period immediately preceding
enrollment. For purposes of ORS 743.730 to 743.773:
(a) Pregnancy does not constitute a preexisting condition
except as provided in ORS 743.766;
(b) Genetic information does not constitute a preexisting
condition in the absence of a diagnosis of the condition related
to such information; and
(c) A preexisting conditions provision shall not be applied to
a newborn child or adopted child who obtains coverage in
accordance with ORS 743.707.
{ - (28) - } { + (27) + } 'Premium' includes insurance
premiums or other fees charged for a health benefit plan,
including the costs of benefits paid or reimbursements made to or
on behalf of enrollees covered by the plan.
{ - (29) - } { + (28) + } 'Rating period' means the
12-month calendar period for which premium rates established by a
carrier are in effect, as determined by the carrier.
{ - (30) - } { + (29) + } 'Small employer' means any
person, firm, corporation, partnership or association actively
engaged in business that, on at least 50 percent of its working
days during the preceding year, employed no more than 25 eligible
employees and no fewer than two eligible employees, the majority
of whom are employed within this state, and in which a bona fide
partnership, independent contractor or employer-employee
relationship exists. ' Small employer' includes companies that
are eligible to file a consolidated tax return pursuant to ORS
317.715.
{ - (31) - } { + (30) + } 'Small employer carrier' means
any carrier that offers health benefit plans covering eligible
employees of one or more small employers. A fully insured
multiple employer welfare arrangement otherwise exempt under ORS
750.303 (4) may elect to be a small employer carrier governed by
the provisions of ORS 743.733 to 743.737.
SECTION 52. ORS 743.736 is amended to read:
743.736. (1) In order to improve the availability and
affordability of health benefit coverage for small employers, the
Health Insurance Reform Advisory Committee created under ORS
743.745 shall submit to the Director of the Department of
Consumer and Business Services two basic health benefit plans
pursuant to ORS 743.745. One plan shall be in the form of
insurance and the second plan shall be consistent with the
requirements of the federal Health Maintenance Organization Act,
42 U.S.C. 300e et seq.
(2) { - (a) - } The director shall approve the basic health
benefit plans following a determination that the plans provide
for maximum accessibility and affordability of needed health care
services
{ - and following a determination that the basic health benefit
plans substantially meet the social values that underlie the
ranking of benefits by the Health Services Commission and that
the basic health benefit plans are substantially similar to the
Medicaid reform program under chapter 836, Oregon Laws 1989,
funded by the Legislative Assembly - } .
{ - (b) The basic health benefit plans shall include benefits
mandated under ORS 743.556 until mental health, alcohol and
chemical dependency services are fully integrated into the Health
Services Commission's priority list, and as funded by the
Legislative Assembly, and chapter 836, Oregon Laws 1989, is
implemented. - }
{ - (c) The commission shall aid the director by reviewing
the basic health benefit plans and commenting on the extent to
which the plans meet these criteria. - }
(3) After the director's approval of the basic health benefit
plans submitted by the committee pursuant to subsection (1) of
this section, each small employer carrier shall submit to the
director the policy form or forms containing its basic health
benefit plan. Each policy form must be submitted as prescribed by
the director and is subject to review and approval pursuant to
ORS 742.003.
(4)(a) As a condition of transacting business in the small
employer health insurance market in this state, every small
employer carrier shall offer small employers an approved basic
health benefit plan and any other plans that have been submitted
by the small employer carrier for use in the small employer
market and approved by the director.
(b) Nothing in this subsection shall require a small employer
carrier to resubmit small employer health benefit plans that were
approved by the director prior to October 1, 1996, nor shall
small employer carriers be required to reinitiate new plan
selection procedures for currently enrolled small employers prior
to the small employer's next health benefit plan coverage
anniversary date.
(c) A carrier that offers a health benefit plan in the small
employer market only through one or more bona fide associations
is not required to offer that health benefit plan to small
employers that are not members of the bona fide association.
(5) A small employer carrier shall issue to a small employer
any small employer health benefit plan offered by the carrier if
the small employer applies for the plan and agrees to make the
required premium payments and to satisfy the other provisions of
the health benefit plan.
(6) A multiple employer welfare arrangement, professional or
trade association or other similar arrangement established or
maintained to provide benefits to a particular trade, business,
profession or industry or their subsidiaries shall not issue
coverage to a group or individual that is not in the same trade,
business, profession or industry as that covered by the
arrangement. The arrangement shall accept all groups and
individuals in the same trade, business, profession or industry
or their subsidiaries that apply for coverage under the
arrangement and that meet the requirements for membership in the
arrangement. For purposes of this subsection, the requirements
for membership in an arrangement shall not include any
requirements that relate to the actual or expected health status
of the prospective enrollee.
(7) A small employer carrier shall, pursuant to subsections (4)
and (5) of this section, offer coverage to or accept applications
from a group covered under an existing small employer health
benefit plan whether or not a prospective enrollee is excluded
from coverage under the existing plan because of late enrollment.
When a small employer carrier accepts an application for such a
group, the carrier may continue to exclude the prospective
enrollee excluded from coverage by the replaced plan until the
prospective enrollee would have become eligible for coverage
under that replaced plan.
(8) No small employer carrier shall be required to offer
coverage or accept applications pursuant to subsections (4) and
(5) of this section if the director finds that acceptance of an
application or applications would endanger the carrier's ability
to fulfill its contractual obligations or result in financial
impairment of the carrier.
(9) Every small employer carrier shall market fairly all small
employer health benefit plans offered by the carrier to small
employers in the geographical areas in which the carrier makes
coverage available or provides benefits.
(10)(a) No small employer carrier shall be required to offer
coverage or accept applications pursuant to subsections (4) and
(5) of this section in the case of any of the following:
(A) To a small employer if the small employer is not physically
located in the carrier's approved service area;
(B) To an employee if the employee does not work or reside
within the carrier's approved service areas; or
(C) Within an area where the carrier reasonably anticipates,
and demonstrates to the satisfaction of the director, that it
will not have the capacity in its network of providers to deliver
services adequately to the enrollees of those groups because of
its obligations to existing group contract holders and enrollees.
(b) A carrier that does not offer coverage pursuant to
paragraph (a)(C) of this subsection shall not offer coverage in
the applicable service area to new employer groups other than
small employers until the carrier resumes enrolling groups of new
small employers in the applicable area.
(11) For purposes of ORS 743.733 to 743.737, except as provided
in this subsection, carriers that are affiliated carriers or that
are eligible to file a consolidated tax return pursuant to ORS
317.715 shall be treated as one carrier and any restrictions or
limitations imposed by ORS 743.733 to 743.737 apply as if all
health benefit plans delivered or issued for delivery to small
employers in this state by the affiliated carriers were issued by
one carrier. However, any insurance company or health maintenance
organization that is an affiliate of a health care service
contractor located in this state, or any health maintenance
organization located in this state that is an affiliate of an
insurance company or health care service contractor, may treat
the health maintenance organization as a separate carrier and
each health maintenance organization that operates only one
health maintenance organization in a service area in this state
may be considered a separate carrier.
(12) A small employer carrier that, after September 29, 1991,
elects to discontinue offering all of its small employer health
benefit plans under ORS 743.737 (5)(e), elects to discontinue
renewing all such plans or elects to discontinue offering and
renewing all such plans is prohibited from offering health
benefit plans in the small employer market in this state for a
period of five years from one of the following dates:
(a) The date of notice to the director pursuant to ORS 743.737
(5)(e); or
(b) If notice is not provided under paragraph (a) of this
subsection, from the date on which the director provides notice
to the carrier that the director has determined that the carrier
has effectively discontinued offering small employer health
benefit plans in this state.
SECTION 53. { + ORS 414.019, 414.107, 414.151, 414.153,
414.211, 414.221, 414.225, 414.350, 414.355, 414.360, 414.365,
414.370, 414.375, 414.380, 414.385, 414.390, 414.395, 414.400,
414.410, 414.415, 414.620, 414.630, 414.670, 414.705, 414.715,
414.720, 414.725, 414.730, 414.735, 414.745, 414.751 and 653.845
and section 6a, chapter 916, Oregon Laws 1991, and section 34,
chapter 683, Oregon Laws 1997, are repealed. + }
SECTION 54. { + This 2001 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2001 Act takes effect
July 1, 2001. + }
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