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 2009
Senate Bill 884
Sponsored by Senator CORCORAN; Senators L BEYER, BROWN, CASTILLO,
Representative LOWE
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Requires all insurers offering health benefit plan to maintain
sufficient number of providers.
A BILL FOR AN ACT
Relating to sufficiency of provider network of health benefit
plan; creating new provisions; and amending ORS 743.804.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 743.804 is amended to read:
743.804. All insurers offering a health benefit plan in this
state shall:
(1) Have a written policy that recognizes the rights of
enrollees:
(a) To voice grievances about the organization or health care
provided;
(b) To be provided with information about the organization, its
services and the providers providing care;
(c) To participate in decision making regarding their health
care; and
(d) To be treated with respect and recognition of their dignity
and need for privacy.
(2) Provide a summary of policies on enrollees' rights and
responsibilities to all participating providers upon request and
to all enrollees either directly or, in the case of group
coverage, to the employer or other policyholder for distribution
to enrollees.
(3) Have a timely and organized system for resolving grievances
and appeals. The system shall include:
(a) A systematic method for recording all grievances and
appeals, including the nature of the grievances, and significant
actions taken;
(b) Written procedures explaining the grievance and appeal
process, including a procedure to assist enrollees in filing
written grievances;
(c) Written decisions in plain language justifying grievance
determinations, including appropriate references to relevant
policies, procedures and contract terms;
(d) Standards for timeliness in responding to grievances or
appeals that accommodate the clinical urgency of the situation;
(e) Notice in all written decisions prepared pursuant to this
subsection that the enrollee may file a complaint with the
Director of the Department of Consumer and Business Services; and
(f) An appeal process for grievances that includes at least the
following:
(A) Two levels of review, the second of which shall be by
persons not previously involved in the dispute;
(B) Opportunity for enrollees and any representatives of the
enrollees to appear before a review panel at either the first or
second level of review. Representatives may include health care
providers or any other persons chosen by the enrollee. The
enrollee and insurer shall each provide advance notification of
the number of representatives who will appear before the panel
and the relationship of the representatives to the enrollee or
insurer; and
(C) Written decisions in plain language justifying appeal
determinations, including specific references to relevant
provisions of the health benefit plan and related written
corporate practices.
(4) If the insurer has a prescription drug formulary, have:
(a) A written procedure by which a provider with authority to
prescribe drugs and medications may prescribe drugs and
medications not included in the formulary. The procedure shall
include the circumstances when a drug or medication not included
in the formulary will be considered a covered benefit; and
(b) A written procedure to provide full disclosure to enrollees
of any cost sharing or other requirements to obtain drugs and
medications not included in the formulary.
(5) Furnish to all enrollees either directly or, in the case of
a group policy, to the employer or other policyholder for
distribution to enrollees written general information informing
enrollees about services provided, access to services, charges
and scheduling applicable to each enrollee's coverage, including:
(a) Benefits and services included and how to obtain them,
including any restrictions that apply to services obtained
outside the insurer's network or outside the insurer's service
area;
(b) Provisions for referrals, if any, for specialty care,
behavioral health services and hospital services and how
enrollees may obtain the care or services;
(c) Provisions for after-hours and emergency care and how
enrollees may obtain that care, including the insurer's policy,
if any, on when enrollees should directly access emergency care
and use 9-1-1 services;
(d) Charges to enrollees, if applicable, including any policy
on cost sharing for which the enrollee is responsible;
(e) Procedures for notifying enrollees of:
(A) A change in or termination of any benefit;
(B) If applicable, termination of a primary care delivery
office or site; and
(C) If applicable, assistance available to enrollees affected
by the termination of a primary care delivery office or site in
selecting a new primary care delivery office or site;
(f) Procedures for appealing decisions adversely affecting the
enrollee's benefits or enrollment status;
(g) Procedures, if any, for changing providers;
(h) Procedures for voicing grievances;
(i) A description of the procedures, if any, by which enrollees
and their representatives may participate in the development of
the insurer's corporate policies and practices;
(j) Summary information on how the insurer makes decisions
regarding coverage and payment for treatment or services,
including a general description of any prior authorization and
utilization review requirements that affect coverage or payment;
(k) A summary of criteria used to determine if a service or
drug is considered experimental or investigational;
(L) Information about provider, clinic and hospital networks,
if any, including a list of network providers and information
about how the enrollee may obtain current information about the
availability of individual providers, the hours the providers are
available and a description of any limitations on the ability of
enrollees to select primary and specialty care providers;
(m) A general disclosure of any risk-sharing arrangements the
insurer has with physicians and other providers;
(n) A summary of the insurer's procedures for protecting the
confidentiality of medical records and other enrollee
information, including the provision required in ORS 743.809;
(o) A description of any assistance provided to
non-English-speaking enrollees;
(p) A summary of the insurer's policies, if any, on drug
prescriptions, including any drug formularies, cost sharing
differentials or other restrictions that affect coverage of drug
prescriptions;
(q) Notice of the enrollee's right to file a complaint or seek
other assistance from the Director of the Department of Consumer
and Business Services; and
(r) Notice of the information that is available upon request
pursuant to subsection (6) of this section and information that
is available from the Department of Consumer and Business
Services pursuant to ORS 743.804, 743.807, 743.814 and 743.817.
(6) Provide the following information upon the request of an
enrollee or prospective enrollee:
(a) Rules related to the insurer's drug formulary, if any,
including information on whether a particular drug is included or
excluded from the formulary;
(b) Provisions for referrals, if any, for specialty care,
behavioral health services and hospital services and how
enrollees may obtain the care or services;
(c) A copy of the insurer's annual report on grievances and
appeals as submitted to the department under subsection (9) of
this section;
(d) A description of the insurer's risk-sharing arrangements
with physicians and other providers consistent with risk-sharing
information required by the federal Health Care Financing
Administration pursuant to 42 CFR 417.124 (3) (b) as in effect on
June 18, 1997;
(e) A description of the insurer's efforts, if any, to monitor
and improve the quality of health services; and
(f) Information about any insurer procedures for credentialing
network providers and how to obtain the names, qualifications and
titles of the providers responsible for an enrollee's care.
(7) Except as otherwise provided in this subsection, provide to
enrollees, upon request, a written summary of information that
the insurer may consider in its utilization review of a
particular condition or disease to the extent the insurer
maintains such criteria. Nothing in this section shall require an
insurer to advise an enrollee how the insurer would cover or
treat that particular enrollee's disease or condition.
Utilization review criteria that is proprietary shall be subject
to verbal disclosure only.
(8) Provide the following information to an enrollee when the
enrollee has filed a grievance:
(a) Detailed information on the insurer's grievance and appeal
procedures and how to use them; and
(b) Information on how to access the complaint line of the
Department of Consumer and Business Services.
(9) Provide annual summaries to the department of the insurer's
aggregate data regarding grievances and appeals in a format
prescribed by the department to ensure consistent reporting on
the number, nature and disposition of grievances and appeals.
(10) Ensure that the confidentiality of specified patient
information and records is protected, and to that end:
(a) Adopt and implement written confidentiality policies and
procedures;
(b) State the insurer's expectations about the confidentiality
of enrollee information and records in medical service contracts;
and
(c) Afford enrollees the opportunity to approve or deny the
release of identifiable medical personal information by the
insurer, except as otherwise required by law.
{ + (11) Maintain a sufficient number of health care
providers to meet the needs of enrollees as described in section
2 of this 2001 Act. + }
SECTION 2. { + (1) An insurer required under ORS 743.804 to
maintain a sufficient number of health care providers to meet the
needs of enrollees shall ensure that enrollees have access to all
covered benefits without unreasonable delay by:
(a) Having a provider network that is sufficient in types and
numbers of providers to meet the needs of enrollees. An insurer
may use, but is not limited to, the following criteria to
determine sufficiency:
(A) Provider to enrollee ratios by specialty;
(B) Primary care provider to enrollee ratios;
(C) Geographic accessibility;
(D) Waiting times for appointments with providers;
(E) Hours of operation; and
(F) The volume of technological and specialty services
available to serve the needs of enrollees requiring
technologically advanced or specialty care.
(b) If the insurer has no network providers to provide a
covered benefit, arranging for a referral to a non-network
provider with the necessary expertise and ensuring that the
enrollee obtains the covered benefit at no greater cost to the
enrollee than if the benefit were obtained from a network
provider.
(c) Guaranteeing that the benefit level for all covered
services and treatment received through a non-network facility is
the same as the plan benefit when an enrollee receives services
or treatment in accordance with plan provisions at a network
facility.
(d) Establishing and maintaining adequate arrangements to
ensure reasonable proximity of network providers to enrollees,
and marketing a provider network plan only in a geographic area
where the network providers are accessible without unreasonable
delay.
(2) When determining whether an insurer has complied with
subsection (1) of this section, consideration shall be given to
the relative availability of health care providers in the service
area under consideration.
(3) As used in this section, 'provider network' means a
specified group of health care providers who deliver covered
services to an enrollee under a health benefit plan. + }
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