72nd OREGON LEGISLATIVE ASSEMBLY--2003 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 669
House Bill 2189
Ordered printed by the Speaker pursuant to House Rule 12.00A (5).
Presession filed (at the request of Governor Theodore R.
Kulongoski for the Insurance Pool Governing Board)
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.
Provides method of funding medical assistance for certain
individuals receiving health insurance under Oregon Health Plan.
Declares emergency, effective on passage.
A BILL FOR AN ACT
Relating to public subsidies for health insurance; creating new
provisions; amending ORS 735.625; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + As used in sections 1 to 4 of this 2003 Act:
(1) 'Benefits plan' has the meaning given that term in ORS
735.605.
(2) 'Premium' has the meaning given that term in ORS 735.700.
(3) 'Subsidized member' means an individual who is enrolled in
a benefits plan and who is receiving a subsidy from the Family
Health Insurance Assistance Program of the Insurance Pool
Governing Board established in ORS 735.720 to 735.740.
(4) 'Subsidy' has the meaning given that term in ORS 735.720.
(5) 'Uncompensated costs' means costs incurred by the Oregon
Medical Insurance Pool, established in ORS 735.610 to administer
a benefits plan, that are not covered by the premiums received by
the pool for a subsidized member. + }
SECTION 2. { + Notwithstanding ORS 735.615 (3)(a) and (f), a
subsidized member is eligible for coverage under ORS 735.600 to
735.650. + }
SECTION 3. { + (1) In order to increase public subsidies for
the purchase of health insurance coverage provided by public
programs or private insurance described by ORS 414.829, the
Insurance Pool Governing Board, the Oregon Medical Insurance Pool
Board and the Department of Human Services shall work
cooperatively to obtain federal matching dollars. The Insurance
Pool Governing Board, the Oregon Medical Insurance Pool Board and
the department shall develop a system for payment or
reimbursement of uncompensated costs and subsidies provided to
subsidized members.
(2) For each subsidized member, the Oregon Medical Insurance
Pool Board shall determine:
(a) The full cost of administering the benefits plan of the
subsidized member; and
(b) The amount of uncompensated costs.
(3) The Oregon Medical Insurance Pool Board shall bill the
Family Health Insurance Assistance Program for the total amount
of the premium received by the Oregon Medical Insurance Pool
Board and for the amount of uncompensated costs. The program
shall forward the bill to the department.
(4) The department shall pay the program an amount equal to the
portion of the premium that is a subsidy and for uncompensated
costs. The program shall forward the payment to the Oregon
Medical Insurance Pool Board. + }
SECTION 4. { + (1) Of payments made to the Family Health
Insurance Assistance Program by the Department of Human Services
under section 3 (4) of this 2003 Act, the department shall
determine:
(a) The portion of a subsidy of a subsidized member that is
from the General Fund; and
(b) The portion of uncompensated costs that is from the General
Fund.
(2) The department shall bill the program for the amounts
determined under subsection (1) of this section. The program
shall forward the bill for the amount determined under subsection
(1)(b) of this section to the Oregon Medical Insurance Pool
Board.
(3) The board shall:
(a) Determine the amount of funds needed for the payment of
uncompensated costs under subsection (1)(b) of this section; and
(b) Impose and collect assessments in that amount against
insurers, using the methodology described in ORS 735.614 (2), (6)
and (9).
(4) The board shall pay the program for the amounts determined
under subsection (1)(b) of this section.
(5) The program shall forward to the department the amounts
determined under subsection (1) of this section.
(6) ORS 735.614 (3), (4), (5), (7) and (8) applies to
assessments collected under this section. + }
SECTION 5. ORS 735.625 is amended to read:
735.625. (1) Except as provided in subsection (3)(b) of this
section, the Oregon Medical Insurance Pool Board shall offer
major medical expense coverage to every eligible person.
(2) The coverage to be issued by the board, its schedule of
benefits, exclusions and other limitations, shall be established
through rules adopted by the board, taking into consideration the
advice and recommendations of the pool members. In the absence of
such rules, the pool shall adopt by rule the minimum benefits
prescribed by section 6 (Alternative 1) of the Model Health
Insurance Pooling Mechanism Act of the National Association of
Insurance Commissioners (1984).
(3)(a) In establishing the pool coverage, the board shall take
into consideration the levels of medical insurance provided in
the state and medical economic factors as may be deemed
appropriate and shall promulgate benefit levels, deductibles,
coinsurance factors, exclusions and limitations determined to be
equivalent to the portability health benefit plans established
under ORS 743.760.
(b) The board may provide a separate Medicare supplement policy
for individuals under the age of 65 who are receiving Medicare
disability benefits. The board shall adopt rules to establish
benefits, deductibles, coinsurance, exclusions and limitations,
premiums and eligibility requirements for the Medicare supplement
policy.
(4)(a) Premiums charged for coverages issued by the board may
not be unreasonable in relation to the benefits provided, the
risk experience and the reasonable expenses of providing the
coverage.
(b) Separate schedules of premium rates based on age and
geographical location may apply for individual risks.
(c) The board shall determine the applicable medical and
portability risk rates either by calculating the average rate
charged by insurers offering coverages in the state comparable to
the pool coverage or by using reasonable actuarial techniques.
The risk rates shall reflect anticipated experience and expenses
for such coverage. Rates for pool coverage may not be more than
125 percent of rates established as applicable for medically
eligible individuals or 100 percent of rates established as
applicable for portability eligible individuals.
(d) The board shall annually determine adjusted benefits and
premiums. Such adjustments will be in keeping with the purposes
of ORS 735.600 to 735.650, subject to a limitation of keeping
pool losses under one percent of the total of all medical
insurance premiums, subscriber contract charges and 110 percent
of all benefits paid by member self-insurance arrangements. The
board may determine the total number of persons that may be
enrolled for coverage at any time and may permit and prohibit
enrollment in order to maintain the number authorized. Nothing in
this paragraph authorizes the board to prohibit enrollment for
any reason other than to control the number of persons in the
pool.
(5)(a) Pool coverage may not exclude coverage for a period
exceeding six months following the effective date of coverage of
an insured pursuant to a preexisting conditions provision or
impose a waiting period longer than 90 days.
(b) In determining whether a preexisting conditions provision
applies to an eligible enrollee, except as provided in this
subsection, the board shall credit the time the eligible enrollee
was covered under a previous health benefit plan if the previous
health benefit plan was continuous to a date not more than 63
days prior to the effective date of the new coverage under the
Oregon Medical Insurance Pool, exclusive of any applicable
waiting period. The Oregon Medical Insurance Pool Board need not
credit the time for previous coverage to which the insured or
dependent is otherwise entitled under this subsection with
respect to benefits and services covered in the pool coverage
that were not covered in the previous coverage.
(6) For purposes of this section, a 'preexisting conditions
provision' means a provision that excludes coverage for services,
charges or expenses incurred during a specified period not to
exceed six months following the insured's effective date of
coverage, for a condition for which medical advice, diagnosis,
care or treatment was recommended or received during the
six-month period immediately preceding the insured's effective
date of coverage.
(7)(a) Benefits otherwise payable under pool coverage shall be
reduced by all amounts paid or payable through any other health
insurance, or self-insurance arrangement, and by all hospital and
medical expense benefits paid or payable under any workers'
compensation coverage, automobile medical payment or liability
insurance whether provided on the basis of fault or nonfault, and
by any hospital or medical benefits paid or payable under or
provided pursuant to any state or federal law or program except
{ + the + } Medicaid { + portion of the Oregon Health Plan
offering a benefit package of health care services described in
ORS 414.837 (1) + }.
(b) The board shall have a cause of action against an eligible
person for the recovery of the amount of benefits paid which are
not for covered expenses. Benefits due from the pool may be
reduced or refused as a setoff against any amount recoverable
under this paragraph.
(8) Except as provided in ORS 735.616, no mandated benefit
statutes apply to pool coverage under ORS 735.600 to 735.650.
(9) Pool coverage may be furnished through a health care
service contractor or such alternative delivery system as will
contain costs while maintaining quality of care.
SECTION 6. { + This 2003 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2003 Act takes effect on its
passage. + }
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