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 3159
House Bill 2944
Sponsored by Representative BATES
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 requirements for insurer offering health benefit plan
relating to prescription drug benefits.
A BILL FOR AN ACT
Relating to prescription drug benefits; 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) Three levels of review, the second of which shall be by
persons not previously involved in the dispute and the third of
which shall provide external review pursuant to an external
review program meeting the requirements of ORS 743.857, 743.859
and 743.861;
(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 { + the prescription drug formulary, + } any cost sharing or
other requirements to obtain drugs and medications { + included
or + } not included in the formulary { + and the reasons for
different requirements; and
(c) A written procedure to provide additional information
concerning the prescription drug benefits, including rebate
agreements with a pharmacy benefits manager + }.
(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, and the availability of continuity of care as required by
ORS 743.854;
(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, including the option of
obtaining external review under the insurer's program established
pursuant to ORS 743.857, 743.859 and 743.861;
(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 C.F.R. 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;
(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; and
(g) A description of the insurer's external review program
established pursuant to ORS 743.857, 743.859 and 743.861.
(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;
(b) Information on how to access the complaint line of the
Department of Consumer and Business Services; and
(c) Information explaining how an enrollee applies for external
review of the insurer's actions under the external review program
established by the insurer pursuant to ORS 743.857.
(9) Provide annual summaries to the Department of Consumer and
Business Services of the insurer's aggregate data regarding
grievances, appeals and applications for external review in a
format prescribed by the department to ensure consistent
reporting on the number, nature and disposition of grievances,
appeals and applications for external review.
(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) Notify an enrollee of the enrollee's rights under the
health benefit plan at the time that the insurer notifies the
enrollee of an adverse decision. The notification shall include:
(a) Notice of the right of the enrollee to apply for internal
and external review of the adverse decision;
(b) A statement whether a decision by an independent review
organization is binding on the insurer and enrollee;
(c) A statement that if the decision is not binding on the
insurer and if the insurer does not comply with the decision, the
enrollee may sue the insurer as provided in ORS 743.864; and
(d) Information on filing a complaint with the Director of the
Department of Consumer and Business Services.
SECTION 2. { + The amendments to ORS 743.804 by section 1 of
this 2003 Act apply to health benefit plans issued or renewed on
or after the effective date of this 2003 Act. + }
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