Relating to continuation of health insurance coverage for medical condition for which a prudent layperson believes immediate medical attention is necessary to stabilize the medical condition; amending ORS 743.801, 743.827, 743.839, 750.


 
 
 
     73rd OREGON LEGISLATIVE ASSEMBLY--2005 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 3567
 
                           A-Engrossed
 
                         House Bill 3465
                  Ordered by the Senate June 13
            Including Senate Amendments dated June 13
 
Sponsored by COMMITTEE ON HEALTH AND HUMAN SERVICES (at the
  request of Oregon Chapter of American College of Emergency
  Physicians)
 
 
                             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.
 
  Repeals sunset on law mandating health insurance coverage of
emergency services.
  Declares emergency, effective on passage.
 
                        A BILL FOR AN ACT
Relating to continuation of health insurance coverage for medical
  condition for which a prudent layperson believes immediate
  medical attention is necessary to stabilize the medical
  condition; amending ORS 743.801, 743.827, 743.839, 750.055 and
  750.333; repealing section 2, chapter 137, Oregon Laws 2003;
  and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
  SECTION 1.  { + Section 2, chapter 137, Oregon Laws 2003, is
repealed. + }
  SECTION 2. ORS 743.801, as amended by section 4, chapter 137,
Oregon Laws 2003, is amended to read:
  743.801. As used in ORS  { + 743.699, + } 743.801, 743.803,
743.804, 743.806, 743.807, 743.808, 743.811, 743.814, 743.817,
743.819, 743.821, 743.823, 743.827, 743.829, 743.831, 743.834,
743.837, 743.839, 743.854, 743.856, 743.857, 743.858, 743.859,
743.861, 743.862, 743.863, 743.864, 743.866 and 743.868:
  (1) 'Emergency medical condition' means a medical condition
that manifests itself by acute symptoms of sufficient severity,
including severe pain, that a prudent layperson possessing an
average knowledge of health and medicine would reasonably expect
that failure to receive immediate medical attention would place
the health of a person, or a fetus in the case of a pregnant
woman, in serious jeopardy.
  (2) 'Emergency medical screening exam' means the medical
history, examination, ancillary tests and medical determinations
required to ascertain the nature and extent of an emergency
medical condition.
  (3) 'Emergency services' means those health care items and
services furnished in an emergency department and all ancillary
services routinely available to an emergency department to the
extent they are required for the stabilization of a patient.
  (4) 'Enrollee' has the meaning given that term in ORS 743.730.
  (5) 'Grievance' means a written complaint submitted by or on
behalf of an enrollee regarding the:
  (a) Availability, delivery or quality of health care services,
including a complaint regarding an adverse determination made
pursuant to utilization review;
  (b) Claims payment, handling or reimbursement for health care
services; or
  (c) Matters pertaining to the contractual relationship between
an enrollee and an insurer.
  (6) 'Health benefit plan' has the meaning provided for that
term in ORS 743.730.
  (7) 'Independent practice association' means a corporation
wholly owned by providers, or whose membership consists entirely
of providers, formed for the sole purpose of contracting with
insurers for the provision of health care services to enrollees,
or with employers for the provision of health care services to
employees, or with a group, as described in ORS 743.522, to
provide health care services to group members.
  (8) 'Insurer' has the meaning provided for that term in ORS
731.106. For purposes of ORS  { + 743.699, + } 743.801, 743.803,
743.804, 743.806, 743.807, 743.808, 743.811, 743.814, 743.817,
743.819, 743.821, 743.823, 743.827, 743.829, 743.831, 743.834,
743.837, 743.839, 743.854, 743.856, 743.857, 743.858, 743.859,
743.861, 743.862, 743.863, 743.864, 743.866, 743.868, 750.055 and
750.333, ' insurer' also includes a health care service
contractor as defined in ORS 750.005.
  (9) 'Managed health insurance' means any health benefit plan
that:
  (a) Requires an enrollee to use a specified network or networks
of providers managed, owned, under contract with or employed by
the insurer in order to receive benefits under the plan, except
for emergency or other specified limited service; or
  (b) In addition to the requirements of paragraph (a) of this
subsection, offers a point-of-service provision that allows an
enrollee to use providers outside of the specified network or
networks at the option of the enrollee and receive a reduced
level of benefits.
  (10) 'Medical services contract' means a contract between an
insurer and an independent practice association, between an
insurer and a provider, between an independent practice
association and a provider or organization of providers, between
medical or mental health clinics, and between a medical or mental
health clinic and a provider to provide medical or mental health
services. 'Medical services contract' does not include a contract
of employment or a contract creating legal entities and ownership
thereof that are authorized under ORS chapter 58, 60 or 70, or
other similar professional organizations permitted by statute.
  (11)(a) 'Preferred provider organization insurance' means any
health benefit plan that:
  (A) Specifies a preferred network of providers managed, owned
or under contract with or employed by an insurer;
  (B) Does not require an enrollee to use the preferred network
of providers in order to receive benefits under the plan; and
  (C) Creates financial incentives for an enrollee to use the
preferred network of providers by providing an increased level of
benefits.
  (b) 'Preferred provider organization insurance' does not mean a
health benefit plan that has as its sole financial incentive a
hold harmless provision under which providers in the preferred
network agree to accept as payment in full the maximum allowable
amounts that are specified in the medical services contracts.
  (12) 'Prior authorization' means a determination by an insurer
prior to provision of services that the insurer will provide
reimbursement for the services. 'Prior authorization ' does not
 
include referral approval for evaluation and management services
between providers.
  (13) 'Provider' means a person licensed, certified or otherwise
authorized or permitted by laws of this state to administer
medical or mental health services in the ordinary course of
business or practice of a profession.
  (14) 'Stabilization' means that, within reasonable medical
probability, no material deterioration of an emergency medical
condition is likely to occur.
  (15) 'Utilization review' means a set of formal techniques used
by an insurer or delegated by the insurer designed to monitor the
use of or evaluate the medical necessity, appropriateness,
efficacy or efficiency of health care services, procedures or
settings.
  SECTION 3. ORS 743.827, as amended by section 5, chapter 137,
Oregon Laws 2003, is amended to read:
  743.827. The Director of the Department of Consumer and
Business Services shall appoint a Health Care Consumer Protection
Advisory Committee with fair representation of health care
consumers, providers and insurers. The committee shall advise the
director regarding the implementation of ORS  { + 743.699, + }
743.801, 743.803, 743.804, 743.806, 743.807, 743.808, 743.811,
743.814, 743.817, 743.819, 743.821, 743.823, 743.827, 743.829,
743.831, 743.834, 743.837 and 743.839 and other issues related to
health care consumer protection.
  SECTION 4. ORS 743.839, as amended by section 6, chapter 137,
Oregon Laws 2003, is amended to read:
  743.839. Nothing in ORS  { + 743.699, + } 743.804, 743.807 and
743.814 to 743.839 shall be construed to require disclosure of
information that is otherwise privileged or confidential under
any other provision of law.
  SECTION 5. ORS 750.055, as amended by section 7, chapter 137,
Oregon Laws 2003, and section 3, chapter 263, Oregon Laws 2003,
is amended to read:
  750.055. (1) The following provisions of the Insurance Code
shall apply to health care service contractors to the extent so
applicable and not inconsistent with the express provisions of
ORS 750.005 to 750.095:
  (a) ORS 705.137, 705.139, 731.004 to 731.150, 731.162, 731.216
to 731.362, 731.382, 731.385, 731.386, 731.390, 731.398 to
731.430, 731.428, 731.450, 731.454, 731.488, 731.504, 731.508,
731.509, 731.510, 731.511, 731.512, 731.574 to 731.620, 731.592,
731.594, 731.640 to 731.652, 731.730, 731.731, 731.735, 731.737,
731.750, 731.752, 731.804 and 731.844 to 731.992.
  (b) ORS 732.215, 732.220, 732.230, 732.245, 732.250, 732.320,
732.325 and 732.517 to 732.592, not including ORS 732.582.
  (c)(A) ORS 733.010 to 733.050, 733.080, 733.140 to 733.170,
733.210, 733.510 to 733.620, 733.635 to 733.680 and 733.695 to
733.780 apply to not-for-profit health care service contractors.
  (B) ORS chapter 733, not including ORS 733.630, applies to
for-profit health care service contractors.
  (d) ORS chapter 734.
  (e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065, 742.150
to 742.162, 742.400, 742.520 to 742.540, 743.010, 743.013,
743.018 to 743.030, 743.050, 743.100 to 743.109, 743.402,
743.412, 743.472, 743.492, 743.495, 743.498, 743.522, 743.523,
743.524, 743.526, 743.527, 743.528, 743.529, 743.549 to 743.555,
743.556, 743.560, 743.600 to 743.610, 743.650 to 743.656,
743.691, 743.693, 743.694, 743.697,  { + 743.699, + } 743.701,
743.706 to 743.712, 743.721, 743.722, 743.727, 743.728, 743.729,
743.793, 743.804, 743.807, 743.808, 743.814 to 743.839, 743.842,
743.845, 743.847, 743.854, 743.856, 743.857, 743.858, 743.859,
743.861, 743.862, 743.863, 743.864, 743.866 and 743.868.
  (f) The provisions of ORS chapter 744 relating to the
regulation of insurance producers.
 
  (g) ORS 746.005 to 746.140, 746.160, 746.220 to 746.370,
746.600, 746.605, 746.607, 746.608, 746.610, 746.615, 746.625,
746.635, 746.650, 746.655, 746.660, 746.668, 746.670, 746.675,
746.680 and 746.690.
  (h) ORS 743.714, except in the case of group practice health
maintenance organizations that are federally qualified pursuant
to Title XIII of the Public Health Service Act unless the patient
is referred by a physician associated with a group practice
health maintenance organization.
  (i) ORS 735.600 to 735.650.
  (j) ORS 743.680 to 743.689.
  (k) ORS 744.700 to 744.740.
  (L) ORS 743.730 to 743.773.
  (m) ORS 731.485, except in the case of a group practice health
maintenance organization that is federally qualified pursuant to
Title XIII of the Public Health Service Act and that wholly owns
and operates an in-house drug outlet.
  (2) For the purposes of this section only, health care service
contractors shall be deemed insurers.
  (3) Any for-profit health care service contractor organized
under the laws of any other state which is not governed by the
insurance laws of such state, will be subject to all requirements
of ORS chapter 732.
  (4) The Director of the Department of Consumer and Business
Services may, after notice and hearing, adopt reasonable rules
not inconsistent with this section and ORS 750.003, 750.005,
750.025 and 750.045 that are deemed necessary for the proper
administration of these provisions.
  SECTION 6. ORS 750.333, as amended by section 8, chapter 137,
Oregon Laws 2003, section 4, chapter 263, Oregon Laws 2003, and
section 3, chapter 446, Oregon Laws 2003, is amended to read:
  750.333. (1) The following provisions of the Insurance Code
apply to trusts carrying out a multiple employer welfare
arrangement:
  (a) ORS 731.004 to 731.150, 731.162, 731.216 to 731.268,
731.296 to 731.316, 731.324, 731.328, 731.378, 731.386, 731.390,
731.398, 731.406, 731.410, 731.414, 731.418 to 731.434, 731.454,
731.484, 731.486, 731.488, 731.512, 731.574 to 731.620, 731.640
to 731.652, 731.804 to 731.992.
  (b) ORS 733.010 to 733.050, 733.140 to 733.170, 733.210,
733.510 to 733.680 and 733.695 to 733.780.
  (c) ORS chapter 734.
  (d) ORS 742.001 to 742.009, 742.013, 742.061 and 742.400.
  (e) ORS 743.028, 743.053, 743.524, 743.526, 743.527, 743.528,
743.529, 743.530, 743.560, 743.562, 743.600, 743.601, 743.602,
743.610, 743.691, 743.693, 743.694,  { + 743.699, + } 743.727,
743.728, 743.730 to 743.773 (except 743.760 to 743.773), 743.793,
743.801, 743.804, 743.807, 743.808, 743.814 to 743.839, 743.842,
743.845, 743.847, 743.854, 743.856, 743.857, 743.858, 743.859,
743.861, 743.862, 743.863 and 743.864.
  (f) ORS 743.556, 743.701, 743.703, 743.706, 743.707, 743.709,
743.710, 743.712, 743.713, 743.714, 743.717, 743.718, 743.719,
743.721 and 743.722. Multiple employer welfare arrangements to
which ORS 743.730 to 743.773 apply are subject to the sections
referred to in this paragraph only as provided in ORS 743.730 to
743.773.
  (g) Provisions of ORS chapter 744 relating to the regulation of
insurance producers and insurance consultants, and ORS 744.700 to
744.740.
  (h) ORS 746.005 to 746.140, 746.160 and 746.220 to 746.370.
  (i) ORS 731.592 and 731.594.
  (2) For the purposes of this section:
  (a) A trust carrying out a multiple employer welfare
arrangement shall be considered an insurer.
 
 
  (b) References to certificates of authority shall be considered
references to certificates of multiple employer welfare
arrangement.
  (c) Contributions shall be considered premiums.
  (3) The provision of health benefits under ORS 750.301 to
750.341 shall be considered to be the transaction of health
insurance.
  SECTION 7.  { + This 2005 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2005 Act takes effect on its
passage. + }
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