Chapter 390
AN ACT
HB 2213
Relating to payments for procedures covered
by health benefit plan.
Be It Enacted by the People of
the State of
SECTION 1. As used in sections 1 to 6 of this 2007 Act:
(1) “In-network” means
performed by a provider or provider group that has directly contracted with the
insurer.
(2) “Out-of-network”
means performed by a provider or provider group that has not contracted or has
indirectly contracted with the insurer.
SECTION 2. (1) An insurer offering a health benefit
plan as defined in ORS 743.730 must establish a procedure for providing to an
enrollee in the plan a reasonable estimate of an enrollee’s costs for an
in-network procedure or service covered by the enrollee’s health benefit plan,
in advance of the procedure or service, when an enrollee or an enrollee’s
authorized representative provides the following information to the insurer:
(a) The type of
procedure or service;
(b) The name of the
provider;
(c) The enrollee’s
member number or policy number; and
(d) If requested by the
insurer, the site where the procedure or service will be performed.
(2) The estimate of
costs described in subsection (1) of this section must include an itemization
of:
(a) The enrollee’s
deductible;
(b) The amount of the
deductible that has been met by processed claims;
(c) Coinsurance,
copayment or other cost share to be paid by the enrollee for the procedure or
service; and
(d) Any applicable
benefit maximum.
(3) Subsections (1) and
(2) of this section apply to the insurer’s five most
common procedures or services within each of the following categories:
(a) Office visits;
(b) Diagnostic radiology
and imaging;
(c) Diagnostic pathology
and laboratory procedures;
(d) Normal vaginal
delivery;
(e) Immunizations;
(f)
Orthopedic-musculoskeletal surgery; and
(g) Digestive system
endoscopy.
(4) In addition to the
information specified in subsections (1) and (2) of this section, the insurer’s
estimate must include the following disclosures:
(a) That other services
may be provided to the enrollee that are medically necessary and appropriate as
part of the common procedures, of which the insurer or enrollee may not be
aware at the time of the inquiry and for which the enrollee may have additional
financial responsibility;
(b) That the enrollee
may be responsible for costs of procedures or services not covered by the plan;
(c) How an enrollee may
contact the insurer for an explanation, if the estimate differs from the actual
cost or if the enrollee has other questions; and
(d) The toll-free
telephone number of the consumer advocacy unit of the Department of Consumer
and Business Services and the address for the department’s consumer information
and complaints website.
(5) An insurer must make
the information required by this section available to enrollees and in-network
providers through an interactive website and by toll-free telephone.
(6) This section does
not prohibit an insurer from providing information in addition to or in more
detail than the information required by this section.
SECTION 3. (1) An insurer offering a health benefit
plan as defined in ORS 743.730 must establish a procedure for providing to an
enrollee in the plan a reasonable estimate of the enrollee’s costs for an
out-of-network procedure or service covered by the enrollee’s health benefit
plan, including the difference between the insurer’s allowable charge and the
billed charge for the procedure or service, in advance of the procedure or
service, when an enrollee or an enrollee’s authorized representative provides
the following information to the insurer:
(a) The type of
procedure or service;
(b) The name of the
provider;
(c) The enrollee’s
member number or policy number;
(d) If requested by the
insurer, the site where the procedure or service will be performed; and
(e) The provider’s
billed charge amount.
(2) The estimate of
costs described in subsection (1) of this section must include an itemization
of:
(a) The enrollee’s
deductible;
(b) The amount of the
deductible that has been met by processed claims;
(c) Coinsurance,
copayment or other cost share to be paid by the enrollee for the procedure or
service;
(d) Any applicable
benefit maximum;
(e) The difference
between the insurer’s allowable charge and the billed charge for the procedure
or service; and
(f) The insurer’s
average payment or allowable charge for the procedure or service if performed
in-network.
(3) Subsections (1) and
(2) of this section apply to the insurer’s five most
common procedures or services within each of the following categories:
(a) Office visits;
(b) Diagnostic radiology
and imaging;
(c) Diagnostic pathology
and laboratory procedures;
(d) Normal vaginal
delivery;
(e) Immunizations;
(f)
Orthopedic-musculoskeletal surgery; and
(g) Digestive system
endoscopy.
(4) In addition to the
information specified in subsections (1) and (2) of this section, the insurer’s
estimate must include the following disclosures:
(a) That other services
may be provided to the enrollee that are medically necessary and appropriate as
part of the common procedures, of which the insurer or enrollee may not be
aware at the time of the inquiry and for which the enrollee may have additional
financial responsibility;
(b) That the enrollee
may be responsible for costs of procedures or services not covered by the plan;
(c) How an enrollee may
contact the insurer for an explanation, if the estimate differs from the actual
cost or if the enrollee has other questions; and
(d) The toll-free
telephone number of the consumer advocacy unit of the Department of Consumer
and Business Services and the address for the department’s consumer information
and complaints website.
(5) An insurer must make
the information required by this section available to enrollees and
out-of-network providers through an interactive website and by toll-free
telephone.
(6) This section does
not prohibit an insurer from providing information in addition to or in more
detail than the information required by this section.
SECTION 4. (1) An insurer offering a health benefit
plan as defined in ORS 743.730 must submit to the Director of the Department of
Consumer and Business Services:
(a) Upon request by the
director, the methodology used to determine the insurer’s allowable charges for
out-of-network procedures and services or, if the insurer uses a third party to
determine the charges, the methodology used by the third party to determine
allowable charges;
(b) For approval, a
written explanation of the method used by the insurer to determine the
allowable charge, that is in plain language and that must be provided upon
request to enrollees directly, or, in the case of group coverage, to the
employer or other policyholder for distribution to enrollees; and
(c) Information
prescribed by the director as necessary to assess the effect of the disclosure
requirements in sections 2 and 3 of this 2007 Act on the individual and group
health insurance markets.
(2) The director shall
consider the recommendations of the Health Insurance Reform Advisory Committee
in prescribing the information required for submission under subsection (1)(c)
of this section.
SECTION 5. The Director of the Department of Consumer
and Business Services may waive the requirements of section 2 or 3 of this 2007
Act to allow an insurer to use an alternative disclosure mechanism, provided
that the mechanism enables enrollees to access information substantially
similar to or more extensive than the information disclosed in section 2 or 3
of this 2007 Act.
SECTION 6. The Director of the Department of Consumer
and Business Services shall adopt rules necessary to carry out the purposes of
sections 1 to 6 of this 2007 Act.
SECTION 7. Sections 2 and 3 of this
2007 Act become operative on July 1, 2009.
Approved by the Governor June 13, 2007
Filed in the office of Secretary of State June 13, 2007
Effective date January 1, 2008
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