Chapter 458 Oregon Laws 2007
AN ACT
HB 2952
Relating to financial reporting of prepaid managed care health services
organizations contracting with Department of Human Services; creating new
provisions; and amending ORS 414.725.
Be It Enacted by the People of
the State of Oregon:
SECTION 1.
ORS 414.725 is amended to read:
414.725. (1)(a) Pursuant
to rules adopted by the Department of Human Services, the department shall
execute prepaid managed care health services contracts for health services
funded by the Legislative Assembly. The contract must require that all services
are provided to the extent and scope of the Health Services Commission’s report
for each service provided under the contract. The contracts are not subject to
ORS chapters 279A and 279B, except ORS 279A.250 to 279A.290 and 279B.235.
Notwithstanding ORS 414.720 (8), the rules adopted by the department shall
establish timelines for executing the contracts described in this paragraph.
(b) It is the intent of
ORS 414.705 to 414.750 that the state use, to the greatest extent possible,
prepaid managed care health services organizations to provide physical health,
dental, mental health and chemical dependency services under ORS 414.705 to
414.750.
(c) The department shall
solicit qualified providers or plans to be reimbursed for providing the covered
services. The contracts may be with hospitals and medical organizations, health
maintenance organizations, managed health care plans and any other qualified
public or private prepaid managed care health services organization. The
department may not discriminate against any contractors that offer services
within their providers’ lawful scopes of practice.
(d) The department
shall establish annual financial reporting requirements for prepaid managed
care health services organizations. The department shall prescribe a reporting
procedure that elicits sufficiently detailed information for the department to
assess the financial condition of each prepaid managed care health services
organization and that includes information on the three highest executive
salary and benefit packages of each prepaid managed care health services
organization.
(e) The department shall
require compliance with the provisions of paragraph (d) of this subsection as a
condition of entering into a contract with a prepaid managed care health
services organization.
(2) The department may
institute a fee-for-service case management system or a fee-for-service payment
system for the same physical health, dental, mental health or chemical
dependency services provided under the health services contracts for persons
eligible for health services under ORS 414.705 to 414.750 in designated areas
of the state in which a prepaid managed care health services organization is
not able to assign an enrollee to a person or entity that is primarily
responsible for coordinating the physical health, dental, mental health or
chemical dependency services provided to the enrollee. In addition, the
department may make other special arrangements as necessary to increase the
interest of providers in participation in the state’s managed care system,
including but not limited to the provision of stop-loss insurance for providers
wishing to limit the amount of risk they wish to underwrite.
(3) As provided in subsections
(1) and (2) of this section, the aggregate expenditures by the department for
health services provided pursuant to ORS 414.705 to 414.750 may not exceed the
total dollars appropriated for health services under ORS 414.705 to 414.750.
(4) Actions taken by
providers, potential providers, contractors and bidders in specific accordance
with ORS 414.705 to 414.750 in forming consortiums or in otherwise entering
into contracts to provide health care services shall be performed pursuant to
state supervision and shall be considered to be conducted at the direction of
this state, shall be considered to be lawful trade practices and may not be
considered to be the transaction of insurance for purposes of the Insurance
Code.
(5) Health care
providers contracting to provide services under ORS 414.705 to 414.750 shall
advise a patient of any service, treatment or test that is medically necessary
but not covered under the contract if an ordinarily careful practitioner in the
same or similar community would do so under the same or similar circumstances.
(6) A prepaid managed
care health services organization shall provide information on contacting
available providers to an enrollee in writing within 30 days of assignment to
the health services organization.
(7) Each prepaid managed
care health services organization shall provide upon the request of an enrollee
or prospective enrollee annual summaries of the organization’s aggregate data
regarding:
(a) Grievances and
appeals; and
(b) Availability and
accessibility of services provided to enrollees.
(8) A prepaid managed
care health services organization may not limit enrollment in a designated area
based on the zip code of an enrollee or prospective enrollee.
SECTION 2. The
amendments to ORS 414.725 by section 1 of this 2007 Act apply to a contract
entered into by the Department of Human Services with a prepaid managed care
health services organization on or after the effective date of this 2007 Act.
Approved by the Governor June 18, 2007
Filed in the office of Secretary of State June 19, 2007
Effective date January 1, 2008
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