74th OREGON LEGISLATIVE ASSEMBLY--2007 Regular Session
 
HA to HB 2213
 
LC 576/HB 2213-5
 
                       HOUSE AMENDMENTS TO
                         HOUSE BILL 2213
 
                   By COMMITTEE ON HEALTH CARE
 
                            March 16
 
  On page 1 of the printed bill, line 2, after 'plan' insert a
period and delete the rest of the line and delete line 3.
  Delete lines 5 through 28 and delete pages 2 through 6 and
insert:
  '  { +  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) For approval, 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 January 1, 2009. + } ' .
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