74th OREGON LEGISLATIVE ASSEMBLY--2007 Regular Session
Enrolled
House Bill 2213
Ordered printed by the Speaker pursuant to House Rule 12.00A (5).
Presession filed (at the request of Governor Theodore R.
Kulongoski for Department of Consumer and Business Services)
CHAPTER ................
AN ACT
Relating to payments for procedures covered by health benefit
plan.
Be It Enacted by the People of the State of Oregon:
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.
Enrolled House Bill 2213 (HB 2213-B) Page 1
(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.
Enrolled House Bill 2213 (HB 2213-B) Page 2
(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. + }
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Enrolled House Bill 2213 (HB 2213-B) Page 3
Passed by House March 21, 2007
Repassed by House June 4, 2007
...........................................................
Chief Clerk of House
...........................................................
Speaker of House
Passed by Senate May 31, 2007
...........................................................
President of Senate
Enrolled House Bill 2213 (HB 2213-B) Page 4
Received by Governor:
......M.,............., 2007
Approved:
......M.,............., 2007
...........................................................
Governor
Filed in Office of Secretary of State:
......M.,............., 2007
...........................................................
Secretary of State
Enrolled House Bill 2213 (HB 2213-B) Page 5