74th OREGON LEGISLATIVE ASSEMBLY--2007 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 1173
A-Engrossed
House Bill 2407
Ordered by the House February 8
Including House Amendments dated February 8
Sponsored by Representatives GELSER, CAMERON, Senators BATES,
MORRISETTE; Representatives BARNHART, BERGER, BUCKLEY, CANNON,
ESQUIVEL, GREENLICK, HUNT, KOTEK, OLSON, ROBLAN, ROSENBAUM,
SCHAUFLER, SHIELDS, TOMEI, Senators BROWN, KRUSE, MORSE,
WINTERS (Presession filed.)
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.
Expands definition of categorically needy persons eligible for
medical assistance to include children with disabilities
{ - whose family income is no more than 300 percent of federal
poverty guidelines - } . Authorizes Department of Human Services
to impose premiums or cost-sharing for medical assistance
provided to specified individuals. Imposes limits on premiums and
cost-sharing. Creates Medicaid buy-in program for children with
disabilities whose family income exceeds 300 percent of federal
poverty guidelines.
{ + Takes effect January 1, 2009. + }
A BILL FOR AN ACT
Relating to medical assistance for persons with disabilities
under 19 years of age; creating new provisions; amending ORS
414.025, 414.042, 414.428, 414.706, 414.707, 414.710 and
414.712; and prescribing an effective date.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 414.025 is amended to read:
414.025. As used in this chapter, unless the context or a
specially applicable statutory definition requires otherwise:
(1) 'Category of aid' means assistance provided by the Oregon
Supplemental Income Program, temporary assistance for needy
families granted under ORS 418.035 to 418.125 or federal
Supplemental Security Income payments.
(2) 'Categorically needy' means, insofar as funds are available
for the category, a person who is a resident of this state and
who:
{ + (a) Is an individual or a member of a group who is
required by the Social Security Act and federal regulations
adopted under the Act to be included in the state's medical
assistance program in order for that program to qualify for
federal funds; or
(b) Is an individual or a member of a group who, subject to the
rules of the Department of Human Services, may optionally be
included in the state's medical assistance program and who
qualifies for federal funds under the Social Security Act and
federal regulations adopted under the Act.
(3) 'Categorically needy' may include, consistent with
subsection (2) of this section, any person who: + }
(a) Is receiving a category of aid.
(b) Would be eligible for, but is not receiving a category of
aid.
(c) Is in a medical facility and, if the person left such
facility, would be eligible for a category of aid.
(d) Is under the age of 21 years and would be a dependent child
under the program for temporary assistance for needy families
except for age and regular attendance in school or in a course of
professional or technical training.
(e)(A) Is a caretaker relative named in ORS 418.035 (2)(a)(C)
who cares for a dependent child who would be a dependent child
under the program for temporary assistance for needy families
except for age and regular attendance in school or in a course of
professional or technical training; or
(B) Is the spouse of such caretaker relative and fulfills the
requirements of ORS 418.035 (1).
(f) Is under the age of 21 years, is in a foster family home or
licensed child-caring agency or institution under a purchase of
care agreement and is one for whom a public agency of this state
is assuming financial responsibility, in whole or in part.
(g) Is a spouse of an individual receiving a category of aid
and who is living with the recipient of a category of aid, whose
needs and income are taken into account in determining the cash
needs of the recipient of a category of aid, and who is
determined by the department { - of Human Services - } to be
essential to the well-being of the recipient of a category of
aid.
(h) Is a caretaker relative named in ORS 418.035 (2)(a)(C) who
cares for a dependent child receiving temporary assistance for
needy families or is the spouse of such caretaker relative and
fulfills the requirements of ORS 418.035 (1).
(i) Is under the age of 21 years, is in a youth care center and
is one for whom a public agency of this state is assuming
financial responsibility, in whole or in part.
(j) Is under the age of 21 years and is in an intermediate care
facility which includes institutions for the mentally retarded
{ - ; or - } { + .
(k) + } Is under the age of 22 years and is in a psychiatric
hospital.
{ - (k) - } { + (L) + } Is under the age of 21 years and is
in an independent living situation with all or part of the
maintenance cost paid by the department { - of Human
Services - } .
{ - (L) - } { + (m) + } Is a member of a family that
received temporary assistance for needy families in at least
three of the six months immediately preceding the month in which
such family became ineligible for such assistance because of
increased hours of or increased income from employment. As long
as the member of the family is employed, such families will
continue to be eligible for medical assistance for a period of at
least six calendar months beginning with the month in which such
family became ineligible for assistance because of increased
hours of employment or increased earnings.
{ - (m) - } { + (n) + } Is an adopted person under 21 years
of age for whom a public agency is assuming financial
responsibility in whole or in part.
{ - (n) Is an individual or is a member of a group who is
required by federal law to be included in the state's medical
assistance program in order for that program to qualify for
federal funds. - }
{ - (o) Is an individual or member of a group who, subject to
the rules of the department and within available funds, may
optionally be included in the state's medical assistance program
under federal law and regulations concerning the availability of
federal funds for the expenses of that individual or group. - }
{ - (p) - } { + (o) + } Is a pregnant woman who would be
eligible for temporary assistance for needy families including
such aid based on the unemployment of a parent, whether or not
the woman is eligible for cash assistance.
{ - (q) - } { + (p) + } Would be eligible for temporary
assistance for needy families pursuant to 42 U.S.C. 607 based
upon the unemployment of a parent, whether or not the state
provides cash assistance.
{ - (r) - } { + (q) + } Except as otherwise provided in
this section { - and to the extent of available funds - } , is
a pregnant woman or child for whom federal financial
participation is available under Title XIX of the federal Social
Security Act.
{ - (s) - } { + (r) + } Is not otherwise categorically
needy and is not eligible for care under Title XVIII of the
federal Social Security Act or is not a full-time student in a
post-secondary education program as defined by the department
{ - of Human Services - } by rule, but whose family income is
less than the federal poverty { - level - } { + guidelines + }
and whose family investments and savings equal less than the
investments and savings limit established by the department by
rule.
{ + (s) Is under the age of 19 years and would be considered
disabled for federal Supplemental Security Income purposes but
whose family income or resources exceed the limits for
Supplemental Security Income payments. + }
{ - (3) - } { + (4) + } 'Income' has the meaning given that
term in ORS 411.704.
{ - (4) - } { + (5) + } 'Investments and savings' means
cash, securities as defined in ORS 59.015, negotiable instruments
as defined in ORS 73.0104 and such similar investments or savings
as the department
{ - of Human Services - } may establish by rule that are
available to the applicant or recipient to contribute toward
meeting the needs of the applicant or recipient.
{ - (5) - } { + (6) + } 'Medical assistance' means so much
of the following medical and remedial care and services as may be
prescribed by the department { - of Human Services - }
according to the standards established pursuant to ORS 414.065,
including payments made for services provided under an insurance
or other contractual arrangement and money paid directly to the
recipient for the purchase of medical care:
(a) Inpatient hospital services, other than services in an
institution for mental diseases;
(b) Outpatient hospital services;
(c) Other laboratory and X-ray services;
(d) Skilled nursing facility services, other than services in
an institution for mental diseases;
(e) Physicians' services, whether furnished in the office, the
patient's home, a hospital, a skilled nursing facility or
elsewhere;
(f) Medical care, or any other type of remedial care recognized
under state law, furnished by licensed practitioners within the
scope of their practice as defined by state law;
(g) Home health care services;
(h) Private duty nursing services;
(i) Clinic services;
(j) Dental services;
(k) Physical therapy and related services;
(L) Prescribed drugs, including those dispensed and
administered as provided under ORS chapter 689;
(m) Dentures and prosthetic devices; and eyeglasses prescribed
by a physician skilled in diseases of the eye or by an
optometrist, whichever the individual may select;
(n) Other diagnostic, screening, preventive and rehabilitative
services;
(o) Inpatient hospital services, skilled nursing facility
services and intermediate care facility services for individuals
65 years of age or over in an institution for mental diseases;
(p) Any other medical care, and any other type of remedial care
recognized under state law;
(q) Periodic screening and diagnosis of individuals under the
age of 21 years to ascertain their physical or mental
impairments, and such health care, treatment and other measures
to correct or ameliorate impairments and chronic conditions
discovered thereby;
(r) Inpatient hospital services for individuals under 22 years
of age in an institution for mental diseases; and
(s) Hospice services.
{ - (6) - } { + (7) + } 'Medical assistance' includes any
care or services for any individual who is a patient in a medical
institution or any care or services for any individual who has
attained 65 years of age or is under 22 years of age, and who is
a patient in a private or public institution for mental diseases.
' Medical assistance' includes 'health services' as defined in
ORS 414.705. 'Medical assistance' does not include care or
services for an inmate in a nonmedical public institution.
{ - (7) - } { + (8) + } 'Medically needy' means a person
who is a resident of this state and who is considered eligible
under federal law for medically needy assistance.
{ - (8) - } { + (9) + } 'Resources' has the meaning given
that term in ORS 411.704. For eligibility purposes, 'resources'
does not include charitable contributions raised by a community
to assist with medical expenses.
SECTION 2. { + Sections 3 and 4 of this 2007 Act are added to
and made a part of ORS chapter 414. + }
SECTION 3. { + (1) The Department of Human Services shall
adopt by rule standards for premiums, copayments or deductibles,
consistent with federal law, for persons who are categorically
needy as described in ORS 414.025 (3)(s) and whose family income
does not exceed 300 percent of the federal poverty guidelines,
subject to the following:
(a) The department may not require copayments or deductibles if
the family income is at or below 250 percent of the federal
poverty guidelines.
(b) Copayments and deductibles may not exceed five percent of
the cost of the treatment or service and may not be required for:
(A) Preventive services such as well baby and well child care
and immunizations.
(B) Services furnished to a terminally ill individual who is
receiving hospice care.
(C) Services to a child described in ORS 414.025 (2)(a).
(D) Services to a child described in ORS 414.025 (3)(f).
(E) Services to a child described in ORS 414.025 (3)(n).
(F) Pregnancy-related services.
(G) Services furnished to a child who is an inpatient in a
medical institution and is required to pay for costs of medical
care all of the child's income except for a minimal amount
required for personal needs.
(H) Emergency services.
(I) Family planning services and supplies.
(J) Services to a child receiving medical assistance under ORS
414.534.
(c) Premiums shall be based upon the capitation rate paid to
prepaid managed care health services organizations under
contracts described in ORS 414.725 for coverage of categorically
needy persons under the age of 19 years. A premium:
(A) May not be imposed if the family income is at or below 250
percent of the federal poverty guidelines; and
(B) If the family income is at or below 300 percent of the
federal poverty guidelines, must be on a sliding scale based
upon:
(i) Family income;
(ii) Family size;
(iii) Number of persons with a disability in a household; and
(iv) Other factors established by the department by rule.
(d) The combined premiums, copayments and deductibles may not
exceed five percent of the family income, as applied on a
quarterly or monthly basis.
(2) The department shall adopt by rule methods for determining
family income under this section and section 4 of this 2007 Act,
including the use of income disregards.
(3) If an employer of a parent of a child described in ORS
414.025 (3)(s) contributes at least 50 percent of the total cost
of annual premiums for family coverage under a health benefit
plan as defined in ORS 743.730, the parent must apply for, enroll
in and pay premiums for such coverage as a condition of the child
being or remaining eligible for medical assistance under this
section.
(4) The amount of the premiums paid under subsection (3) of
this section shall be deducted from premiums due the department
under subsection (1)(c) of this section and section 4 of this
2007 Act.
(5) The department may not impose a prior period of uninsurance
on a person who is categorically needy under ORS 414.025 (3)(s)
and otherwise meets the requirements of this section.
(6) The Administrator of the Office for Oregon Health Policy
and Research shall be responsible for analyzing and reporting on
the implementation and operation of this section and section 4 of
this 2007 Act, including an analysis of the impact of premiums
and cost-sharing on utilization and access to health care by
children.
(7) Except as provided in subsection (3) of this section, this
section does not require the department to impose premiums,
copayments or deductibles upon categorically needy persons whose
family income is at or below 300 percent of the federal poverty
guidelines. + }
SECTION 4. { + (1)(a) Subject to available funds, persons who
are categorically needy as described in ORS 414.025 (3)(s) with
family income exceeding 300 percent of the federal poverty
guidelines may qualify for medical assistance under this chapter
upon payment of a premium according to standards prescribed by
the Department of Human Services by rule.
(b) A premium under this subsection:
(A) Must be based upon the following factors:
(i) Family income;
(ii) Family size;
(iii) Number of persons with a disability in a household; and
(iv) Other factors established by the department by rule; and
(B) May not exceed the capitation rate paid to prepaid managed
care health services organizations under contracts described in
ORS 414.725 for coverage of categorically needy persons under the
age of 19 years.
(2) The department may adopt rules prescribing copayments and
deductibles required for health services provided to persons who
qualify for medical assistance under this section. + }
SECTION 5. ORS 414.042 is amended to read:
414.042. (1) The need for and the amount of medical assistance
to be made available for each eligible group of recipients of
medical assistance shall be determined, in accordance with the
rules of the Department of Human Services, taking into account:
(a) The requirements and needs of the person, the spouse and
other dependents;
(b) The income, resources and maintenance available to the
person but, except as provided in ORS 414.025 { - (2)(s) - }
{ + (3)(r) + }, resources shall be disregarded for those
eligible by reason of having income below the federal poverty
{ - level - } { + guidelines + } and who are eligible for
medical assistance only because of the enactment of chapter 836,
Oregon Laws 1989;
(c) The responsibility of the spouse and, with respect to a
person who is blind or is permanently and totally disabled or is
under 21 years of age, the responsibility of the parents; and
(d) The report of the Health Services Commission as funded by
the Legislative Assembly and such other programs as the
Legislative Assembly may authorize. However, medical assistance,
including health services, shall not be provided to persons
described in ORS 414.025 { - (2)(s) - } { + (3)(r) + } unless
the Legislative Assembly specifically appropriates funds to
provide such assistance.
(2) Such amounts of income and resources may be disregarded as
the department may prescribe by rules, except that the department
may not require any needy person over 65 years of age, as a
condition of entering or remaining in a hospital, nursing home or
other congregate care facility, to sell any real property
normally used as such person's home. Any rule of the department
inconsistent with this section is to that extent invalid. The
amounts to be disregarded shall be within the limits required or
permitted by federal law, rules or orders applicable thereto.
(3) In the determination of the amount of medical assistance
available to a medically needy person, all income and resources
available to the person in excess of the amounts prescribed in
ORS 414.038, within limits prescribed by the department, shall be
applied first to costs of needed medical and remedial care and
services not available under the medical assistance program and
then to the costs of benefits under the medical assistance
program.
SECTION 6. ORS 414.428 is amended to read:
414.428. (1) An individual described in ORS 414.025
{ - (2)(s) - } { + (3)(r) + } who is eligible for or receiving
medical assistance and who is an American Indian and Alaskan
Native beneficiary shall receive the benefit package of health
care services described in ORS 414.835 if:
(a) The Department of Human Services receives 100 percent
federal medical assistance percentage for payments made by the
department for the health care services provided as part of the
benefit package described in ORS 414.835 that are not included in
the benefit package described in ORS 414.834; or
(b) The department receives funding from the Indian tribes for
which federal financial participation is available.
(2) As used in this section, 'American Indian and Alaskan
Native beneficiary' means:
(a) A member of a federally recognized Indian tribe, band or
group;
(b) An Eskimo or Aleut or other Alaskan native enrolled by the
United States Secretary of the Interior pursuant to the Alaska
Native Claims Settlement Act, 43 U.S.C. 1601; or
(c) A person who is considered by the United States Secretary
of the Interior to be an Indian for any purpose.
SECTION 7. ORS 414.706 is amended to read:
414.706. The Legislative Assembly shall approve and fund health
services to the following persons:
(1) Persons who are categorically needy as described in ORS
414.025 { - (2)(n) and (o) - } ;
(2) Pregnant women with incomes no more than 185 percent of the
federal poverty guidelines;
(3) Persons under 19 years of age with incomes no more than 200
percent of the federal poverty guidelines;
(4) Persons described in ORS 414.708; and
(5) Persons 19 years of age or older with incomes no more than
100 percent of the federal poverty guidelines who do not have
federal Medicare coverage.
SECTION 8. ORS 414.707 is amended to read:
414.707. (1) Subject to funds available:
(a) Persons who are categorically needy as described in ORS
414.025 { - (2)(n) and (o), - } and persons under 19 years of
age and pregnant women who are eligible to receive health
services under ORS 414.706, are eligible to receive all the
health services approved and funded by the Legislative Assembly.
(b) Persons described in ORS 414.708 are eligible to receive
the health services described in ORS 414.705 (1)(c), (f) and (g).
(c) Persons 19 years of age and older who are eligible to
receive health services under ORS 414.706 are eligible to receive
the health services described in ORS 414.705 (1)(b) to (m).
(2) Persons who are categorically needy as described in ORS
414.025 { - (2)(n) and (o), - } and persons under 19 years of
age and pregnant women who are eligible to receive health
services under ORS 414.706, must be provided, at a minimum, the
health services described in ORS 414.705 (1)(a) to (g).
(3) Persons 19 years of age and older who are eligible to
receive health services under ORS 414.706 must be provided, at a
minimum, health services described in ORS 414.705 (1)(b) to (h).
(4) Persons described in ORS 414.708 must be provided, at a
minimum, the health services described in ORS 414.705 (1)(c).
(5) The Department of Human Services shall:
(a) Develop at least three benefit packages of provider
services to be offered under ORS 414.705 (1)(j); and
(b) Define by rule the services to be offered under ORS 414.705
(1)(k).
(6) Notwithstanding ORS 414.735, the Legislative Assembly shall
adjust health services funded under ORS 414.705 (1) by increasing
or reducing benefit packages or health services and, subject to
ORS 414.709, by increasing or reducing the population of eligible
persons.
SECTION 9. ORS 414.710 is amended to read:
414.710. The following services are available to persons
eligible for services under ORS 414.025, 414.036, 414.042,
414.065 and 414.705 to 414.750 but such services are not subject
to ORS 414.720:
(1) Nursing facilities and home- and community-based waivered
services funded through the Department of Human Services;
(2) Medical assistance to eligible persons who receive
assistance under ORS 411.706 or to children described in ORS
414.025 { - (2)(f), - } { + (3)(f), + }(i), (j), (k) { + ,
(L), (n) and (s) + } { - and (m) - } , 418.001 to 418.034,
418.189 to 418.970 and 657A.020 to 657A.460;
(3) Institutional, home- and community-based waivered services
or community mental health program care for persons with mental
retardation, a developmental disability or a severe mental
illness and for the treatment of alcohol and drug dependent
persons; and
(4) Services to children who are wards of the Department of
Human Services by order of the juvenile court and services to
children and families for health care or mental health care
through the department.
SECTION 10. ORS 414.712 is amended to read:
414.712. The Department of Human Services shall provide medical
assistance under ORS 414.705 to 414.750 to eligible persons who
receive assistance under ORS 411.706 and to children described in
ORS 414.025 { - (2)(f), - } { + (3)(f), + }(i), (j),
(k) { + , (L), (n) and (s) + } { - and (m) - } , 418.001 to
418.034, 418.189 to 418.970 and 657A.020 to 657A.460 and those
mental health and chemical dependency services recommended
according to standards of medical assistance and according to the
schedule of implementation established by the Legislative
Assembly. In providing medical assistance services described in
ORS 414.018 to 414.024, 414.042, 414.107, 414.710, 414.720 and
735.712, the Department of Human Services shall also provide the
following:
(1) Ombudsman services for eligible persons who receive
assistance under ORS 411.706. With the concurrence of the
Governor, the Director of Human Services shall appoint ombudsmen
and may terminate an ombudsman. Ombudsmen are under the
supervision and control of the director. An ombudsman shall serve
as a patient's advocate whenever the patient or a physician or
other medical personnel serving the patient is reasonably
concerned about access to, quality of or limitations on the care
being provided by a health care provider. Patients shall be
informed of the availability of an ombudsman. Ombudsmen shall
report to the Governor in writing at least once each quarter. A
report shall include a summary of the services that the ombudsman
provided during the quarter and the ombudsman's recommendations
for improving ombudsman services and access to or quality of care
provided to eligible persons by health care providers.
(2) Case management services in each health care provider
organization for those eligible persons who receive assistance
under ORS 411.706. Case managers shall be trained in and shall
exhibit skills in communication with and sensitivity to the
unique health care needs of people who receive assistance under
ORS 411.706. Case managers shall be reasonably available to
assist patients served by the organization with the coordination
of the patient's health care services at the reasonable request
of the patient or a physician or other medical personnel serving
the patient. Patients shall be informed of the availability of
case managers.
(3) A mechanism, established by rule, for soliciting consumer
opinions and concerns regarding accessibility to and quality of
the services of each health care provider.
(4) A choice of available medical plans and, within those
plans, choice of a primary care provider.
(5) Due process procedures for any individual whose request for
medical assistance coverage for any treatment or service is
denied or is not acted upon with reasonable promptness. These
procedures shall include an expedited process for cases in which
a patient's medical needs require swift resolution of a dispute.
SECTION 11. { + This 2007 Act takes effect on January 1,
2009. + }
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