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 387
 
                           A-Engrossed
 
                         Senate Bill 153
                   Ordered by the Senate May 9
             Including Senate Amendments dated May 9
 
Printed pursuant to Senate Interim Rule 213.28 by order of the
  President of the Senate in conformance with presession filing
  rules, indicating neither advocacy nor opposition on the part
  of the President (at the request of Governor Theodore R.
  Kulongoski for Department of Human Services)
 
 
                             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.
 
  Requires employee benefit plan and health insurer to reimburse
state Medicaid expenditures made for benefit of enrollee under
specified circumstances. Requires employee benefit plan and
health insurer to provide eligibility and claims data to state
Medicaid agency upon request.
  Declares emergency, effective on passage.
 
                        A BILL FOR AN ACT
Relating to health insurers; creating new provisions; amending
  ORS 659.830 and 743.847; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
  SECTION 1. ORS 659.830 is amended to read:
  659.830. (1)   { - No - }   { + An + } employee benefit plan
may  { + not + } include any provision which has the effect of
limiting or excluding coverage or payment for any health care for
an individual who would otherwise be covered or entitled to
benefits or services under the terms of the employee benefit plan
because that individual is provided, or is eligible for, benefits
or services pursuant to a plan under Title XIX of the Social
Security Act.  This section applies to employee benefit plans,
whether sponsored by an employer or a labor union.
  (2) A group health plan is prohibited from considering the
availability or eligibility for medical assistance in this or any
other state under 42 U.S.C. 1396a (section 1902 of the Social
Security Act), herein referred to as Medicaid, when considering
eligibility for coverage or making payments under its plan for
eligible enrollees, subscribers, policyholders or certificate
holders.
  (3) To the extent that payment for covered expenses has been
made under the state Medicaid program for health care items or
services furnished to an individual, in any case where a third
party has a legal liability to make payments, the state is
considered to have acquired the rights of the individual to
 
payment by any other party for those health care items or
services.
   { +  (4) An employee benefit plan, self-insured plan, managed
care organization or group health plan, a third party
administrator, fiscal intermediary or pharmacy benefit manager of
the plan or organization, or other party that is, by statute,
contract or agreement legally responsible for payment of a claim
for a health care item or service, may not deny a claim submitted
by the state Medicaid agency under subsection (3) of this section
based on the date of submission of the claim, the type or format
of the claim form or a failure to present proper documentation at
the point of sale that is the basis of the claim if:
  (a) The claim is submitted by the agency within the three-year
period beginning on the date on which the health care item or
service was furnished; and
  (b) Any action by the agency to enforce its rights with respect
to the claim is commenced within six years of the agency's
submission of the claim.
  (5) An employee benefit plan, self-insured plan, managed care
organization or group health plan, a third party administrator,
fiscal intermediary or pharmacy benefit manager of the plan or
organization, or other party that is, by statute, contract or
agreement legally responsible for payment of a claim for a health
care item or service, must provide to the state Medicaid agency
or prepaid managed care health services organization described in
ORS 414.725, upon the request of the agency or contractor, the
following information:
  (a) The period during which a Medicaid recipient, the spouse or
dependents may be or may have been covered by the plan or
organization;
  (b) The nature of coverage that is or was provided by the plan
or organization; and
  (c) The name, address and identifying numbers of the plan or
organization. + }
    { - (4) - }  { +  (6) + } A group health plan   { - shall - }
 { +  may + } not deny enrollment of a child under the health
plan of the child's parent on the grounds that:
  (a) The child was born out of wedlock;
  (b) The child is not claimed as a dependent on the parent's
federal tax return; or
  (c) The child does not reside with the child's parent or in the
group health plan service area.
    { - (5) - }  { +  (7) + } Where a child has health coverage
through a group health plan of a noncustodial parent, the group
health plan
  { - shall - }  { +  must + }:
  (a) Provide such information to the custodial parent as may be
necessary for the child to obtain benefits through that coverage;
  (b) Permit the custodial parent or the provider, with the
custodial parent's approval, to submit claims for covered
services without the approval of the noncustodial parent; and
    { - (c) Make payments on claims submitted in accordance with
paragraph (b) of this subsection directly to the custodial
parent, the provider or the state Medicaid agency. - }
   { +  (c) Make payments on claims submitted in accordance with
paragraph (b) of this subsection directly to the custodial
parent, to the provider or, if a claim is filed by the state
Medicaid agency, directly to the state Medicaid agency. + }
    { - (6) - }  { +  (8) + } Where a parent is required by a
court or administrative order to provide health coverage for a
child, and the parent is eligible for family health coverage, the
group health plan   { - shall be - }   { + is + } required:
  (a) To permit the parent to enroll, under the family coverage,
a child who is otherwise eligible for the coverage without regard
to any enrollment season restrictions;
 
  (b) If the parent is enrolled but fails to make application to
obtain coverage for the child, to enroll the child under family
coverage upon application of the child's other parent, the state
agency administering the Medicaid program or the state agency
administering 42 U.S.C. 651 to 669, the child support enforcement
program; and
  (c) Not to disenroll or eliminate coverage of the child unless
the group health plan is provided satisfactory written evidence
that:
  (A) The court or administrative order is no longer in effect;
or
  (B) The child is or will be enrolled in comparable health
coverage through another insurer which will take effect not later
than the effective date of disenrollment.
    { - (7) - }  { +  (9) + } A group health plan may not impose
requirements on a state agency  { - , which - }   { + that + }
has been assigned the rights of an individual eligible for
medical assistance under Medicaid and covered for health benefits
from   { - such - }   { + the + } plan  { - , that - }   { + if
the requirements + } are different from requirements applicable
to an agent or assignee of any other individual so covered.
    { - (8)(a) - }  { +  (10)(a) + } In any case in which a group
health plan provides coverage for dependent children of
participants or beneficiaries, the plan   { - shall - }  { +
must + } provide benefits to dependent children placed with
participants or beneficiaries for adoption under the same terms
and conditions as apply to the natural, dependent children of the
participants and beneficiaries, regardless of whether the
adoption has become final.
  (b) A group health plan may not restrict coverage under the
plan of any dependent child adopted by a participant or
beneficiary, or placed with a participant or beneficiary for
adoption, solely on the basis of a preexisting condition of the
child at the time that the child would otherwise become eligible
for coverage under the plan if the adoption or placement for
adoption occurs while the participant or beneficiary is eligible
for coverage under the plan.
    { - (9) - }  { +  (11) + } As used in this section:
  (a) 'Child' means, in connection with any adoption, or
placement for adoption of the child, an individual who has not
attained 18 years of age as of the date of the adoption or
placement for adoption.
  (b) 'Group health plan' means a group health plan as defined in
29 U.S.C. 1167.
  (c) 'Placement for adoption' means the assumption and retention
by a person of a legal obligation for total or partial support of
a child in anticipation of the adoption of the child.  The
child's placement with a person terminates upon the termination
of such legal obligations.
  SECTION 2. ORS 743.847 is amended to read:
  743.847. (1) For the purposes of this section:
  (a) 'Health insurer' or 'insurer' means   { - the issuer of any
individual, franchise, group or blanket health policy or
certificate or of any stop-loss or excess insurance issued in
relation to a plan of a self-insured employer. - }   { + an
employee benefit plan, self-insured plan, managed care
organization or group health plan, a third party administrator,
fiscal intermediary or pharmacy benefit manager of the plan or
organization, or other party that is by statute, contract or
agreement legally responsible for payment of a claim for a health
care item or service. + }
  (b) 'Medicaid' means medical assistance provided under 42
U.S.C. 1396a (section 1902 of the Social Security Act).
  (2) A health insurer is prohibited from considering the
availability or eligibility for medical assistance in this or any
other state under Medicaid  { - , - }  when considering
eligibility for coverage or making payments under its group or
individual plan for eligible enrollees, subscribers,
policyholders or certificate holders.
  (3) To the extent that payment for covered expenses has been
made under the state Medicaid program for health care items or
services furnished to an individual, in any case when a third
party has a legal liability to make payments, the state is
considered to have acquired the rights of the individual to
payment by any other party for those health care items or
services.
   { +  (4) An insurer may not deny a claim submitted by the
state Medicaid agency, or a prepaid managed care health services
organization described in ORS 414.725, under subsection (3) of
this section based on the date of submission of the claim, the
type or format of the claim form or a failure to present proper
documentation at the point of sale that is the basis of the claim
if:
  (a) The claim is submitted by the agency within the three-year
period beginning on the date on which the health care item or
service was furnished; and
  (b) Any action by the agency to enforce its rights with respect
to the claim is commenced within six years of the agency's
submission of the claim.
  (5) An insurer must provide to the state Medicaid agency or a
prepaid managed care health services organization, upon request,
the following information:
  (a) The period during which a Medicaid recipient, the spouse or
dependents may be or may have been covered by the plan;
  (b) The nature of coverage that is or was provided by the plan;
and
  (c) The name, address and identifying numbers of the plan. + }
    { - (4) - }  { +  (6) + } An insurer   { - shall - }  { +
may + } not deny enrollment of a child under the group or
individual health plan of the child's parent on the ground that:
  (a) The child was born out of wedlock;
  (b) The child is not claimed as a dependent on the parent's
federal tax return; or
  (c) The child does not reside with the child's parent or in the
insurer's service area.
    { - (5) - }  { +  (7) + } When a child has group or
individual health coverage through an insurer of a noncustodial
parent, the insurer
  { - shall - }  { +  must + }:
  (a) Provide such information to the custodial parent as may be
necessary for the child to obtain benefits through that coverage;
  (b) Permit the custodial parent or the provider, with the
custodial parent's approval, to submit claims for covered
services without the approval of the noncustodial parent; and
  (c) Make payments on claims submitted in accordance with  { +
paragraph (b) of this + } subsection   { - (6) of this
section - }  directly to the custodial parent, the provider or
 { - the state Medicaid agency. - }  { + , if a claim is filed by
the state Medicaid agency or a prepaid managed health care
services organization, directly to the agency or the
organization. + }
    { - (6) - }  { +  (8) + } When a parent is required by a
court or administrative order to provide health coverage for a
child, and the parent is eligible for family health coverage, the
insurer
  { - shall - }  { +  must + }:
  (a) Permit the parent to enroll, under the family coverage, a
child who is otherwise eligible for the coverage without regard
to any enrollment season restrictions;
  (b) If the parent is enrolled but fails to make application to
obtain coverage for the child, enroll the child under family
coverage upon application of the child's other parent, the state
agency administering the Medicaid program or the state agency
administering 42 U.S.C. 651 to 669, the child support enforcement
program; and
  (c) Not disenroll or eliminate coverage of the child unless the
insurer is provided satisfactory written evidence that:
  (A) The court or administrative order is no longer in effect;
or
  (B) The child is or will be enrolled in comparable health
coverage through another insurer which will take effect not later
than the effective date of disenrollment.
    { - (7) - }   { + (9) + } An insurer may not impose
requirements on a state agency that has been assigned the rights
of an individual eligible for medical assistance under Medicaid
and covered for health benefits from the insurer if the
requirements are different from requirements applicable to an
agent or assignee of any other individual so covered.
    { - (8) - }   { + (10) + } The provisions of ORS 743.700 do
not apply to this section.
  SECTION 3.  { + The amendments to ORS 659.830 and 743.847 by
sections 1 and 2 of this 2007 Act apply to claims submitted by
the state Medicaid agency or a prepaid managed care health
services organization described in ORS 414.725 and to requests
for information made by the agency or organization on or after
the effective date of this 2007 Act. + }
  SECTION 4.  { + This 2007 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2007 Act takes effect on its
passage. + }
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