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 536
 
                         Senate Bill 159
 
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 as
introduced.
 
  Specifies maximum payment that noncontracted emergency services
provider must accept for services provided to enrollee in fully
capitated health plan.
 
                        A BILL FOR AN ACT
Relating to payments for noncontracted emergency services;
  creating new provisions; and amending ORS 414.736 and 414.743.
Be It Enacted by the People of the State of Oregon:
  SECTION 1. ORS 414.743 is amended to read:
  414.743. (1) As used in this section, 'fully capitated health
plan' means an organization that contracts with the Department of
Human Services on a prepaid capitated basis under ORS 414.725 to
provide an adequate network of providers to ensure that all
health services described in ORS 414.705 are reasonably
accessible to enrollees.
  (2) A fully capitated health plan that does not have a contract
with a hospital to provide inpatient or outpatient hospital
services under ORS 414.705 to 414.750 must pay for hospital
services as follows:
  (a) For inpatient hospital services, based on the capitation
rates developed for the budget period, at the level of the
statewide average unit cost, multiplied by the geographic factor,
the payment discount factor and an adjustment factor of 0.925.
  (b)  { + Except as provided in subsection (4) of this section,
 + }for outpatient hospital services, based on the capitation
rates developed for the budget period, at the level of charges
multiplied by the statewide average cost-to-charge ratio, the
geographic factor, the payment discount factor and an adjustment
factor of 0.925.
  (3) A hospital that does not have a contract with a fully
capitated health plan to provide inpatient or outpatient hospital
services under ORS 414.705 to 414.750 must accept { + , as
payment in full, + } payment for hospital services as follows:
  (a) For inpatient hospital services, based on the capitation
rates developed for the budget period, at the level of the
statewide average unit cost, multiplied by the geographic factor,
the payment discount factor and an adjustment factor of 0.925.
  (b)  { + Except as provided in subsection (4) of this
section, + } for outpatient hospital services, based on the
capitation rates developed for the budget period, at the level of
charges multiplied by the statewide average cost-to-charge ratio,
the geographic factor, the payment discount factor and an
adjustment factor of 0.925.
   { +  (4) Payments under subsection (3)(b) of this section for
emergency services provided to an enrollee in a fully capitated
health plan may not exceed the amount the emergency services
provider would receive based upon fee-for-service rates adopted
by the Department of Human Services minus the amount of payments
due the emergency services provider for indirect costs of medical
education and for direct costs of graduate medical education. + }
    { - (4) - }   { + (5) + } This section does not apply to type
A and type B hospitals, as described in ORS 442.470, and rural
critical access hospitals, as defined in ORS 315.613.
    { - (5) - }   { + (6) + } The Department of Human Services
shall adopt rules to implement and administer this section.
  SECTION 2. ORS 414.736 is amended to read:
  414.736. As used in this section and ORS 414.725, 414.737,
414.738, 414.739, 414.740, 414.741, 414.742  { - , 414.743 - }
and 414.744:
  (1) 'Designated area' means a geographic area of the state
defined by the Department of Human Services by rule that is
served by a prepaid managed care health services organization.
  (2) 'Fully capitated health plan' means an organization that
contracts with the Department of Human Services on a prepaid
capitated basis under ORS 414.725 to provide an adequate network
of providers to ensure that the health services provided under
the contract are reasonably accessible to enrollees.
  (3) 'Physician care organization' means an organization that
contracts with the Department of Human Services on a prepaid
capitated basis under ORS 414.725 to provide an adequate network
of providers to ensure that the health services described in ORS
414.705 (1)(b), (c), (d), (e), (g) and (j) are reasonably
accessible to enrollees. A physician care organization may also
contract with the department on a prepaid capitated basis to
provide the health services described in ORS 414.705 (1)(k) and
(L).
  (4) 'Prepaid managed care health services organization ' means
a managed physical health, dental, mental health or chemical
dependency organization that contracts with the Department of
Human Services on a prepaid capitated basis under ORS 414.725. A
prepaid managed care health services organization may be a dental
care organization, fully capitated health plan, physician care
organization, mental health organization or chemical dependency
organization.
  SECTION 3.  { + The amendments to ORS 414.743 by section 1 of
this 2007 Act apply to claims for payment + }  { + billed by an
emergency services provider on or after January 1, 2007. + }
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