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 1598
A-Engrossed
Senate Bill 360
Ordered by the Senate April 30
Including Senate Amendments dated April 30
Sponsored by Senator MORRISETTE (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.
Establishes Office of Health Care Ombudsman to receive and
investigate complaints about provision of { + Oregon Health
Plan + } care or services by { + employees or agents of
Department of Human Services, + } fully capitated health plans
and prepaid managed care health services organizations.
{ - Establishes Health Care Ombudsman Advisory Council. - }
{ + Provides specified protections to persons filing
complaint with ombudsman or participating in investigation of
complaint. + }
Declares emergency, effective July 1, 2007.
A BILL FOR AN ACT
Relating to ombudsman services for persons receiving medical
assistance; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Sections 2 to 7 of this 2007 Act are added to
and made a part of ORS chapter 414. + }
SECTION 2. { + As used in sections 2 to 6 of this 2007 Act:
(1) 'Action' means:
(a) A determination of a member's eligibility or continuing
eligibility for an Oregon Health Plan benefit;
(b) An administrator's treatment of a member or another person
acting on behalf of the member in according dignity and respect;
or
(c) An administrator's explanation of the basis for a
determination of eligibility or continuing eligibility.
(2) 'Administrator' means any employee or agent of the
Department of Human Services or of a fully capitated health plan
or a prepaid managed care health services organization that
contracts with the department to provide services under the
Oregon Health Plan.
(3) 'Complaint' means any expression of disagreement made by or
on behalf of a member regarding an action of an administrator in
administering Oregon Health Plan benefits.
(4) 'Elderly or disabled' means eligible for federal
Supplemental Security Income benefits or Oregon Supplemental
Income Program benefits under ORS 411.706.
(5) 'Fully capitated health plan' has the meaning given that
term in ORS 414.736.
(6) 'Member' means an elderly or disabled recipient of Oregon
Health Plan benefits.
(7) 'Oregon Health Plan' means medical assistance provided
pursuant to ORS chapter 414.
(8) 'Prepaid managed care health services organization' has the
meaning given that term in ORS 414.736. + }
SECTION 3. { + (1) The Office of the Health Care Ombudsman is
established. The office shall operate independently of the
Department of Human Services. The department, including the
Governor's Advocacy Office within the department, shall refer
complaints requiring further investigation to the office.
(2) The office shall maintain a state toll-free telephone line
to accept and record:
(a) Complaints regarding the actions and conduct of an
administrator that affect a member.
(b) Complaints concerning access to, quality of or limitations
on the care or services being provided by an administrator to a
member. + }
SECTION 4. { + (1) The Office of the Health Care Ombudsman is
under the supervision and control of a Health Care Ombudsman, who
is responsible for the performance of the duties, functions and
powers of the office.
(2) The Governor shall appoint the ombudsman, who holds office
at the pleasure of the Governor.
(3) The ombudsman shall be paid a salary as provided by law or,
if not so provided, as prescribed by the Governor.
(4) The ombudsman shall:
(a) Investigate and resolve complaints received under section 3
of this 2007 Act that are made by or for members, by:
(A) Issuing recommendations regarding further action; and
(B) Attempting to facilitate a settlement of the complaint in a
manner acceptable to both the member and the administrator.
(b) Serve as an advocate for a member whenever the member or a
physician or other person serving the member is concerned about
access to, quality of or limitations on the care or services
being provided to the member by an administrator.
(c) Ensure that members are informed of the availability of
health care ombudsman services.
(5) The ombudsman shall report quarterly to the Governor. The
report shall be available to the public and shall include but not
be limited to:
(a) A summary of each complaint recorded by the office and
identification of the administrator against whom the complaint
was made;
(b) A summary of the services provided by the office with
respect to each complaint; and
(c) Recommendations for modifications to the contracts between
the department and fully capitated health plans or prepaid
managed care health services organizations to provide care or
services to members under the Oregon Health Plan.
(6) In conducting an investigation, the ombudsman shall have
the power to issue subpoenas, compel testimony and command the
production of documents.
(7) The ombudsman may hire staff to carry out the duties,
functions and powers of the office. However, to the maximum
extent possible consistent with the proper performance of the
duties of the office, the ombudsman shall employ unpaid
volunteers to carry out such duties, functions and powers.
(8) The ombudsman, any agent or designee of the ombudsman and
any immediate family member of the ombudsman shall be free of any
conflict of interest. As used in this subsection, 'conflict of
interest' means any present employment by or agency relationship
with a fully capitated health plan, a prepaid managed care health
services organization or the department, any present financial
interest in such entities, any fiduciary relationship to such
entities or any direct involvement in any licensing or
certification of such entities.
(9) The ombudsman may adopt rules necessary to carry out the
provisions of sections 2 to 6 of this 2007 Act. + }
SECTION 5. { + (1) All agencies of state government, as
defined in ORS 174.111, and fully capitated health plans, prepaid
managed care health services organizations and health care
providers shall assist the Health Care Ombudsman in the
performance of the duties of the office of Health Care Ombudsman
and shall furnish such information and advice as the ombudsman
considers necessary to perform the duties of the office.
(2) Upon written authorization by a member or the member's
legal representative, any designee of the ombudsman providing
proper identification shall have direct access to any member's
records held by or within the control of an administrator or a
health care provider and shall be entitled without charge to have
photocopies of such records. The administrator or health care
provider shall provide access to records within five working days
of receiving a written request for access that is accompanied by
the member's authorization. Except as otherwise provided in this
section, nothing in ORS 192.518 to 192.526 shall be interpreted
to limit access to records by the ombudsman or the ombudsman's
designee.
(3) The Office of the Health Care Ombudsman shall be considered
to be a health oversight agency for purposes of 45 C.F.R. 164.501
and shall have access to records of any administrator, public
agency or health care provider that are necessary for the
investigation and resolution of any member complaint.
(4) Except as provided in subsections (1) to (3) of this
section, the ombudsman and all agents or designees of the
ombudsman shall be subject to the confidentiality provisions of
the federal Health Insurance Portability and Accountability Act
of 1996 (P.L. 104-191) and all federal and state rules
implementing the Act.
(5) Upon the ombudsman's request, the Department of Human
Services shall investigate a complaint about an action taken by a
fully capitated health plan or a prepaid managed care health
services organization for any possible violations by such entity
of the entity's contract with the department or any possible
violations of state or federal laws.
(6) As used in subsection (1) of this section, 'assist ' means
to respond promptly to the ombudsman's or designee's oral and
written inquiries, to provide complete and accurate responses to
the ombudsman's or designee's written or oral questions about the
action taken and to engage in a good faith attempt with the
ombudsman or designee to resolve the complaint to the member's
satisfaction. + }
SECTION 6. { + A person who files a complaint with the Office
of the Health Care Ombudsman under sections 2 to 6 of this 2007
Act or who participates in an investigation under sections 2 to 6
of this 2007 Act may not be, as a result of filing the complaint:
(1) Subject to any penalties, sanctions or restrictions imposed
by the Department of Human Services;
(2) Subject to any penalties, sanctions or restrictions
connected with the person's employment; or
(3) Denied any right, privilege or benefit by the department, a
fully capitated health plan or a prepaid managed care health
services organization on account of the complaint. + }
SECTION 7. { + All contracts entered into by the Department of
Human Services for the purpose of administering the Oregon Health
Plan shall include a provision stating that the administrator
agrees to comply fully with the provisions of sections 2 to 6 of
this 2007 Act. + }
SECTION 8. { + 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 July 1,
2007. + }
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