75th OREGON LEGISLATIVE ASSEMBLY--2009 Regular Session
Enrolled
Senate Bill 862
Sponsored by Senator TELFER; Senators ATKINSON, BATES, FERRIOLI,
GEORGE, GIROD, KRUSE, MONNES ANDERSON, MORRISETTE, MORSE,
VERGER, WHITSETT, Representatives GARRETT, GREENLICK, KENNEMER,
MAURER, STIEGLER, THOMPSON, WHISNANT
CHAPTER ................
AN ACT
Relating to reimbursement of health care costs; creating new
provisions; amending ORS 731.036; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + As used in sections 1 to 4 of this 2009 Act:
(1) 'Community' means the area of geographically contiguous
political subdivisions as determined by the Office for Oregon
Health Policy and Research in collaboration with the board of
directors of a community-based health care initiative.
(2) 'Qualified employee' means an individual who:
(a) Is employed by a qualified employer;
(b) Resides or works within a community;
(c) Does not have health insurance; and
(d) Does not qualify for publicly funded health care.
(3) 'Qualified employer' means an employer that:
(a) Employs 1 to 50 employees;
(b) Pays a median wage to its employees that is equal to or
below an amount that is 300 percent of the federal poverty
guidelines;
(c) For 12 months prior to enrollment in a community-based
health care improvement program, or for the duration of the
employer's operation if the employer has been in operation less
than 12 months, has not provided to employees employer-based
health insurance coverage for which the employer contributes at
least 50 percent of the cost of premiums;
(d) Offers community-based health care services through a
community-based health care improvement program to all qualified
employees and their dependents regardless of health status;
(e) Agrees to participate in a community-based health care
improvement program for at least 12 months; and
(f) Agrees to provide information that is deemed necessary by
the community-based health care initiative to determine
eligibility, assess dues and pay claims. + }
SECTION 2. { + (1) The Administrator of the Office for Oregon
Health Policy and Research shall adopt rules for the approval of
one community-based health care initiative per community that
meets the requirements under subsection (2) of this section and
of a community-based health care improvement program that meets
the requirements under subsection (3) of this section. The office
may not approve community-based health care initiatives for more
Enrolled Senate Bill 862 (SB 862-B) Page 1
than three communities during the period beginning with the
effective date of this 2009 Act and ending June 30, 2013.
(2) An approved community-based health care initiative shall:
(a) Be a nonprofit corporation governed by a board of directors
that includes, but is not limited to, representatives of
participating health care providers and qualified employers. At
least 80 percent of the board members must be residents of the
community.
(b) Contract with health care providers that offer health care
services in the community to provide services to enrollees in the
program.
(c) Recruit qualified employers to enroll in the program.
(d) Establish an operational structure for:
(A) Assisting employees of qualified employers or their
dependents to enroll in state medical assistance programs if
appropriate;
(B) Enrolling qualified employees and their dependents in the
community-based health care improvement program;
(C) Billing and collecting dues from qualified employers and
qualified employees; and
(D) Reimbursing participating health care providers for
services to enrollees.
(e) Establish a set of health care services that are covered in
the community-based health care improvement program, cost-sharing
requirements and incentives to encourage the utilization of
primary care, wellness and chronic disease management services.
(f) Maintain a liquid reserve account in an amount sufficient
to pay all claims that have been incurred but not yet charged for
a period of at least two months.
(g) Provide to each qualified employee enrolled in the program
a clear and concise written statement that describes the
community-based health care improvement program and that
includes:
(A) The health care services that are covered;
(B) Any exclusions or limitations on coverage of health care
services, including any requirements for prior authorization;
(C) Copayments, coinsurance, deductibles and any other
cost-sharing requirements;
(D) A list of participating health care providers;
(E) The complaint process described in subsection (3)(b) of
this section; and
(F) The conditions under which the program or coverage through
the program may be terminated.
(h) Comply with the requirements of sections 3 and 4 of this
2009 Act.
(3) An approved community-based health care improvement program
shall:
(a) Reimburse the cost of the set of health care services
established by the initiative and provided in the community to
qualified employers, qualified employees and their dependents.
(b) Include an enrollee complaint process that ensures the
resolution of complaints within 45 days. + }
SECTION 3. { + (1) A community-based health care initiative
may limit enrollment in a community-based health care improvement
program. If enrollment is limited, the initiative must establish
a waiting list.
(2) Except as provided in this section, an initiative may not
restrict or deny enrollment in the program except for nonpayment
of dues, fraud or misrepresentation.
Enrolled Senate Bill 862 (SB 862-B) Page 2
(3) As a condition for enrolling a qualified employer and
maintaining the employer's enrollment in the program, an
initiative may require a minimum percentage of participation by
qualified employees of an employer. + }
SECTION 4. { + A community-based health care initiative
approved by the Administrator of the Office for Oregon Health
Policy and Research must report to the Legislative Assembly no
later than October 1 of each year. The report must contain at a
minimum the following information:
(1) The financial status of the community-based health care
improvement program, including the dues, the costs per enrollee
per month, the total amount of claims paid, the total amount of
dues collected and the administrative expenses;
(2) A description of the set of health care services covered by
the program and an analysis of service utilization;
(3) The number of qualified employers, qualified employees and
dependents enrolled;
(4) The number and scope of practice of participating health
care providers;
(5) Recommendations for improving the program and establishing
programs in other geographical regions of the state; and
(6) Any other information requested by the administrator or the
Legislative Assembly. + }
SECTION 5. ORS 731.036 is amended to read:
731.036. The Insurance Code does not apply to any of the
following to the extent of the subject matter of the exemption:
(1) A bail bondsman, other than a corporate surety and its
agents.
(2) A fraternal benefit society that has maintained lodges in
this state and other states for 50 years prior to January 1,
1961, and for which a certificate of authority was not required
on that date.
(3) A religious organization providing insurance benefits only
to its employees, which organization is in existence and exempt
from taxation under section 501(c)(3) of the federal Internal
Revenue Code on September 13, 1975.
(4) Public bodies, as defined in ORS 30.260, that either
individually or jointly establish a self-insurance program for
tort liability in accordance with ORS 30.282.
(5) Public bodies, as defined in ORS 30.260, that either
individually or jointly establish a self-insurance program for
property damage in accordance with ORS 30.282.
(6) Cities, counties, school districts, community college
districts, community college service districts or districts, as
defined in ORS 198.010 and 198.180, that either individually or
jointly insure for health insurance coverage, excluding
disability insurance, their employees or retired employees, or
their dependents, or students engaged in school activities, or
combination of employees and dependents, with or without employee
or student contributions, if all of the following conditions are
met:
(a) The individual or jointly self-insured program meets the
following minimum requirements:
(A) In the case of a school district, community college
district or community college service district, the number of
covered employees and dependents and retired employees and
dependents aggregates at least 500 individuals;
(B) In the case of an individual public body program other than
a school district, community college district or community
college service district, the number of covered employees and
Enrolled Senate Bill 862 (SB 862-B) Page 3
dependents and retired employees and dependents aggregates at
least 500 individuals; and
(C) In the case of a joint program of two or more public
bodies, the number of covered employees and dependents and
retired employees and dependents aggregates at least 1,000
individuals;
(b) The individual or jointly self-insured health insurance
program includes all coverages and benefits required of group
health insurance policies under ORS chapters 743 and 743A;
(c) The individual or jointly self-insured program must have
program documents that define program benefits and
administration;
(d) Enrollees must be provided copies of summary plan
descriptions including:
(A) Written general information about services provided, access
to services, charges and scheduling applicable to each enrollee's
coverage;
(B) The program's grievance and appeal process; and
(C) Other group health plan enrollee rights, disclosure or
written procedure requirements established under ORS chapters 743
and 743A;
(e) The financial administration of an individual or jointly
self-insured program must include the following requirements:
(A) Program contributions and reserves must be held in separate
accounts and used for the exclusive benefit of the program;
(B) The program must maintain adequate reserves. Reserves may
be invested in accordance with the provisions of ORS chapter 293.
Reserve adequacy must be calculated annually with proper
actuarial calculations including the following:
(i) Known claims, paid and outstanding;
(ii) A history of incurred but not reported claims;
(iii) Claims handling expenses;
(iv) Unearned contributions; and
(v) A claims trend factor; and
(C) The program must maintain adequate reinsurance against the
risk of economic loss in accordance with the provisions of ORS
742.065 unless the program has received written approval for an
alternative arrangement for protection against economic loss from
the Director of the Department of Consumer and Business Services;
(f) The individual or jointly self-insured program must have
sufficient personnel to service the employee benefit program or
must contract with a third party administrator licensed under ORS
chapter 744 as a third party administrator to provide such
services;
(g) The individual or jointly self-insured program shall be
subject to assessment in accordance with ORS 735.614 and former
enrollees shall be eligible for portability coverage in
accordance with ORS 735.616;
(h) The public body, or the program administrator in the case
of a joint insurance program of two or more public bodies, files
with the Director of the Department of Consumer and Business
Services copies of all documents creating and governing the
program, all forms used to communicate the coverage to
beneficiaries, the schedule of payments established to support
the program and, annually, a financial report showing the total
incurred cost of the program for the preceding year. A copy of
the annual audit required by ORS 297.425 may be used to satisfy
the financial report filing requirement; and
(i) Each public body in a joint insurance program is liable
only to its own employees and no others for benefits under the
Enrolled Senate Bill 862 (SB 862-B) Page 4
program in the event, and to the extent, that no further funds,
including funds from insurance policies obtained by the pool, are
available in the joint insurance pool.
(7) All ambulance services.
(8) A person providing any of the services described in this
subsection. The exemption under this subsection does not apply to
an authorized insurer providing such services under an insurance
policy. This subsection applies to the following services:
(a) Towing service.
(b) Emergency road service, which means adjustment, repair or
replacement of the equipment, tires or mechanical parts of a
motor vehicle in order to permit the motor vehicle to be operated
under its own power.
(c) Transportation and arrangements for the transportation of
human remains, including all necessary and appropriate
preparations for and actual transportation provided to return a
decedent's remains from the decedent's place of death to a
location designated by a person with valid legal authority under
ORS 97.130.
(9)(a) A person described in this subsection who, in an
agreement to lease or to finance the purchase of a motor vehicle,
agrees to waive for no additional charge the amount specified in
paragraph (b) of this subsection upon total loss of the motor
vehicle because of physical damage, theft or other occurrence, as
specified in the agreement. The exemption established in this
subsection applies to the following persons:
(A) The seller of the motor vehicle, if the sale is made
pursuant to a motor vehicle retail installment contract.
(B) The lessor of the motor vehicle.
(C) The lender who finances the purchase of the motor vehicle.
(D) The assignee of a person described in this paragraph.
(b) The amount waived pursuant to the agreement shall be the
difference, or portion thereof, between the amount received by
the seller, lessor, lender or assignee, as applicable, which
represents the actual cash value of the motor vehicle at the date
of loss, and the amount owed under the agreement.
{ + (10) A community-based health care initiative approved by
the Administrator of the Office for Oregon Health Policy and
Research under section 2 of this 2009 Act operating a
community-based health care improvement program approved by the
administrator. + }
SECTION 6. { + This 2009 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2009 Act takes effect on its
passage. + }
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Enrolled Senate Bill 862 (SB 862-B) Page 5
Passed by Senate April 22, 2009
Repassed by Senate June 5, 2009
...........................................................
Secretary of Senate
...........................................................
President of Senate
Passed by House June 3, 2009
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Speaker of House
Enrolled Senate Bill 862 (SB 862-B) Page 6
Received by Governor:
......M.,............., 2009
Approved:
......M.,............., 2009
...........................................................
Governor
Filed in Office of Secretary of State:
......M.,............., 2009
...........................................................
Secretary of State
Enrolled Senate Bill 862 (SB 862-B) Page 7