76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
SA to A-Eng. HB 2679
LC 445/HB 2679-A9
SENATE AMENDMENTS TO
A-ENGROSSED HOUSE BILL 2679
By COMMITTEE ON FINANCE AND REVENUE
June 15
On page 1 of the printed A-engrossed bill, line 3, after '
735.485' delete the rest of the line and insert ', 735.490,
743.912, 743.917, 750.055 and 750.333; and'.
In line 12, after the third comma insert 'after receiving
express legislative approval,'.
On page 12, after line 45, insert:
' { + SECTION 21. + } ORS 743.912 is amended to read:
' 743.912. (1) As used in this section, 'refund' means the
return, either directly or through an offset to a future claim,
of some or all of a payment already received by a health care
provider.
' (2) Except in the case of fraud or abuse of billing, and
except as provided in subsections (3) and (5) of this section, a
health insurer may not:
' (a) Request from a health care provider a refund of a payment
previously made to satisfy a claim unless the health insurer:
' (A) Requests the refund in writing { - within 24 months - }
{ + on or before the last day of the period specified by the
contract with the health care provider or 18 months + } after the
date the payment was made { + , whichever is earlier + }; and
' (B) Specifies in the written request why the health insurer
believes the provider owes the refund.
' (b) Request that a contested refund be paid earlier than six
months after the health care provider receives the request.
' (3) A health insurer may not do the following for reasons
related to coordination of benefits with another health insurer
or entity responsible for payment of a claim:
' (a) Request from a health care provider a refund of a payment
previously made to satisfy a claim unless the health insurer:
' (A) Requests the refund in writing within 30 months after the
date the payment was made;
' (B) Specifies in the written request why the health insurer
believes the provider owes the refund; and
' (C) Includes in the written request the name and mailing
address of the other health insurer or entity that has primary
responsibility for payment of the claim.
' (b) Request that a contested refund be paid earlier than six
months after the provider receives the request.
' (4) If a health care provider fails to contest a refund
request in writing to the health insurer within 30 days after
receiving the request, the request is deemed accepted and the
provider must pay the refund within 30 days after the request is
deemed accepted. If the provider has not paid the refund within
30 days after the request is deemed accepted, the health insurer
may recover the amount through an offset to a future claim.
' (5) A health insurer may at any time request from a health
care provider a refund of a payment previously made to satisfy a
claim if:
' (a) A third party, including a government entity, is found
responsible for satisfaction of the claim as a consequence of
liability imposed by law; and
' (b) The health insurer is unable to recover directly from the
third party because the third party has already paid or will pay
the provider for the health care services covered by the claim.
' (6) If a contract between a health insurer and a health care
provider conflicts with this section, the provisions of this
section prevail. However, nothing in this section prohibits a
health care provider from choosing at any time to refund to a
health insurer any payment previously made to satisfy a claim.
' (7) This section neither permits nor precludes a health
insurer from recovering from a subscriber, enrollee or
beneficiary any amounts paid to a health care provider for
benefits to which the subscriber, enrollee or beneficiary was not
entitled under the terms and conditions of the health plan,
insurance policy or other benefit agreement.
' (8) This section { - does not apply to claims for health
care services provided through dental-only health insurers,
through Medicare or through Medicare supplemental plans - } { +
applies to health benefit plans + }.
' { + SECTION 22. + } ORS 743.917 is amended to read:
' 743.917. (1) Except in the case of fraud and except as
provided in subsection { - (2) - } { + (3) + } of this
section, a health care provider may not:
' (a) Request additional payment from a health insurer to
satisfy a claim unless the provider:
' (A) Requests the additional payment in writing { - within
24 months - } { + on or before the last day of the period
specified by the contract or 18 months + } after the date the
claim was denied or payment intended to satisfy the claim was
made { + , whichever is earlier + }; and
' (B) Specifies in the written request why the provider
believes the health insurer owes the additional payment.
' (b) Request that an additional payment be paid earlier than
six months after the health insurer receives the request.
' { + (2) A health insurer may not consider a health care
provider's claim untimely if the claim is made no later than 12
months after a different insurer:
' (a) Denied the claim in whole or in part; or
' (b) Requested a refund of an erroneous payment made on the
claim. + }
' { - (2) - } { + (3) + } A health care provider may not do
the following for reasons related to coordination of benefits
with another health insurer or entity responsible for payment of
a claim:
' (a) Request additional payment from a health insurer to
satisfy a claim unless the provider:
' (A) Requests the additional payment in writing within 30
months after the date the claim was denied or payment intended to
satisfy the claim was made;
' (B) Specifies in the written request why the provider
believes the health insurer owes the additional payment; and
' (C) Includes in the written request the name and mailing
address of the other health insurer or entity that has disclaimed
responsibility for payment of the claim.
' (b) Request that the additional payment be paid earlier than
six months after the health insurer receives the request.
' { - (3) - } { + (4) + } If a contract between a health
insurer and a health care provider conflicts with this section,
the provisions of this section prevail. However, nothing in this
section prohibits a health insurer from choosing at any time to
make additional payments to a health care provider to satisfy a
claim.
' { - (4) - } { + (5) + } This section { - does not apply
to claims for health care services provided through dental-only
health insurers, through Medicare or through Medicare
supplemental plans - } { + applies to health benefit plans + }.
' { + SECTION 23. + } { + The amendments to ORS 743.912 and
743.917 by sections 21 and 22 of this 2011 Act apply to contracts
between health insurers and health care providers that are in
effect on or after the effective date of this 2011 Act. + }
' { + SECTION 24. + } { + Section 25 of this 2011 Act is
added to and made a part of the Insurance Code. + }
' { + SECTION 25. + } { + An insurer offering a health
benefit plan, as defined in ORS 743.730, that provides coverage
of prescription eye drops shall provide coverage for one early
refill of a prescription for eye drops to treat glaucoma if all
of the following criteria are met:
' (1) The refill is requested by an insured less than 30 days
after the later of:
' (a) The date the original prescription was dispensed to the
insured; or
' (b) The date that the last refill of the prescription was
dispensed to the insured.
' (2) The prescriber indicates on the original prescription
that a specific number of refills will be needed.
' (3) The refill does not exceed the number of refills that the
prescriber indicated under subsection (2) of this section.
' (4) The prescription has not been refilled more than once
during the 30-day period prior to the request for an early
refill. + }
' { + SECTION 26. + } ORS 750.055 is amended to read:
' 750.055. (1) The following provisions of the Insurance Code
apply to health care service contractors to the extent not
inconsistent with the express provisions of ORS 750.005 to
750.095:
' (a) ORS 705.137, 705.139, 731.004 to 731.150, 731.162,
731.216 to 731.362, 731.382, 731.385, 731.386, 731.390, 731.398
to 731.430, 731.428, 731.450, 731.454, 731.488, 731.504, 731.508,
731.509, 731.510, 731.511, 731.512, 731.574 to 731.620, 731.592,
731.594, 731.640 to 731.652, 731.730, 731.731, 731.735, 731.737,
731.750, 731.752, 731.804, 731.844 to 731.992 and 731.870.
' (b) ORS 732.215, 732.220, 732.230, 732.245, 732.250, 732.320,
732.325 and 732.517 to 732.592, not including ORS 732.582.
' (c) ORS 733.010 to 733.050, 733.080, 733.140 to 733.170,
733.210, 733.510 to 733.680 and 733.695 to 733.780.
' (d) ORS chapter 734.
' (e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065,
742.150 to 742.162, 742.400, 742.520 to 742.540, 743.010,
743.013, 743.018 to 743.030, 743.050, 743.100 to 743.109,
743.402, 743.472, 743.492, 743.495, 743.498, 743.522, 743.523,
743.524, 743.526, 743.527, 743.528, 743.529, 743.549 to 743.552,
743.560, 743.600 to 743.610, 743.650 to 743.656, 743.804,
743.807, 743.808, 743.814 to 743.839, 743.842, 743.845, 743.847,
743.854, 743.856, 743.857, 743.858, 743.859, 743.861, 743.862,
743.863, 743.864, 743.911, 743.912, 743.913, 743.917, 743A.010,
743A.012, 743A.020, 743A.036, 743A.048, 743A.058, 743A.062,
743A.064, 743A.066, 743A.068, 743A.070, 743A.080, 743A.084,
743A.088, 743A.090, 743A.100, 743A.104, 743A.105, 743A.110,
743A.140, 743A.141, 743A.144, 743A.148, 743A.160, 743A.164,
743A.168, 743A.170, 743A.175, 743A.184, 743A.188, 743A.190 and
743A.192 { + and section 25 of this 2011 Act + }.
' (f) The provisions of ORS chapter 744 relating to the
regulation of insurance producers.
' (g) ORS 746.005 to 746.140, 746.160, 746.220 to 746.370,
746.600, 746.605, 746.607, 746.608, 746.610, 746.615, 746.625,
746.635, 746.650, 746.655, 746.660, 746.668, 746.670, 746.675,
746.680 and 746.690.
' (h) ORS 743A.024, except in the case of group practice health
maintenance organizations that are federally qualified pursuant
to Title XIII of the Public Health Service Act unless the patient
is referred by a physician associated with a group practice
health maintenance organization.
' (i) ORS 735.600 to 735.650.
' (j) ORS 743.680 to 743.689.
' (k) ORS 744.700 to 744.740.
' (L) ORS 743.730 to 743.773.
' (m) ORS 731.485, except in the case of a group practice
health maintenance organization that is federally qualified
pursuant to Title XIII of the Public Health Service Act and that
wholly owns and operates an in-house drug outlet.
' (2) For the purposes of this section, health care service
contractors shall be deemed insurers.
' (3) Any for-profit health care service contractor organized
under the laws of any other state that is not governed by the
insurance laws of the other state is subject to all requirements
of ORS chapter 732.
' (4) The Director of the Department of Consumer and Business
Services may, after notice and hearing, adopt reasonable rules
not inconsistent with this section and ORS 750.003, 750.005,
750.025 and 750.045 that are deemed necessary for the proper
administration of these provisions.
' { + SECTION 27. + } ORS 750.333 is amended to read:
' 750.333. (1) The following provisions of the Insurance Code
apply to trusts carrying out a multiple employer welfare
arrangement:
' (a) ORS 731.004 to 731.150, 731.162, 731.216 to 731.268,
731.296 to 731.316, 731.324, 731.328, 731.378, 731.386, 731.390,
731.398, 731.406, 731.410, 731.414, 731.418 to 731.434, 731.454,
731.484, 731.486, 731.488, 731.512, 731.574 to 731.620, 731.640
to 731.652 and 731.804 to 731.992.
' (b) ORS 733.010 to 733.050, 733.140 to 733.170, 733.210,
733.510 to 733.680 and 733.695 to 733.780.
' (c) ORS chapter 734.
' (d) ORS 742.001 to 742.009, 742.013, 742.061 and 742.400.
' (e) ORS 743.028, 743.053, 743.524, 743.526, 743.527, 743.528,
743.529, 743.530, 743.560, 743.562, 743.600, 743.601, 743.602,
743.610, 743.730 to 743.773 (except 743.760 to 743.773), 743.801,
743.804, 743.807, 743.808, 743.814 to 743.839, 743.842, 743.845,
743.847, 743.854, 743.856, 743.857, 743.858, 743.859, 743.861,
743.862, 743.863, 743.864, 743.912, 743.917, 743A.012, 743A.020,
743A.052, 743A.064, 743A.080, 743A.100, 743A.104, 743A.110,
743A.144, 743A.170, 743A.175, 743A.184 and 743A.192 { + and
section 25 of this 2011 Act + }.
' (f) ORS 743A.010, 743A.014, 743A.024, 743A.028, 743A.032,
743A.036, 743A.040, 743A.048, 743A.058, 743A.066, 743A.068,
743A.070, 743A.084, 743A.088, 743A.090, 743A.105, 743A.140,
743A.141, 743A.148, 743A.168, 743A.180, 743A.188 and 743A.190.
Multiple employer welfare arrangements to which ORS 743.730 to
743.773 apply are subject to the sections referred to in this
paragraph only as provided in ORS 743.730 to 743.773.
' (g) Provisions of ORS chapter 744 relating to the regulation
of insurance producers and insurance consultants, and ORS 744.700
to 744.740.
' (h) ORS 746.005 to 746.140, 746.160 and 746.220 to 746.370.
' (i) ORS 731.592 and 731.594.
' (j) ORS 731.870.
' (2) For the purposes of this section:
' (a) A trust carrying out a multiple employer welfare
arrangement shall be considered an insurer.
' (b) References to certificates of authority shall be
considered references to certificates of multiple employer
welfare arrangement.
' (c) Contributions shall be considered premiums.
' (3) The provision of health benefits under ORS 750.301 to
750.341 shall be considered to be the transaction of health
insurance.
' { + SECTION 28. + } { + Section 25 of this 2011 Act and
the amendments to ORS 750.055 and 750.333 by sections 26 and 27
of this 2011 Act apply to contracts entered into or renewed, and
policies or certificates issued or renewed, on or after the
effective date of this 2011 Act. + } ' .
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