76th OREGON LEGISLATIVE ASSEMBLY--2011 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 2602
House Bill 3510
Sponsored by Representative DEMBROW; Representatives BAILEY,
FREDERICK, GREENLICK, NOLAN, TOMEI, Senators DINGFELDER,
SHIELDS
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.
Establishes Affordable Health Care for All Oregon Plan,
operated by Oregon Health Authority according to policies
established by Affordable Health Care for All Oregon Board.
Provides comprehensive health care coverage to all individuals
residing or working in Oregon. Supplants coverage by private
insurers for health services covered by plan. Requires public
employees to be covered by plan. Creates Affordable Health Care
for All Oregon Fund. Continuously appropriates moneys in fund to
authority. Provides for implementation of plan on January 2,
2014.
Requires board to establish policies and approve administrative
rules for certificate of need process. Expands certificate of
need to include both new and existing health care facilities.
Repeals Oregon Health Insurance Exchange, Oregon Medical
Insurance Pool Board, Oregon Medical Insurance Pool, Office of
Private Health Partnerships, Family Health Insurance Assistance
Program and private health option under Health Care for All
Oregon Children program on January 2, 2014.
Appropriates moneys from General Fund to authority for purposes
of plan.
A BILL FOR AN ACT
Relating to statewide coverage of health care; creating new
provisions; amending ORS 65.957, 192.519, 243.105, 243.125,
243.135, 243.215, 243.860, 243.864, 243.866, 243.868, 291.055,
413.011, 413.017, 413.032, 413.033, 413.201, 414.041, 414.231,
430.315, 433.443, 442.015, 442.315, 442.325, 705.145, 731.036,
734.790, 743.402, 743.730, 743.748, 743.766, 743.767, 743.769,
743A.001, 744.704, 746.600, 748.603 and 750.055 and section 1,
chapter 867, Oregon Laws 2009; repealing ORS 413.064, 413.075,
414.825, 414.826, 414.828, 414.831, 414.839, 414.841, 414.842,
414.844, 414.846, 414.848, 414.851, 414.852, 414.854, 414.856,
414.858, 414.861, 414.862, 414.864, 414.866, 414.868, 414.870,
414.872, 735.600, 735.605, 735.610, 735.612, 735.614, 735.615,
735.616, 735.620, 735.625, 735.630, 735.635, 735.640, 735.645,
735.650, 735.700, 735.701, 735.702, 735.703, 735.705, 735.707,
735.709, 735.710, 735.711, 735.712, 735.714 and 746.222 and
section 17, chapter 595, Oregon Laws 2009, and sections 1, 2,
3, 4 and 5, chapter 47, Oregon Laws 2010; and appropriating
money.
Be It Enacted by the People of the State of Oregon:
{ +
ESTABLISHMENT OF THE AFFORDABLE HEALTH CARE + }
{ +
FOR ALL OREGON PLAN + }
SECTION 1. { + (1) The Affordable Health Care for All Oregon
Plan is established to ensure access to quality, patient-centered
and affordable health care for all individuals living or working
in Oregon, to improve the public's health and to control the cost
of health care for the benefit of individuals, families,
businesses and society.
(2) The plan shall pay the costs of medically necessary health
services in the following categories within the scope prescribed
by the Affordable Health Care for All Oregon Board, excluding
health services provided for cosmetic purposes only:
(a) Primary and preventive care, including health education;
(b) Specialty care;
(c) Inpatient and outpatient hospital care;
(d) Emergency care;
(e) Home health care;
(f) Prescription drugs according to a formulary;
(g) Durable medical equipment;
(h) Mental health services;
(i) Substance abuse treatment;
(j) Dental services;
(k) Chiropractic services;
(L) Basic vision and vision correction;
(m) Diagnostic imaging, laboratory services and other
diagnostic and evaluation services;
(n) Inpatient and outpatient rehabilitative services;
(o) Emergency transportation;
(p) Translation of verbal and written language;
(q) Hospice care;
(r) Podiatry;
(s) Acupuncture; and
(t) Dialysis.
(3) A person and the immediate family members of a person are
eligible to enroll in the plan if the person:
(a) Resides in this state; or
(b) Is employed in this state.
(4) Except as provided in section 2 of this 2011 Act, no
copayments, deductibles or other form of cost sharing may be
imposed on enrollees under the plan.
(5) Enrollees in the plan may choose any health care provider
licensed or certified in this state or in another state for
services within the scope of the provider's license or
certification.
(6) Within the scope of services covered within each category,
enrollees and their health care providers shall determine what
treatment is medically necessary.
(7) A health care provider may not discriminate against any
enrollee on the basis of race, religion, nationality, sex, sexual
orientation, age, wealth or any basis prohibited by the civil
rights laws of this state.
(8) A health care provider must accept payment from the plan as
payment in full and may not bill a patient for an amount
exceeding the payment made by the plan.
(9) A payment under the plan to a health care facility for
operational expenses may not be used by the facility to pay for
or to replace other funds used to pay for capital expenditures.
(10) Administrative costs of the plan may not exceed:
(a) Twelve percent of total costs of the plan during the first
two years of plan operation.
(b) Eight percent of total costs of the plan during the third
and fourth years of plan operation.
(c) Five percent of total costs of the plan during the fifth
and subsequent years of plan operation.
(11) Loss of eligibility due to no longer meeting the criteria
in subsection (3) of this section shall be considered a
qualifying event, and the Oregon Health Authority shall be
considered to be a plan sponsor of a group health plan for
purposes of continuation coverage required by 29 U.S.C. 1161. + }
SECTION 2. { + No later than January 1, 2015, the Affordable
Health Care for All Oregon Board established under section 5 of
this 2011 Act shall develop and submit to the Legislative
Assembly a recommendation for the coverage of long term care
services by the Affordable Health Care for All Oregon Plan. The
recommendation may allow for the imposition on enrollees of
copayments, deductibles or other forms of cost sharing. + }
SECTION 3. { + An insurer with a certificate of authority to
transact insurance issued by the Department of Consumer and
Business Services may not offer in this state a policy or
certificate of health insurance that covers services provided
under the Affordable Health Care for All Oregon Plan. + }
SECTION 4. { + Actions taken by insurers may not be considered
to be the transaction of insurance for purposes of the Insurance
Code if the actions are:
(1) Taken in accordance with the requirements adopted pursuant
to sections 1, 7 and 10 of this 2011 Act; and
(2) Approved by the Oregon Health Authority or the Affordable
Health Care for All Oregon Board. + }
{ +
AFFORDABLE HEALTH CARE FOR ALL OREGON BOARD + }
SECTION 5. { + (1) There is established the Affordable Health
Care for All Oregon Board, consisting of nine members appointed
by the Governor, subject to confirmation by the Senate in the
manner prescribed by ORS 171.562 and 171.565, who shall include:
(a) A licensed or certified health care provider;
(b) A public health official;
(c) A representative of organized labor; and
(d) A representative of business who is not employed by a
health care provider, pharmaceutical company, health insurer or
medical supply company.
(2) The term of office of each member is four years and begins
on January 2. A new term begins on the expiration of the previous
term. A member is eligible for reappointment. The Governor shall
appoint a person to fill any vacancy, subject to confirmation by
the Senate. Any appointment to a vacant position shall become
immediately effective for the unexpired term.
(3) The board shall select one of its members as chairperson
and another as vice chairperson, for such terms and with duties
and powers necessary for the performance of the functions of such
offices as the board determines.
(4) A majority of the members of the board constitutes a quorum
for the transaction of business.
(5) The board shall meet at least once every three months at a
place, day and hour determined by the chairperson. The board may
also meet at other times and places specified by the call of the
chairperson or of a majority of the members of the board.
(6) The board shall adopt rules of ethics and definitions of
conflicts of interest for determining the circumstances under
which members of the board must recuse themselves from voting.
(7) The Oregon Health Authority shall provide staff support for
the board.
(8) A member of the board is entitled to compensation and
expenses as provided in ORS 292.495 for participation in board
and subcommittee meetings.
(9) In accordance with applicable provisions of ORS chapter
183, the board may adopt rules necessary for the administration
of the laws that the board is charged with administering. + }
SECTION 6. { + Notwithstanding section 5 of this 2011 Act, of
the members first appointed to the Affordable Health Care for All
Oregon Board:
(1) Three shall serve for terms ending December 31, 2013.
(2) Three shall serve for terms ending December 31, 2014.
(3) Three shall serve for terms ending December 31, 2015. + }
SECTION 7. { + The Affordable Health Care for All Oregon Board
is responsible for the development, implementation, management
and oversight of the Affordable Health Care for All Oregon Plan
established in section 1 of this 2011 Act, including but not
limited to all of the following duties:
(1) Determining and regularly updating the scope of coverage
within each category described in section 1 (2) of this 2011 Act
in consultation with enrollees and guided by evidence-based
practices that integrate clinical expertise, patient values and
current research.
(2) Approving the package of benefits covered in the plan.
(3) Overseeing management of the Affordable Health Care for All
Oregon Fund.
(4) Determining policies and adopting rules to guide the
operation of the plan, including but not limited to:
(a) Establishing eligibility standards for enrollment,
including standards for presumptive eligibility determinations;
(b) Ensuring meaningful access by enrollees to quality health
services included in the benefit package;
(c) Ensuring that the plan covers health services that:
(A) Are evidence-based and cost-effective in promoting health;
and
(B) Emphasize disease prevention and health promotion;
(d) Developing quality of care indicators;
(e) Establishing policies regarding conflicts of interest for
health care providers and health care facilities;
(f) Regularly soliciting input from the public, including
individuals with specialized health service needs, through
district advisory committees and other means;
(g) Hiring an executive director for the plan who serves at the
pleasure of the board;
(h) Approving contracts for services provided by health care
facilities;
(i) Approving contracts with pharmaceutical and durable medical
equipment providers;
(j) Seeking all waivers, exemptions and agreements from
federal, state and local government sources that are necessary to
provide funding for the plan; and
(k) Ensuring that implementation of the plan affects all
individuals equitably, regardless of health status, age,
disability, employment status or income.
(5) Partnering with public health agencies to improve the
public's health.
(6) Reporting, at least annually, to the Legislative Assembly
on the performance of the plan and recommending needed
legislative changes.
(7) Implementing a program to provide retraining for workers
dislocated by the creation of the plan.
(8) Establishing an appeal process, in accordance with ORS
chapter 183, and an ombudsman office for both health care
providers and enrollees to appeal adverse determinations by the
board or the Oregon Health Authority and to resolve complaints.
(9) Submitting to the Legislative Assembly an estimate of the
funding needed to operate the plan.
(10) Ensuring an annual audit is conducted of the revenue and
expenses of the plan.
(11) Establishing procedures and terms for payments to in-state
and out-of-state health care providers for covered services
provided under the plan.
(12) Establishing policies for the certificate of need process
under ORS 442.315. + }
SECTION 8. { + (1) The Affordable Health Care for All Oregon
Board shall establish a program to operate during the first four
years of operation of the Affordable Health Care for All Oregon
Plan to pay for or to reimburse the costs of retraining for
workers who are displaced by the implementation of the plan.
(2) The board shall apply for federal and private gifts and
grants available to operate the program.
(3) A worker is eligible for no more than 24 months of
retraining under this section. + }
SECTION 9. { + (1) The Affordable Health Care for All Oregon
Board shall appoint for each congressional district a district
advisory committee consisting of residents of the district, to
solicit input, receive complaints, conduct public hearings,
facilitate accountability or assist the board in any manner
deemed appropriate by the board to meet the health service needs
of residents of the congressional district.
(2) The Oregon Health Authority shall provide staff support to
each district advisory committee. + }
{ +
DUTIES OF THE OREGON HEALTH AUTHORITY IN ADMINISTER- + }
{ +
ING THE AFFORDABLE HEALTH CARE FOR ALL OREGON PLAN + }
SECTION 10. { + The Oregon Health Authority, under the
direction, policies and oversight of the Affordable Health Care
for All Oregon Board, shall:
(1) Adopt rules approved by the board necessary for carrying
out the authority's duties under this section;
(2) Propose goals, objectives and standards to achieve quality
and affordable health care accessible to all Oregonians and
propose major policy changes to the board;
(3) Establish systems to monitor and evaluate access, quality
and cost of health services provided to Oregonians;
(4) Direct research to improve health and health services;
(5) Identify legislation needed to improve health services
covered under the Affordable Health Care for All Oregon Plan;
(6) Establish collaborative partnerships with public health
agencies;
(7) Make recommendations to the board for ensuring equity in
the delivery of culturally sensitive health care to all Oregon
populations;
(8) Develop a biennial budget for board and legislative
approval;
(9) Administer the legislatively approved budget for the plan;
(10) Report periodically to the board, the Governor and the
Legislative Assembly on the progress of implementing the plan and
on the financial status of the plan;
(11) Arrange for appropriate and timely support for the board
to carry out the board's functions;
(12) Ensure prompt payment for all plan expenditures;
(13) Contract with health care providers, insurers and health
care service contractors to provide or administer health services
under the plan and contract for actuarial, legal, technical or
other professional services as needed;
(14) Negotiate favorable prices in contracts entered into with
health care providers, insurers and health care service
contractors;
(15) Direct ongoing, effective communication and outreach to
ensure Oregonians are well-informed about the plan;
(16) Process applications and determine eligibility for
individuals seeking to enroll or to renew enrollment in the plan;
(17) Operate the program developed by the board under section 8
of this 2011 Act to provide retraining for workers dislocated by
the creation of the plan;
(18) Provide prompt responses to suggestions, complaints and
grievances submitted by health care providers and enrollees under
the process established by the board in section 7 (8) of this
2011 Act; and
(19) Perform other functions delegated by the board to the
authority. + }
{ +
CERTIFICATES OF NEED + }
SECTION 11. ORS 442.315 is amended to read:
442.315. (1) Any { - new hospital or new skilled nursing or
intermediate care service or - } { + health care + } facility
not excluded pursuant to ORS 441.065 shall obtain a certificate
of need from the Oregon Health Authority prior to an offering or
development.
(2) The authority shall adopt rules { + , in compliance with
policies developed and subject to approval by the Affordable
Health Care for All Oregon Board, + } specifying criteria and
procedures for making decisions as to the need for the new
services or facilities.
(3)(a) An applicant for a certificate of need shall apply to
the authority on forms provided for this purpose by authority
rule.
(b) An applicant shall pay a fee prescribed as provided in this
section. Subject to the approval of the { - Oregon Department
of Administrative Services - } { + Affordable Health Care for
All Oregon Board + }, the authority shall prescribe application
fees, based on the complexity and scope of the proposed project.
(4) The authority shall be the decision-making authority for
the purpose of certificates of need.
(5)(a) An applicant or any affected person who is dissatisfied
with the proposed decision of the authority is entitled to an
informal hearing in the course of review and before a final
decision is rendered.
(b) Following a final decision being rendered by the authority,
an applicant or any affected person may request a reconsideration
hearing pursuant to ORS chapter 183.
(c) In any proceeding brought by an affected person or an
applicant challenging an authority decision under this
subsection, the authority shall follow procedures consistent with
the provisions of ORS chapter 183 relating to a contested case.
(6) Once a certificate of need has been issued, it may not be
revoked or rescinded unless it was acquired by fraud or deceit.
However, if the authority finds that a person is offering or
developing a project that is not within the scope of the
certificate of need, the authority may limit the project as
specified in the issued certificate of need or reconsider the
application. A certificate of need is not transferable.
(7) Nothing in this section applies to any { - hospital,
skilled nursing or intermediate care service or - } { + health
care + } facility that seeks to replace equipment with equipment
of similar basic technological function or an upgrade that
improves the quality or cost-effectiveness of the service
provided. Any person acquiring such replacement or upgrade shall
file a letter of intent for the project in accordance with the
rules of the authority if the price of the replacement equipment
or upgrade exceeds $1 million.
(8) { - Except as required in subsection (1) of this section
for a new hospital or new skilled nursing or intermediate care
service or facility not operating as a Medicare swing bed
program, nothing in - } This section { - requires - } { +
does not require + } a rural hospital as defined in ORS 442.470
(5)(a)(A) and (B) to obtain a certificate of need.
(9) Nothing in this section applies to basic health services,
but basic health services do not include:
(a) Magnetic resonance imaging scanners;
(b) Positron emission tomography scanners;
(c) Cardiac catheterization equipment;
(d) Megavoltage radiation therapy equipment;
(e) Extracorporeal shock wave lithotriptors;
(f) Neonatal intensive care;
(g) Burn care;
(h) Trauma care;
(i) Inpatient psychiatric services;
(j) Inpatient chemical dependency services;
(k) Inpatient rehabilitation services;
(L) Open heart surgery; or
(m) Organ transplant services.
(10) In addition to any other remedy provided by law, whenever
it appears that any person is engaged in, or is about to engage
in, any acts that constitute a violation of this section, or any
rule or order issued by the authority under this section, the
authority may institute proceedings in the circuit courts to
enforce obedience to such statute, rule or order by injunction or
by other processes, mandatory or otherwise.
{ - (11) As used in this section, 'basic health services '
means health services offered in or through a hospital licensed
under ORS chapter 441, except skilled nursing or intermediate
care nursing facilities or services and those services specified
in subsection (9) of this section. - }
SECTION 12. ORS 442.325 is amended to read:
442.325. (1) A certificate of need shall be required for the
development or establishment of a health care facility of any
{ - new - } health maintenance organization.
(2) Any activity of a health maintenance organization which
does not involve the direct delivery of health services, as
distinguished from arrangements for indirect delivery of health
services through contracts with providers, shall be exempt from
certificate of need review.
(3) { - Nothing in ORS 244.050, 431.250, - } { + ORS + }
441.015 to 441.087 { - , - } { + and + } 442.015 to 442.420
{ - and 442.450 applies - } { + do not apply + } to any
decision of a health maintenance organization involving its
organizational structure, its arrangements for financing health
services, the terms of its contracts with enrolled beneficiaries
or its scope of benefits.
(4) With the exception of certificate of need requirements,
when applicable, the licensing and regulation of health
maintenance organizations shall be controlled by ORS 750.005 to
750.095 and statutes incorporated by reference therein.
(5) It is the policy of ORS { - 244.050, 431.250, - }
441.015 to 441.087 { - , - } { + and + } 442.015 to 442.420
{ - and 442.450 - } to encourage the growth of health
maintenance organizations as an alternative delivery system and
to provide the facilities for the provision of quality health
care to the present and future members who may enroll within
their defined service area.
(6)(a) It is also the policy of ORS { - 244.050, 431.250, - }
441.015 to 441.087 { - , - } { + and + } 442.015 to 442.420
{ - and 442.450 - } to consider the special needs and
circumstances of health maintenance organizations. Such needs and
circumstances include the needs of and costs to members and
projected members of the health maintenance organization in
obtaining health services and the potential for a reduction in
the use of inpatient care in the community through an extension
of preventive health services and the provision of more
systematic and comprehensive health services. The consideration
of a new health service proposed by a health maintenance
organization shall also address the availability and cost of
obtaining the proposed new health service from the existing
providers in the area that are not health maintenance
organizations.
(b) The Oregon Health Authority shall issue a certificate of
need for beds, services or equipment to meet the needs or
reasonably anticipated needs of members of health maintenance
organizations when beds, services or equipment are not available
from nonplan providers.
{ +
PUBLIC EMPLOYEE PARTICIPATION IN + }
{ +
THE AFFORDABLE HEALTH CARE FOR ALL OREGON PLAN + }
{ +
(Public Employees' Benefit Board) + }
SECTION 13. ORS 243.105 is amended to read:
243.105. As used in ORS 243.105 to 243.285, unless the context
requires otherwise:
(1) 'Benefit plan' includes, but is not limited to:
(a) Contracts for insurance or other benefits, including
medical, dental, vision, life, disability and other health care
recognized by state law, and related services and supplies;
(b) Comparable benefits for employees who rely on spiritual
means of healing; { - and - }
(c) Self-insurance programs managed by the Public Employees'
Benefit Board { + ; and
(d) The Affordable Health Care for All Oregon Plan + }.
(2) 'Board' means the Public Employees' Benefit Board.
(3) 'Carrier' means an insurance company or health care service
contractor holding a valid certificate of authority from the
Director of the Department of Consumer and Business Services, or
two or more companies or contractors acting together pursuant to
a joint venture, partnership or other joint means of operation,
or a board-approved guarantor of benefit plan coverage and
compensation.
(4)(a) 'Eligible employee' means an officer or employee of a
state agency who elects to participate in one of the group
benefit plans described in ORS 243.135. The term includes state
officers and employees in the exempt, unclassified and classified
service, and state officers and employees, whether or not
retired, who:
(A) Are receiving a service retirement allowance, a disability
retirement allowance or a pension under the Public Employees
Retirement System or are receiving a service retirement
allowance, a disability retirement allowance or a pension under
any other retirement or disability benefit plan or system offered
by the State of Oregon for its officers and employees;
(B) Are eligible to receive a service retirement allowance
under the Public Employees Retirement System and have reached
earliest retirement age under ORS chapter 238;
(C) Are eligible to receive a pension under ORS 238A.100 to
238A.245, and have reached earliest retirement age as described
in ORS 238A.165; or
(D) Are eligible to receive a service retirement allowance or
pension under another retirement benefit plan or system offered
by the State of Oregon and have attained earliest retirement age
under the plan or system.
(b) 'Eligible employee' does not include individuals:
(A) Engaged as independent contractors;
(B) Whose periods of employment in emergency work are on an
intermittent or irregular basis;
(C) Who are employed on less than half-time basis unless the
individuals are employed in positions classified as job-sharing
positions, unless the individuals are defined as eligible under
rules of the board;
(D) Appointed under ORS 240.309;
(E) Provided sheltered employment or make-work by the state in
an employment or industries program maintained for the benefit of
such individuals; or
(F) Provided student health care services in conjunction with
their enrollment as students at the state institutions of higher
education.
(5) 'Family member' means an eligible employee's spouse and any
unmarried child or stepchild within age limits and other
conditions imposed by the board with regard to unmarried children
or stepchildren.
(6) 'Payroll disbursing officer' means the officer or official
authorized to disburse moneys in payment of salaries and wages of
employees of a state agency.
(7) 'Premium' means the monthly or other periodic charge for a
benefit plan.
(8) 'State agency' means every state officer, board,
commission, department or other activity of state government.
SECTION 14. ORS 243.125 is amended to read:
243.125. (1) The Public Employees' Benefit Board shall
prescribe rules for the conduct of its business. The board shall
study all matters connected with the providing of adequate
benefit plan coverage for eligible state employees on the best
basis possible with relation both to the welfare of the employees
and to the state. The board shall design benefits, devise
specifications, analyze carrier responses to advertisements for
bids and decide on the award of contracts. Contracts shall be
signed by the chairperson on behalf of the board.
(2) In carrying out its duties under subsection (1) of this
section, the goal of the board shall be to provide a high quality
plan of health and other benefits for state employees at a cost
affordable to both the employer and the employees.
(3) Subject to ORS chapter 183, the board may make rules not
inconsistent with ORS 243.105 to 243.285 and 292.051 to determine
the terms and conditions of eligible employee participation and
coverage.
(4) The board shall prepare specifications, invite bids and do
acts necessary to award contracts for health benefit plan and
dental benefit plan coverage of eligible employees in accordance
with the criteria set forth in ORS 243.135 { - (1) - } { +
(2) + }.
(5) The board may retain consultants, brokers or other advisory
personnel when necessary and, subject to the State Personnel
Relations Law, shall employ such personnel as are required to
perform the functions of the board.
SECTION 15. ORS 243.135, as amended by section 1, chapter 49,
Oregon Laws 2010, is amended to read:
243.135. { + (1) Any person who is eligible to participate in
a health benefit plan available to state employees pursuant to
ORS 243.105 to 243.285 shall enroll in the Affordable Health Care
for All Oregon Plan. + }
{ - (1) - } { + (2) + } { - Notwithstanding any other
benefit plan contracted for and offered by the Public Employees'
Benefit Board - } { + If the Public Employees' Benefit Board
contracts for health benefit plans to supplement coverage
provided in the Affordable Health Care for All Oregon Plan + },
the board shall contract for a { + supplemental + } health
benefit plan or plans best designed to meet the needs and provide
for the welfare of eligible employees and the state. In
considering whether to enter into a contract for a
{ + supplemental + } plan, the board shall place emphasis on:
(a) Employee choice among high quality plans;
(b) A competitive marketplace;
(c) Plan performance and information;
(d) Employer flexibility in plan design and contracting;
(e) Quality customer service;
(f) Creativity and innovation;
(g) Plan benefits as part of total employee compensation; and
(h) The improvement of employee health.
{ - (2) - } { + (3) + } The board may approve more than one
carrier for each type of { + supplemental + } plan contracted
for and offered but the number of carriers shall be held to a
number consistent with adequate service to eligible employees and
their family members.
{ - (3) - } { + (4) + } Where appropriate for a contracted
and offered { + supplemental + } health benefit plan, the board
shall provide options under which an eligible employee may
arrange coverage for family members.
{ - (4) - } { + (5) + } Payroll deductions for such costs
as are not payable by the state may be made upon receipt of a
signed authorization from the employee indicating an election to
participate in the { + supplemental + } plan or plans selected
and the deduction of a certain sum from the employee's pay.
{ - (5) - } { + (6) + } In developing any
{ + supplemental + } health benefit plan, the board may provide
an option of additional coverage for eligible employees and their
family members at an additional cost or premium.
{ - (6) - } { + (7) + } Transfer of enrollment from one
plan to another shall be open to all eligible employees and their
family members under rules adopted by the board. Because of the
special problems that may arise in individual instances under
comprehensive group practice plan coverage involving acceptable
physician-patient relations between a particular panel of
physicians and particular eligible employees and their family
members, the board shall provide a procedure under which any
eligible employee may apply at any time to substitute a health
service benefit plan for participation in a comprehensive group
practice benefit plan.
{ - (7) - } { + (8) + } The board shall evaluate a
{ + supplemental + } benefit plan that serves a limited
geographic region of this state according to the criteria
described in subsection { - (1) - } { + (2) + } of this
section.
SECTION 16. ORS 243.215 is amended to read:
243.215. Any eligible employee unable to participate in one or
more of the plans described in ORS 243.135 { - (1) - } solely
because the employee is assigned to perform duties outside the
state may be eligible to receive the monthly state contribution,
less administrative expenses, as payment of all or part of the
cost of a health benefit plan of choice, subject to the approval
of the Public Employees' Benefit Board and such rules as the
board may adopt.
{ +
(Oregon Educators Benefit Board) + }
SECTION 17. ORS 243.860 is amended to read:
243.860. As used in ORS 243.860 to 243.886, unless the context
requires otherwise:
(1) 'Benefit plan' includes but is not limited to:
(a) Contracts for insurance or other benefits, including
medical, dental, vision, life, disability and other health care
recognized by state law, and related services and supplies;
(b) Self-insurance programs managed by the Oregon Educators
Benefit Board; { - and - }
(c) Comparable benefits for employees who rely on spiritual
means of healing { + ; and
(d) The Affordable Health Care for All Oregon Plan + }.
(2) 'Carrier' means an insurance company or health care service
contractor holding a valid certificate of authority from the
Director of the Department of Consumer and Business Services, or
two or more companies or contractors acting together pursuant to
a joint venture, partnership or other joint means of operation,
or a board-approved provider or guarantor of benefit plan
coverage and compensation.
(3) 'District' means a common school district, a union high
school district, an education service district, as defined in ORS
334.003, or a community college district, as defined in ORS
341.005.
(4)(a) 'Eligible employee' includes:
(A) An officer or employee of a district who elects to
participate in one of the benefit plans described in ORS 243.864
to 243.874; and
(B) An officer or employee of a district, whether or not
retired, who:
(i) Is receiving a service retirement allowance, a disability
retirement allowance or a pension under the Public Employees
Retirement System or is receiving a service retirement allowance,
a disability retirement allowance or a pension under any other
retirement or disability benefit plan or system offered by the
district for its officers and employees;
(ii) Is eligible to receive a service retirement allowance
under the Public Employees Retirement System and has reached
earliest service retirement age under ORS chapter 238;
(iii) Is eligible to receive a pension under ORS 238A.100 to
238A.245 and has reached earliest retirement age as described in
ORS 238A.165; or
(iv) Is eligible to receive a service retirement allowance or
pension under any other retirement benefit plan or system offered
by the district and has attained earliest retirement age under
the plan or system.
(b) Except as provided in paragraph (a)(B) of this subsection,
'eligible employee' does not include an individual:
(A) Engaged as an independent contractor;
(B) Whose periods of employment in emergency work are on an
intermittent or irregular basis; or
(C) Who is employed on less than a half-time basis unless the
individual is employed in a position classified as a job-sharing
position or unless the individual is defined as eligible under
rules of the Oregon Educators Benefit Board or under a collective
bargaining agreement.
(5) 'Family member' means an eligible employee's spouse or
domestic partner and any unmarried child or stepchild of an
eligible employee within age limits and other conditions imposed
by the Oregon Educators Benefit Board with regard to unmarried
children or stepchildren.
(6) 'Payroll disbursing officer' means the officer or official
authorized to disburse moneys in payment of salaries and wages of
officers and employees of a district.
(7) 'Premium' means the monthly or other periodic charge,
including administrative fees of the Oregon Educators Benefit
Board, for a benefit plan.
SECTION 18. ORS 243.864 is amended to read:
243.864. (1) The Oregon Educators Benefit Board:
(a) Shall adopt rules for the conduct of its business; and
(b) May adopt rules not inconsistent with ORS 243.860 to
243.886 to determine the terms and conditions of eligible
employee participation in and coverage under benefit plans.
(2) The board shall study all matters connected with the
provision of adequate benefit plan coverage for eligible
employees on the best basis possible with regard to the welfare
of the employees and affordability for the districts. The board
shall design benefits, prepare specifications, analyze carrier
responses to advertisements for bids and award contracts.
Contracts shall be signed by the chairperson on behalf of the
board.
(3) In carrying out its duties under subsections (1) and (2) of
this section, the goal of the board is to provide high-quality
health, dental and other benefit plans for eligible employees at
a cost affordable to the districts, the employees and the
taxpayers of Oregon.
(4) The board shall prepare specifications, invite bids and
take actions necessary to award contracts for health and dental
benefit plan coverage of eligible employees in accordance with
the criteria set forth in ORS 243.866 { - (1) - } { +
(2) + }. The Public Contracting Code does not apply to contracts
for benefit plans provided under ORS 243.860 to 243.886. The
board may not exclude from competition to contract for a benefit
plan an Oregon carrier solely because the carrier does not serve
all counties in Oregon.
(5) The board may retain consultants, brokers or other advisory
personnel when necessary and shall employ such personnel as are
required to perform the functions of the board.
SECTION 19. ORS 243.866, as amended by section 2, chapter 49,
Oregon Laws 2010, is amended to read:
243.866. { + (1) Any person who is eligible to participate in
a health benefit plan under ORS 243.860 to 243.886 shall enroll
in the Affordable Health Care for All Oregon Plan. + }
{ - (1) - } { + (2) If + } the Oregon Educators Benefit
Board { + contracts for health benefit plans to supplement
coverage provided in the Affordable Health Care for All Oregon
Plan, the board + } shall contract for { + supplemental + }
benefit plans best designed to meet the needs and provide for the
welfare of eligible employees and the districts. In considering
whether to enter into a contract for a { + supplemental + }
benefit plan, the board shall place emphasis on:
(a) Employee choice among high-quality plans;
(b) Encouragement of a competitive marketplace;
(c) Plan performance and information;
(d) District flexibility in plan design and contracting;
(e) Quality customer service;
(f) Creativity and innovation;
(g) Plan benefits as part of total employee compensation; and
(h) Improvement of employee health.
{ - (2) - } { + (3) + } The board may approve more than one
carrier for each type of { + supplemental + } benefit plan
offered, but the board shall limit the number of carriers to a
number consistent with adequate service to eligible employees and
family members.
{ - (3) - } { + (4) + } When appropriate, the board shall
provide options under which an eligible employee may arrange
coverage for family members under a { + supplemental + } benefit
plan.
{ - (4) - } { + (5) + } A district shall provide that
payroll deductions for { + supplemental + } benefit plan costs
that are not payable by the district may be made upon receipt of
a signed authorization from the employee indicating an election
to participate in the { + supplemental + } benefit plan or
plans selected and allowing the deduction of those costs from the
employee's pay.
{ - (5) - } { + (6) + } In developing any
{ + supplemental + } benefit plan, the board may provide an
option of additional coverage for eligible employees and family
members at an additional premium.
{ - (6) - } { + (7) + } The board shall adopt rules
providing that transfer of enrollment from one benefit plan to
another is open to all eligible employees and family members.
Because of the special problems that may arise involving
acceptable physician-patient relations between a particular panel
of physicians and a particular eligible employee or family member
under a comprehensive group practice benefit plan, the board
shall provide a procedure under which any eligible employee may
apply at any time to substitute another benefit plan for
participation in a comprehensive group practice benefit plan.
{ - (7) An eligible employee who is retired is not required
to participate in a health benefit plan offered under this
section in order to obtain dental benefit plan coverage. The
board shall establish by rule standards of eligibility for
retired employees to participate in a dental benefit plan. - }
(8) The board shall evaluate a { + supplemental + } benefit
plan that serves a limited geographic region of this state
according to the criteria described in subsection { - (1) - }
{ + (2) + } of this section.
SECTION 20. ORS 243.868 is amended to read:
243.868. (1) { - In addition to contracting for health and
dental benefit plans, - } The Oregon Educators Benefit Board may
contract with carriers to provide { - other - } benefit plans
including, but not limited to, insurance or other benefits based
on life, supplemental medical, supplemental dental, supplemental
vision, accidental death or disability insurance plans.
(2) The premium for each eligible employee for coverage under a
benefit plan { - other than a health or dental benefit plan - }
described in subsection (1) of this section shall be the total
cost per month of the coverage afforded the employee under the
plan for which the employee exercises an option, including the
cost of enrollment of the eligible employee and administrative
expenses for the plan.
(3) The board may withdraw approval of any additional benefit
plan in the same manner as it withdraws approval of a health or
dental benefit plan as described and authorized by ORS 243.878.
(4) If the board does not contract for a benefit plan described
in subsection (1) of this section, a district may contract for
the benefit plan on behalf of any district employees. The
administrative expenses of the plan shall be paid in accordance
with the district's negotiated agreement with the employees.
Benefit plans entered into by a district are subject to approval
by the board before they become operative. The board may withdraw
approval of any such benefit plan in the same manner as it
withdraws approval of a benefit plan under ORS 243.878.
{ +
AFFORDABLE HEALTH CARE FOR ALL OREGON FUND + }
SECTION 21. { + (1) The Affordable Health Care for All Oregon
Fund is established in the State Treasury, separate and distinct
from the General Fund, consisting of moneys received under ORS
243.185 and 243.882 and sections 8 and 23 of this 2011 Act,
moneys appropriated by the Legislative Assembly and moneys
received from federal, state, county and local governments and
private sources to pay for health care services covered by the
Affordable Health Care for All Oregon Plan. Moneys in the
Affordable Health Care for All Oregon Fund are continuously
appropriated to the Oregon Health Authority to administer the
Affordable Health Care for All Oregon Plan and to carry out
sections 1, 5, 7, 8, 9, 10, 23 and 24 of this 2011 Act and ORS
442.315 and 442.325.
(2) The Affordable Health Care for All Oregon Reserve Account
is established in the Affordable Health Care for All Oregon Fund
and consists of moneys transferred from the fund to the reserve
account under section 22 of this 2011 Act. Notwithstanding ORS
293.190, any moneys remaining in the account at the end of a
biennium that were appropriated from the General Fund do not
revert to the General Fund. + }
SECTION 22. { + (1) Whenever the amount of moneys in the
Affordable Health Care for All Oregon Fund exceeds the amount
obligated for the remainder of the biennium, the Oregon Health
Authority shall transfer the excess amount to the Affordable
Health Care for All Oregon Reserve Account. Moneys in the reserve
account may be transferred to the fund as necessary to carry out
the provisions specified in section 21 of this 2011 Act.
(2) The Affordable Health Care for All Oregon Board shall
establish a maximum cap for the amount of moneys to be maintained
in the reserve account. + }
SECTION 23. { + (1) The Affordable Health Care for All Oregon
Plan shall be the primary payer of reimbursement for health
services provided through the plan, including but not limited to
compensable medical expenses covered by workers' compensation
insurance.
(2) The Oregon Health Authority is subrogated to the rights of
any person that has a claim against an insurer, tortfeasor,
employer, third party administrator, pension manager, public or
private corporation, government entity or any other person that
may be liable for the cost of health services paid for by the
Affordable Health Care for All Oregon Plan.
(3) The authority may enter into an agreement with any person
for the prepayment of claims anticipated to arise under
subsection (2) of this section during a biennium. At the end of
the biennium, the authority shall appropriately charge or refund
to the payer the difference between the amount prepaid and the
amount due.
(4) All moneys recovered pursuant to this section shall be
deposited in the Affordable Health Care for All Oregon Fund
established in section 21 of this 2011 Act. + }
{ +
FINANCING OF THE AFFORDABLE HEALTH CARE + }
{ +
FOR ALL OREGON PLAN + }
SECTION 24. { + (1) The Affordable Health Care for All Oregon
Board shall develop recommendations for dedicated funding
mechanisms to finance the Affordable Health Care for All Oregon
Plan. In lieu of premiums, copayments, coinsurance and
deductibles, the plan must be funded by a system of dedicated,
progressive taxes that are based on the payer's ability to pay.
The board shall consider an employer payroll tax, a graduated
personal income tax, a transaction tax on stocks and bonds, other
taxes on unearned income, a progressive surtax on higher incomes
and a progressive tax on gross business receipts divided by
full-time equivalent employment. Funding sources must be assessed
based on the capacity of the source to generate sufficient
revenue to fund the plan and maintain an adequate reserve. The
burden of the assessments must be distributed according to
ability to pay.
(2) The board shall report its recommendations to the 2013
regular session of the Legislative Assembly as specified in ORS
171.010. + }
{ +
ABOLISHMENT OF OREGON MEDICAL + }
{ +
INSURANCE POOL PROGRAM + }
SECTION 25. { + (1) The Oregon Medical Insurance Pool Board is
abolished. On the operative date of this section, the tenure of
office of the members of the Oregon Medical Insurance Pool Board
ceases.
(2) All moneys remaining in the Oregon Medical Insurance Pool
Account and the Temporary High Risk Pool Program Fund on the
operative date of this section are transferred for deposit in the
Affordable Health Care for All Oregon Fund. + }
SECTION 26. { + The abolishment of the Oregon Medical
Insurance Pool Board by section 25 of this 2011 Act does not
affect any action, proceeding or prosecution involving or with
respect to the duties, functions and powers of the board begun
before and pending at the time of the abolishment, except that
the Oregon Health Authority is substituted for the board in the
action, proceeding or prosecution. + }
SECTION 27. { + (1) Nothing in sections 25 and 26 of this 2011
Act, the amendments to statutes by sections 38 to 67 of this 2011
Act or the repeal of statutes by sections 69 and 70 of this 2011
Act relieves a person of a liability, duty or obligation accruing
under or with respect to the duties, functions and powers of the
Oregon Medical Insurance Pool Board that accrues before the
operative date of section 25 of this 2011 Act. The Oregon Health
Authority may undertake the collection or enforcement of any such
liability, duty or obligation.
(2) The rights and obligations of the board legally incurred
under contracts, leases and business transactions executed,
entered into or begun before the operative date of section 25 of
this 2011 Act are transferred to the authority. For the purpose
of succession to these rights and obligations, the Oregon Health
Authority is a continuation of the board and not a new
authority. + }
SECTION 28. { + The rules of the Oregon Medical Insurance Pool
Board in effect on the operative date of section 25 of this 2011
Act continue in effect until superseded or repealed by rules of
the Oregon Health Authority. References in rules of the board to
the board or an officer or employee of the board are considered
to be references to the authority or an officer or employee of
the authority. + }
SECTION 29. { + Whenever, in any uncodified law or resolution
of the Legislative Assembly or in any rule, document, record or
proceeding authorized by the Legislative Assembly, reference is
made to the Oregon Medical Insurance Pool Board or an officer or
employee of the board, the reference is considered to be a
reference to the Oregon Health Authority or an officer or
employee of the authority. + }
SECTION 30. { + For the purpose of harmonizing and clarifying
statutory law, the Legislative Counsel may substitute for words
designating the 'Oregon Medical Insurance Pool Board' or its
officers, wherever they occur in statutory law, words designating
the 'Oregon Health Authority' or its officers. + }
SECTION 31. { + For the purpose of harmonizing and clarifying
statutory law, the Legislative Counsel may substitute for words
designating the 'Oregon Medical Insurance Pool Account' or '
Temporary High Risk Pool Program Fund,' wherever they occur in
statutory law, words designating the 'Affordable Health Care for
All Oregon Fund.' + }
{ +
ABOLISHMENT OF OFFICE OF + }
{ +
PRIVATE HEALTH PARTNERSHIPS + }
SECTION 32. { + The Office of Private Health Partnerships is
abolished. On the operative date of this section, the tenure of
the Administrator of the Office of Private Health Partnerships
ceases. + }
SECTION 33. { + The abolishment of the Office of Private
Health Partnerships by section 32 of this 2011 Act does not
affect any action, proceeding or prosecution involving or with
respect to the duties, functions and powers of the office begun
before and pending at the time of the abolishment, except that
the Oregon Health Authority is substituted for the Office of
Private Health Partnerships in the action, proceeding or
prosecution. + }
SECTION 34. { + (1) Nothing in sections 32 and 33 of this 2011
Act, the amendments to statutes by sections 38 to 67 of this 2011
Act or the repeal of statutes by sections 69 and 70 of this 2011
Act relieves a person of a liability, duty or obligation accruing
under or with respect to the duties, functions and powers of the
Office of Private Health Partnerships that accrues before the
operative date of section 32 of this 2011 Act. The Oregon Health
Authority may undertake the collection or enforcement of any such
liability, duty or obligation.
(2) The rights and obligations of the Office of Private Health
Partnerships legally incurred under contracts, leases and
business transactions executed, entered into or begun before the
operative date of section 32 of this 2011 Act are transferred to
the authority. For the purpose of succession to these rights and
obligations, the Oregon Health Authority is a continuation of the
office and not a new authority. + }
SECTION 35. { + The rules of the Office of Private Health
Partnerships in effect on the operative date of section 32 of
this 2011 Act continue in effect until superseded or repealed by
rules of the Oregon Health Authority. References in rules of the
office to the office or an administrator or employee of the
office are considered to be references to the authority or an
administrator or employee of the authority. + }
SECTION 36. { + Whenever, in any uncodified law or resolution
of the Legislative Assembly or in any rule, document, record or
proceeding authorized by the Legislative Assembly, reference is
made to the Office of Private Health Partnerships or to an
administrator or employee of the office, the reference is
considered to be a reference to the Oregon Health Authority or an
administrator or employee of the authority. + }
SECTION 37. { + For the purpose of harmonizing and clarifying
statutory law, the Legislative Counsel may substitute for words
designating the 'Office of Private Health Partnerships' or its
administrator, wherever they occur in statutory law, words
designating the 'Oregon Health Authority' or its director. + }
{ +
CONFORMING AMENDMENTS + }
SECTION 38. ORS 65.957 is amended to read:
65.957. (1) This chapter applies to all domestic corporations
in existence on October 3, 1989, that were incorporated under any
general statute of this state providing for incorporation of
nonprofit corporations if power to amend or repeal the statute
under which the corporation was incorporated was reserved.
(2) Without limitation as to any other corporations that may be
outside the scope of subsection (1) of this section, this chapter
does not apply to the following:
(a) The Oregon State Bar and the Oregon State Bar Professional
Liability Fund created under ORS 9.005 to 9.755;
(b) The State Accident Insurance Fund Corporation created under
ORS chapter 656;
(c) The Oregon Insurance Guaranty Association and the Oregon
Life and Health Insurance Guaranty Association created under ORS
chapter 734; and
(d) The Oregon FAIR Plan Association { - and the Oregon
Medical Insurance Pool - } created under ORS chapter 735.
SECTION 39. ORS 192.519 is amended to read:
192.519. As used in ORS 192.518 to 192.529:
(1) 'Authorization' means a document written in plain language
that contains at least the following:
(a) A description of the information to be used or disclosed
that identifies the information in a specific and meaningful way;
(b) The name or other specific identification of the person or
persons authorized to make the requested use or disclosure;
(c) The name or other specific identification of the person or
persons to whom the covered entity may make the requested use or
disclosure;
(d) A description of each purpose of the requested use or
disclosure, including but not limited to a statement that the use
or disclosure is at the request of the individual;
(e) An expiration date or an expiration event that relates to
the individual or the purpose of the use or disclosure;
(f) The signature of the individual or personal representative
of the individual and the date;
(g) A description of the authority of the personal
representative, if applicable; and
(h) Statements adequate to place the individual on notice of
the following:
(A) The individual's right to revoke the authorization in
writing;
(B) The exceptions to the right to revoke the authorization;
(C) The ability or inability to condition treatment, payment,
enrollment or eligibility for benefits on whether the individual
signs the authorization; and
(D) The potential for information disclosed pursuant to the
authorization to be subject to redisclosure by the recipient and
no longer protected.
(2) 'Covered entity' means:
(a) A state health plan;
(b) A health insurer;
(c) A health care provider that transmits any health
information in electronic form to carry out financial or
administrative activities in connection with a transaction
covered by ORS 192.518 to 192.529; or
(d) A health care clearinghouse.
(3) 'Health care' means care, services or supplies related to
the health of an individual.
(4) 'Health care operations' includes but is not limited to:
(a) Quality assessment, accreditation, auditing and improvement
activities;
(b) Case management and care coordination;
(c) Reviewing the competence, qualifications or performance of
health care providers or health insurers;
(d) Underwriting activities;
(e) Arranging for legal services;
(f) Business planning;
(g) Customer services;
(h) Resolving internal grievances;
(i) Creating de-identified information; and
(j) Fundraising.
(5) 'Health care provider' includes but is not limited to:
(a) A psychologist, occupational therapist, regulated social
worker, professional counselor or marriage and family therapist
licensed or otherwise authorized to practice under ORS chapter
675 or an employee of the psychologist, occupational therapist,
regulated social worker, professional counselor or marriage and
family therapist;
(b) A physician, podiatric physician and surgeon, physician
assistant or acupuncturist licensed under ORS chapter 677 or an
employee of the physician, podiatric physician and surgeon,
physician assistant or acupuncturist;
(c) A nurse or nursing home administrator licensed under ORS
chapter 678 or an employee of the nurse or nursing home
administrator;
(d) A dentist licensed under ORS chapter 679 or an employee of
the dentist;
(e) A dental hygienist or denturist licensed under ORS chapter
680 or an employee of the dental hygienist or denturist;
(f) A speech-language pathologist or audiologist licensed under
ORS chapter 681 or an employee of the speech-language pathologist
or audiologist;
(g) An emergency medical technician certified under ORS chapter
682;
(h) An optometrist licensed under ORS chapter 683 or an
employee of the optometrist;
(i) A chiropractic physician licensed under ORS chapter 684 or
an employee of the chiropractic physician;
(j) A naturopathic physician licensed under ORS chapter 685 or
an employee of the naturopathic physician;
(k) A massage therapist licensed under ORS 687.011 to 687.250
or an employee of the massage therapist;
(L) A direct entry midwife licensed under ORS 687.405 to
687.495 or an employee of the direct entry midwife;
(m) A physical therapist licensed under ORS 688.010 to 688.201
or an employee of the physical therapist;
(n) A medical imaging licensee under ORS 688.405 to 688.605 or
an employee of the medical imaging licensee;
(o) A respiratory care practitioner licensed under ORS 688.800
to 688.840 or an employee of the respiratory care practitioner;
(p) A pharmacist licensed under ORS chapter 689 or an employee
of the pharmacist;
(q) A dietitian licensed under ORS 691.405 to 691.585 or an
employee of the dietitian;
(r) A funeral service practitioner licensed under ORS chapter
692 or an employee of the funeral service practitioner;
(s) A health care facility as defined in ORS 442.015;
(t) A home health agency as defined in ORS 443.005;
(u) A hospice program as defined in ORS 443.850;
(v) A clinical laboratory as defined in ORS 438.010;
(w) A pharmacy as defined in ORS 689.005;
(x) A diabetes self-management program as defined in ORS
743A.184; and
(y) Any other person or entity that furnishes, bills for or is
paid for health care in the normal course of business.
(6) 'Health information' means any oral or written information
in any form or medium that:
(a) Is created or received by a covered entity, a public health
authority, an employer, a life insurer, a school, a university or
a health care provider that is not a covered entity; and
(b) Relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(7) 'Health insurer' means { - : - }
{ - (a) - } an insurer as defined in ORS 731.106 who offers:
{ - (A) - } { + (a) + } A health benefit plan as defined in
ORS 743.730;
{ - (B) - } { + (b) + } A short term health insurance
policy, the duration of which does not exceed six months
including renewals;
{ - (C) - } { + (c) + } A student health insurance policy;
{ - (D) - } { + (d) + } A Medicare supplemental policy; or
{ - (E) - } { + (e) + } A dental only policy.
{ - (b) The Oregon Medical Insurance Pool operated by the
Oregon Medical Insurance Pool Board under ORS 735.600 to
735.650. - }
(8) 'Individually identifiable health information' means any
oral or written health information in any form or medium that is:
(a) Created or received by a covered entity, an employer or a
health care provider that is not a covered entity; and
(b) Identifiable to an individual, including demographic
information that identifies the individual, or for which there is
a reasonable basis to believe the information can be used to
identify an individual, and that relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(9) 'Payment' includes but is not limited to:
(a) Efforts to obtain premiums or reimbursement;
(b) Determining eligibility or coverage;
(c) Billing activities;
(d) Claims management;
(e) Reviewing health care to determine medical necessity;
(f) Utilization review; and
(g) Disclosures to consumer reporting agencies.
(10) 'Personal representative' includes but is not limited to:
(a) A person appointed as a guardian under ORS 125.305,
419B.370, 419C.481 or 419C.555 with authority to make medical and
health care decisions;
(b) A person appointed as a health care representative under
ORS 127.505 to 127.660 or a representative under ORS 127.700 to
127.737 to make health care decisions or mental health treatment
decisions;
(c) A person appointed as a personal representative under ORS
chapter 113; and
(d) A person described in ORS 192.526.
(11)(a) 'Protected health information' means individually
identifiable health information that is maintained or transmitted
in any form of electronic or other medium by a covered entity.
(b) 'Protected health information' does not mean individually
identifiable health information in:
(A) Education records covered by the federal Family Educational
Rights and Privacy Act (20 U.S.C. 1232g);
(B) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); or
(C) Employment records held by a covered entity in its role as
employer.
(12) 'State health plan' means:
(a) Medical assistance as defined in ORS 414.025;
(b) The Health Care for All Oregon Children program;
{ - (c) The Family Health Insurance Assistance Program
established in ORS 414.841 to 414.864; or - }
{ + (c) The Affordable Health Care for All Oregon Plan
established by section 1 of this 2011 Act; or + }
(d) Any medical assistance or premium assistance program
operated by the Oregon Health Authority.
(13) 'Treatment' includes but is not limited to:
(a) The provision, coordination or management of health care;
and
(b) Consultations and referrals between health care providers.
SECTION 40. ORS 291.055 is amended to read:
291.055. (1) Notwithstanding any other law that grants to a
state agency the authority to establish fees, all new state
agency fees or fee increases adopted after July 1 of any
odd-numbered year:
(a) Are not effective for agencies in the executive department
of government unless approved in writing by the Director of the
Oregon Department of Administrative Services;
(b) Are not effective for agencies in the judicial department
of government unless approved in writing by the Chief Justice of
the Supreme Court;
(c) Are not effective for agencies in the legislative
department of government unless approved in writing by the
President of the Senate and the Speaker of the House of
Representatives;
(d) Shall be reported by the state agency to the Oregon
Department of Administrative Services within 10 days of their
adoption; and
(e) Are rescinded on July 1 of the next following odd-numbered
year, or on adjournment sine die of the regular session of the
Legislative Assembly meeting in that year, whichever is later,
unless otherwise authorized by enabling legislation setting forth
the approved fees.
(2) This section does not apply to:
(a) Any tuition or fees charged by the State Board of Higher
Education and state institutions of higher education.
(b) Taxes or other payments made or collected from employers
for unemployment insurance required by ORS chapter 657 or premium
assessments required by ORS 656.612 and 656.614 or contributions
and assessments calculated by cents per hour for workers'
compensation coverage required by ORS 656.506.
(c) Fees or payments required for:
(A) Health care services provided by the Oregon Health and
Science University, by the Oregon Veterans' Homes and by other
state agencies and institutions pursuant to ORS 179.610 to
179.770.
{ - (B) Assessments and premiums paid to the Oregon Medical
Insurance Pool established by ORS 735.614 and 735.625. - }
{ - (C) - } { + (B) + } Copayments and premiums paid to the
Oregon medical assistance program.
{ - (D) - } { + (C) + } Assessments paid to the Department
of Consumer and Business Services under ORS 743.951 and 743.961.
(d) Fees created or authorized by statute that have no
established rate or amount but are calculated for each separate
instance for each fee payer and are based on actual cost of
services provided.
(e) State agency charges on employees for benefits and
services.
(f) Any intergovernmental charges.
(g) Forest protection district assessment rates established by
ORS 477.210 to 477.265 and the Oregon Forest Land Protection Fund
fees established by ORS 477.760.
(h) State Department of Energy assessments required by ORS
469.421 (8) and 469.681.
(i) Any charges established by the State Parks and Recreation
Director in accordance with ORS 565.080 (3).
(j) Assessments on premiums charged by the Insurance Division
of the Department of Consumer and Business Services pursuant to
ORS 731.804 or fees charged by the Division of Finance and
Corporate Securities of the Department of Consumer and Business
Services to banks, trusts and credit unions pursuant to ORS
706.530 and 723.114.
(k) Public Utility Commission operating assessments required by
ORS 756.310 or charges paid to the Residential Service Protection
Fund required by chapter 290, Oregon Laws 1987.
(L) Fees charged by the Housing and Community Services
Department for intellectual property pursuant to ORS 456.562.
(m) New or increased fees that are anticipated in the
legislative budgeting process for an agency, revenues from which
are included, explicitly or implicitly, in the legislatively
adopted budget for the agency.
(n) Tolls approved by the Oregon Transportation Commission
pursuant to ORS 383.004.
(o) Convenience fees as defined in ORS 182.126 and established
by the Oregon Department of Administrative Services under ORS
182.132 (3) and recommended by the Electronic Government Portal
Advisory Board.
(3)(a) Fees temporarily decreased for competitive or
promotional reasons or because of unexpected and temporary
revenue surpluses may be increased to not more than their prior
level without compliance with subsection (1) of this section if,
at the time the fee is decreased, the state agency specifies the
following:
(A) The reason for the fee decrease; and
(B) The conditions under which the fee will be increased to not
more than its prior level.
(b) Fees that are decreased for reasons other than those
described in paragraph (a) of this subsection may not be
subsequently increased except as allowed by ORS 291.050 to
291.060 and 294.160.
SECTION 41. ORS 413.011 is amended to read:
413.011. (1) The duties of the Oregon Health Policy Board are
to:
(a) Be the policy-making and oversight body for the Oregon
Health Authority established in ORS 413.032 and all of the
authority's departmental divisions { - , including the Oregon
Health Insurance Exchange described in section 17, chapter 595,
Oregon Laws 2009 - } .
{ - (b) Develop and submit a plan to the Legislative Assembly
by December 31, 2010, to provide and fund access to affordable,
quality health care for all Oregonians by 2015. - }
{ - (c) Develop a program to provide health insurance premium
assistance to all low and moderate income individuals who are
legal residents of Oregon. - }
{ - (d) - } { + (b) + } Establish and continuously refine
uniform, statewide health care quality standards for use by all
purchasers of health care, third-party payers and health care
providers as quality performance benchmarks.
{ - (e) - } { + (c) + } Establish evidence-based clinical
standards and practice guidelines that may be used by providers.
{ - (f) - } { + (d) + } Approve and monitor
community-centered health initiatives described in ORS 413.032
{ - (1)(g) - } that are consistent with public health goals,
strategies, programs and performance standards adopted by the
Oregon Health Policy Board to improve the health of all
Oregonians, and shall regularly report to the Legislative
Assembly on the accomplishments and needed changes to the
initiatives.
{ - (g) - } { + (e) + } Establish cost containment
mechanisms to reduce health care costs.
{ - (h) - } { + (f) + } Ensure that Oregon's health care
workforce is sufficient in numbers and training to meet the
demand that will be created by the expansion in health coverage,
health care system transformations, an increasingly diverse
population and an aging workforce.
{ - (i) - } { + (g) + } Work with the Oregon congressional
delegation to advance the adoption of changes in federal law or
policy to promote Oregon's comprehensive health reform plan.
{ - (j) Establish a health benefit package in accordance with
ORS 413.064 to be used as the baseline for all health benefit
plans offered through the Oregon Health Insurance Exchange. - }
{ - (k) Develop and submit a plan to the Legislative Assembly
by December 31, 2010, with recommended policies and procedures
for the Oregon Health Insurance Exchange developed in accordance
with section 17, chapter 595, Oregon Laws 2009. - }
{ - (L) Develop and submit a plan to the Legislative Assembly
by December 31, 2010, with recommendations for the development of
a publicly owned health benefit plan that operates in the
exchange under the same rules and regulations as all health
insurance plans offered through the exchange, including fully
allocated fixed and variable operating and capital costs. - }
{ - (m) - } { + (h) + } By December 31, 2010, investigate
and report to the Legislative Assembly, and annually thereafter,
on the feasibility and advisability of future changes to the
health insurance market in Oregon, including but not limited to
the following:
(A) A requirement for every resident to have health insurance
coverage.
{ - (B) A payroll tax as a means to encourage employers to
continue providing health insurance to their employees. - }
{ - (C) Expansion of the exchange to include a program of
premium assistance and to advance reforms of the insurance
market. - }
{ - (D) - } { + (B) + } The implementation of a system of
interoperable electronic health records utilized by all health
care providers in this state.
{ - (n) - } { + (i) + } Meet cost-containment goals by
structuring reimbursement rates to reward comprehensive
management of diseases, quality outcomes and the efficient use of
resources by promoting cost-effective procedures, services and
programs including, without limitation, preventive health, dental
and primary care services, web-based office visits, telephone
consultations and telemedicine consultations.
{ - (o) - } { + (j) + } Oversee the expenditure of moneys
from the Health Care Workforce Strategic Fund to support grants
to primary care providers and rural health practitioners, to
increase the number of primary care educators and to support
efforts to create and develop career ladder opportunities.
{ - (p) - } { + (k) + } Work with the Public Health Benefit
Purchasers Committee, administrators of the medical assistance
program and the Department of Corrections to identify uniform
contracting standards for health benefit plans that achieve
maximum quality and cost outcomes and align the contracting
standards for all state programs to the greatest extent
practicable.
(2) The Oregon Health Policy Board is authorized to:
(a) Subject to the approval of the Governor { + and the
Affordable Health Care for All Oregon Board established in
section 5 of this 2011 Act + }, organize and reorganize the
authority as the { + Oregon Health Policy + } Board considers
necessary to properly conduct the work of the authority.
(b) Submit directly to the Legislative Counsel, no later than
October 1 of each even-numbered year, requests for measures
necessary to provide statutory authorization to carry out any of
the board's duties or to implement any of the board's
recommendations. The measures may be filed prior to the beginning
of the legislative session in accordance with the rules of the
House of Representatives and the Senate.
(3) If the board or the authority is unable to perform, in
whole or in part, any of the duties described in ORS 413.006 to
413.064 without federal approval, the board is authorized to
request waivers or other approval necessary to perform those
duties. The board shall implement any portions of those duties
not requiring legislative authority or federal approval, to the
extent practicable.
(4) The enumeration of duties, functions and powers in this
section is not intended to be exclusive nor to limit the duties,
functions and powers imposed on the board by ORS 413.006 to
413.064 and by other statutes.
(5) The board shall consult with the Department of Consumer and
Business Services in completing the { - tasks - } { +
task + } set forth in subsection { - (1)(j), (k) and (m)(A) and
(C) - } { + (1)(h)(A) + } of this section.
SECTION 42. ORS 413.017 is amended to read:
413.017. (1) The Oregon Health Policy Board shall establish the
committees described in subsections (2) and (3) of this section.
(2)(a) The Public Health Benefit Purchasers Committee shall
include individuals who purchase health care for the following:
(A) The Public Employees' Benefit Board.
(B) The Oregon Educators Benefit Board.
(C) Trustees of the Public Employees Retirement System.
(D) A city government.
(E) A county government.
(F) A special district.
(G) Any private nonprofit organization that receives the
majority of its funding from the state and requests to
participate on the committee.
(b) The Public Health Benefit Purchasers Committee shall:
(A) Identify and make specific recommendations to achieve
uniformity across all public health benefit plan designs based on
the best available clinical evidence, recognized best practices
for health promotion and disease management, demonstrated
cost-effectiveness and shared demographics among the enrollees
within the pools covered by the benefit plans.
(B) Develop an action plan for ongoing collaboration to
implement the benefit design alignment described in subparagraph
(A) of this paragraph and shall leverage purchasing to achieve
benefit uniformity if practicable.
(C) Continuously review and report to the Oregon Health Policy
Board on the committee's progress in aligning benefits while
minimizing the cost shift to individual purchasers of insurance
without shifting costs to the private sector { - or the Oregon
Health Insurance Exchange - } .
(c) The Oregon Health Policy Board shall work with the Public
Health Benefit Purchasers Committee to identify uniform
provisions for state and local public contracts for health
benefit plans that achieve maximum quality and cost outcomes. The
board shall collaborate with the committee to develop steps to
implement joint contract provisions. The committee shall identify
a schedule for the implementation of contract changes. The
process for implementation of joint contract provisions must
include a review process to protect against unintended cost
shifts to enrollees or agencies.
(d) Proposals and plans developed in accordance with this
subsection shall be completed by October 1, 2010, and shall be
submitted to the Oregon Health Policy Board for its approval and
possible referral to the Legislative Assembly no later than
December 31, 2010.
(3)(a) The Health Care Workforce Committee shall include
individuals who have the collective expertise, knowledge and
experience in a broad range of health professions, health care
education and health care workforce development initiatives.
(b) The Health Care Workforce Committee shall coordinate
efforts to recruit and educate health care professionals and
retain a quality workforce to meet the demand that will be
created by the expansion in health care coverage, system
transformations and an increasingly diverse population.
(c) The Health Care Workforce Committee shall conduct an
inventory of all grants and other state resources available for
addressing the need to expand the health care workforce to meet
the needs of Oregonians for health care.
(4) Members of the committees described in subsections (2) and
(3) of this section who are not members of the Oregon Health
Policy Board are not entitled to compensation but shall be
reimbursed from funds available to the board for actual and
necessary travel and other expenses incurred by them by their
attendance at committee meetings, in the manner and amount
provided in ORS 292.495.
SECTION 43. ORS 413.032 is amended to read:
413.032. (1) The Oregon Health Authority is established. The
authority shall:
(a) Carry out policies adopted by the Oregon Health Policy
Board { + and the Affordable Health Care for All Oregon
Board + };
{ - (b) Develop a plan for the Oregon Health Insurance
Exchange in accordance with section 17, chapter 595, Oregon Laws
2009; - }
{ - (c) - } { + (b) + } Administer the Oregon Prescription
Drug Program;
{ - (d) - } { + (c) + } Administer the Family Health
Insurance Assistance Program;
{ - (e) - } { + (d) + } Provide regular reports to the
{ + Oregon Health Policy + } Board with respect to the
performance of health services contractors serving recipients of
medical assistance, including reports of trends in health
services and enrollee satisfaction;
{ - (f) - } { + (e) + } Guide and support, with the
authorization of the { + Oregon Health Policy + } Board,
community-centered health initiatives designed to address
critical risk factors, especially those that contribute to
chronic disease;
{ - (g) - } { + (f) + } Be the state Medicaid agency for
the administration of funds from Titles XIX and XXI of the Social
Security Act and administer medical assistance under ORS chapter
414;
{ - (h) - } { + (g) + } In consultation with the Director
of the Department of Consumer and Business Services, periodically
review and recommend standards and methodologies to the
Legislative Assembly for:
(A) Review of administrative expenses of health insurers;
(B) Approval of rates; and
(C) Enforcement of rating rules adopted by the Department of
Consumer and Business Services;
{ - (i) - } { + (h) + } Structure reimbursement rates for
providers that serve recipients of medical assistance to reward
comprehensive management of diseases, quality outcomes and the
efficient use of resources and to promote cost-effective
procedures, services and programs including, without limitation,
preventive health, dental and primary care services, web-based
office visits, telephone consultations and telemedicine
consultations; { + and + }
{ - (j) - } { + (i) + } Guide and support community
three-share agreements in which an employer, state or local
government and an individual all contribute a portion of a
premium for a community-centered health initiative or for
insurance coverage { + . + } { - ; and - }
{ - (k) Develop, in consultation with the Department of
Consumer and Business Services and the Health Insurance Reform
Advisory Committee, one or more products designed to provide more
affordable options for the small group market. - }
(2) The Oregon Health Authority is authorized to:
(a) Create an all-claims, all-payer database to collect health
care data and monitor and evaluate health care reform in Oregon
and to provide comparative cost and quality information to
consumers, providers and purchasers of health care about Oregon's
health care systems and health plan networks in order to provide
comparative information to consumers.
(b) Develop uniform contracting standards for the purchase of
health care, including the following:
(A) Uniform quality standards and performance measures;
(B) Evidence-based guidelines for major chronic disease
management and health care services with unexplained variations
in frequency or cost;
(C) Evidence-based effectiveness guidelines for select new
technologies and medical equipment; and
(D) A statewide drug formulary that may be used by publicly
funded health benefit plans.
(c) Submit directly to the Legislative Counsel, no later than
October 1 of each even-numbered year, requests for measures
necessary to provide statutory authorization to carry out any of
the authority's duties or to implement any of the board's
recommendations. The measures may be filed prior to the beginning
of the legislative session in accordance with the rules of the
House of Representatives and the Senate.
(3) The enumeration of duties, functions and powers in this
section is not intended to be exclusive nor to limit the duties,
functions and powers imposed on or vested in the Oregon Health
Authority by ORS 413.006 to 413.064 { + or section 10 of this
2011 Act + } or by other statutes.
SECTION 44. ORS 413.032, as amended by section 43 of this 2011
Act, is amended to read:
413.032. (1) The Oregon Health Authority is established. The
authority shall:
(a) Carry out policies adopted by the Oregon Health Policy
Board and the Affordable Health Care for All Oregon Board;
{ + (b) Implement and administer the Affordable Health Care
for All Oregon Plan established in section 1 of this 2011
Act; + }
{ - (b) - } { + (c) + } Administer the Oregon Prescription
Drug Program;
{ - (c) Administer the Family Health Insurance Assistance
Program; - }
(d) Provide regular reports to the Oregon Health Policy Board
with respect to the performance of health services contractors
serving recipients of medical assistance, including reports of
trends in health services and enrollee satisfaction;
(e) Guide and support, with the authorization of the Oregon
Health Policy Board, community-centered health initiatives
designed to address critical risk factors, especially those that
contribute to chronic disease;
(f) Be the state Medicaid agency for the administration of
funds from Titles XIX and XXI of the Social Security Act and
administer medical assistance under ORS chapter 414;
(g) In consultation with the Director of the Department of
Consumer and Business Services, periodically review and recommend
standards and methodologies to the Legislative Assembly for:
(A) Review of administrative expenses of health insurers;
(B) Approval of rates; and
(C) Enforcement of rating rules adopted by the Department of
Consumer and Business Services;
(h) Structure reimbursement rates for providers that serve
recipients of medical assistance to reward comprehensive
management of diseases, quality outcomes and the efficient use of
resources and to promote cost-effective procedures, services and
programs including, without limitation, preventive health, dental
and primary care services, web-based office visits, telephone
consultations and telemedicine consultations; and
(i) Guide and support community three-share agreements in which
an employer, state or local government and an individual all
contribute a portion of a premium for a community-centered health
initiative or for insurance coverage.
(2) The Oregon Health Authority is authorized to:
(a) Create an all-claims, all-payer database to collect health
care data and monitor and evaluate health care reform in Oregon
and to provide comparative cost and quality information to
consumers, providers and purchasers of health care about Oregon's
health care systems and health plan networks in order to provide
comparative information to consumers.
(b) Develop uniform contracting standards for the purchase of
health care, including the following:
(A) Uniform quality standards and performance measures;
(B) Evidence-based guidelines for major chronic disease
management and health care services with unexplained variations
in frequency or cost;
(C) Evidence-based effectiveness guidelines for select new
technologies and medical equipment; and
(D) A statewide drug formulary that may be used by publicly
funded health benefit plans.
(c) Submit directly to the Legislative Counsel, no later than
October 1 of each even-numbered year, requests for measures
necessary to provide statutory authorization to carry out any of
the authority's duties or to implement any of the board's
recommendations. The measures may be filed prior to the beginning
of the legislative session in accordance with the rules of the
House of Representatives and the Senate.
(3) The enumeration of duties, functions and powers in this
section is not intended to be exclusive nor to limit the duties,
functions and powers imposed on or vested in the Oregon Health
Authority by ORS 413.006 to 413.064 or section 10 of this 2011
Act or by other statutes.
SECTION 45. ORS 413.033 is amended to read:
413.033. (1) The Oregon Health Authority is under the
supervision and control of a director, who is responsible for the
performance of the duties, functions and powers of the authority.
(2) The Governor shall appoint the Director of the Oregon
Health Authority, who holds office at the pleasure of the
Governor { + and the Affordable Health Care for All Oregon
Board + }. The appointment of the director shall be subject to
confirmation by the Senate in the manner provided by ORS 171.562
and 171.565.
(3) The director shall have the power to:
(a) Contract for and procure, on a fee or part-time basis, or
both, such actuarial, technical or other professional services as
may be required for the discharge of duties.
(b) Obtain such other services as the director considers
necessary or desirable, including participation in organizations
of state insurance supervisory officials and appointment of
advisory committees. A member of an advisory committee so
appointed shall receive no compensation for services as a member,
but, subject to any other applicable law regulating travel and
other expenses of state officers, shall receive actual and
necessary travel and other expenses incurred in the performance
of official duties.
(4) The director may apply for, receive and accept grants,
gifts or other payments, including property or services from any
governmental or other public or private person and may make
arrangement for the use of the receipts, including the
undertaking of special studies and other projects relating to the
costs of health care, access to health care, public health and
health care reform.
SECTION 46. ORS 413.201 is amended to read:
413.201. (1) The Oregon Health Authority is responsible for
statewide outreach and marketing of the Health Care for All
Oregon Children program established in ORS 414.231 { - and
administered by the authority and the Office of Private Health
Partnerships - } with the goal of enrolling in those programs
all eligible children residing in this state.
(2) To maximize the enrollment and retention of eligible
children in the Health Care for All Oregon Children program, the
authority shall develop and administer a grant program to provide
funding to organizations and community based groups to deliver
culturally specific and targeted outreach and direct application
assistance to:
(a) Members of racial, ethnic and language minority
communities;
(b) Children living in geographic isolation; and
(c) Children and family members with additional barriers to
accessing health care, such as cognitive, mental health or
sensory disorders, physical disabilities or chemical dependency,
and children experiencing homelessness.
SECTION 47. ORS 414.041 is amended to read:
414.041. (1) The Department of Human Services, under the
direction of the Oregon Health Policy Board and in collaboration
with the Oregon Health Authority, shall implement a streamlined
and simple application process for the medical assistance
{ - and premium assistance programs - } { + program + }
administered by the Oregon Health Authority { - and the Office
of Private Health Partnerships - } . The process shall include,
but not be limited to:
(a) An online application that may be submitted via the
Internet;
(b) Application forms that are readable at a sixth grade level
and that request the minimum amount of information necessary to
begin processing the application; and
(c) Application assistance from qualified staff to aid
individuals who have language, cognitive, physical or geographic
barriers to applying for medical assistance { - or premium
assistance - } .
(2) In developing the simplified application forms, the
department shall consult with persons not employed by the
department who have experience in serving vulnerable and
hard-to-reach populations.
(3) The Oregon Health Authority shall facilitate outreach and
enrollment efforts to connect eligible individuals with all
available publicly funded health programs { - , including but
not limited to the Family Health Insurance Assistance Program - }
.
SECTION 48. ORS 414.231 is amended to read:
414.231. (1) As used in this section { - : - } { + , + }
{ - (a) - } 'child' means a person under 19 years of age.
{ - (b) 'Health benefit plan' has the meaning given that term
in ORS 414.841. - }
(2) The Health Care for All Oregon Children program is
established to make affordable, accessible health care available
to all of Oregon's children. The program is composed of
{ - : - }
{ - (a) - } medical assistance funded in whole or in part by
Title XIX of the Social Security Act, by the State Children's
Health Insurance Program under Title XXI of the Social Security
Act and by moneys appropriated or allocated for that purpose by
the Legislative Assembly { + . + } { - ; and - }
{ - (b) A private health option administered by the Office of
Private Health Partnerships under ORS 414.826. - }
(3) A child is eligible for the program if the child is
lawfully present in this state and the income of the child's
family is at or below 300 percent of the federal poverty
guidelines. There is no asset limit to qualify for the program.
(4)(a) A child receiving medical assistance under the program
is continuously eligible for a minimum period of 12 months.
(b) The Department of Human Services shall reenroll a child for
successive 12-month periods of enrollment as long as the child is
eligible for medical assistance on the date of reenrollment.
(c) The department may not require a new application as a
condition of reenrollment under paragraph (b) of this subsection
and must determine the person's eligibility for medical
assistance using information and sources available to the
department or documentation readily available to the person.
(5) Except for medical assistance funded by Title XIX of the
Social Security Act, the department may prescribe by rule a
period of uninsurance prior to enrollment in the program.
SECTION 49. Section 1, chapter 867, Oregon Laws 2009, as
amended by section 46, chapter 828, Oregon Laws 2009, and section
2, chapter 73, Oregon Laws 2010, is amended to read:
{ + Sec. 1. + } (1) The Health System Fund is established in
the State Treasury, separate and distinct from the General Fund.
Interest earned by the Health System Fund shall be credited to
the fund.
(2) Amounts in the Health System Fund are continuously
appropriated to the Oregon Health Authority for the purpose of
funding the Health Care for All Oregon Children program
established in ORS 414.231, health services described in ORS
414.705 (1)(a) to (j) and other health services. Moneys in the
fund may also be used by the authority to:
(a) Provide grants to community health centers and safety net
clinics under ORS 413.225.
(b) Pay refunds due under section 41, chapter 736, Oregon Laws
2003, and under section 11, chapter 867, Oregon Laws 2009.
(c) Pay administrative costs incurred by the authority to
administer the assessment in section 9, chapter 867, Oregon Laws
2009.
(d) Provide health services described in ORS 414.705 to
individuals described in ORS 414.025 (2)(f)(B).
{ - (3) The authority shall develop a system for
reimbursement by the authority to the Office of Private Health
Partnerships out of the Health System Fund for costs associated
with administering the private health option pursuant to ORS
414.826. - }
SECTION 50. ORS 430.315 is amended to read:
430.315. The Legislative Assembly finds alcoholism or drug
dependence is an illness. The alcoholic or drug-dependent person
is ill and should be afforded treatment for that illness. To the
greatest extent possible, the least costly settings for
treatment, outpatient services and residential facilities shall
be widely available and utilized except when contraindicated
because of individual health care needs. State agencies that
purchase treatment for alcoholism or drug dependence shall
develop criteria consistent with this policy in consultation with
the Oregon Health Authority. In { - reviewing applications
for - } { + developing policies and approving the adoption of
rules for + } certificate of need, the
{ - Director of the Oregon Health Authority - } { +
Affordable Health Care for All Oregon Board + } shall take this
policy into account.
SECTION 51. ORS 433.443 is amended to read:
433.443. (1) As used in this section:
(a) 'Covered entity' means:
(A) The { - Children's Health Insurance Program - } { +
Oregon Health Authority + };
(B) The { - Family Health Insurance Assistance Program
established under ORS 414.842 - } { + Department of Human
Services + };
(C) A health insurer that is an insurer as defined in ORS
731.106 and that issues health insurance as defined in ORS
731.162; { + and + }
{ - (D) The state medical assistance program; and - }
{ - (E) - } { + (D) + } A health care provider.
(b) 'Health care provider' includes but is not limited to:
(A) A psychologist, occupational therapist, regulated social
worker, professional counselor or marriage and family therapist
licensed or otherwise authorized to practice under ORS chapter
675 or an employee of the psychologist, occupational therapist,
regulated social worker, professional counselor or marriage and
family therapist;
(B) A physician, podiatric physician and surgeon, physician
assistant or acupuncturist licensed under ORS chapter 677 or an
employee of the physician, podiatric physician and surgeon,
physician assistant or acupuncturist;
(C) A nurse or nursing home administrator licensed under ORS
chapter 678 or an employee of the nurse or nursing home
administrator;
(D) A dentist licensed under ORS chapter 679 or an employee of
the dentist;
(E) A dental hygienist or denturist licensed under ORS chapter
680 or an employee of the dental hygienist or denturist;
(F) A speech-language pathologist or audiologist licensed under
ORS chapter 681 or an employee of the speech-language pathologist
or audiologist;
(G) An emergency medical technician certified under ORS chapter
682;
(H) An optometrist licensed under ORS chapter 683 or an
employee of the optometrist;
(I) A chiropractic physician licensed under ORS chapter 684 or
an employee of the chiropractic physician;
(J) A naturopathic physician licensed under ORS chapter 685 or
an employee of the naturopathic physician;
(K) A massage therapist licensed under ORS 687.011 to 687.250
or an employee of the massage therapist;
(L) A direct entry midwife licensed under ORS 687.405 to
687.495 or an employee of the direct entry midwife;
(M) A physical therapist licensed under ORS 688.010 to 688.201
or an employee of the physical therapist;
(N) A medical imaging licensee under ORS 688.405 to 688.605 or
an employee of the medical imaging licensee;
(O) A respiratory care practitioner licensed under ORS 688.800
to 688.840 or an employee of the respiratory care practitioner;
(P) A pharmacist licensed under ORS chapter 689 or an employee
of the pharmacist;
(Q) A dietitian licensed under ORS 691.405 to 691.585 or an
employee of the dietitian;
(R) A funeral service practitioner licensed under ORS chapter
692 or an employee of the funeral service practitioner;
(S) A health care facility as defined in ORS 442.015;
(T) A home health agency as defined in ORS 443.005;
(U) A hospice program as defined in ORS 443.850;
(V) A clinical laboratory as defined in ORS 438.010;
(W) A pharmacy as defined in ORS 689.005;
(X) A diabetes self-management program as defined in ORS
743A.184; and
(Y) Any other person or entity that furnishes, bills for or is
paid for health care in the normal course of business.
(c) 'Individual' means a natural person.
(d) 'Individually identifiable health information' means any
oral or written health information in any form or medium that is:
(A) Created or received by a covered entity, an employer or a
health care provider that is not a covered entity; and
(B) Identifiable to an individual, including demographic
information that identifies the individual, or for which there is
a reasonable basis to believe the information can be used to
identify an individual, and that relates to:
(i) The past, present or future physical or mental health or
condition of an individual;
(ii) The provision of health care to an individual; or
(iii) The past, present or future payment for the provision of
health care to an individual.
(e) 'Legal representative' means attorney at law, person
holding a general power of attorney, guardian, conservator or any
person appointed by a court to manage the personal or financial
affairs of a person, or agency legally responsible for the
welfare or support of a person.
(2)(a) During a public health emergency declared under ORS
433.441, the Public Health Director may, as necessary to
appropriately respond to the public health emergency:
(A) Adopt reporting requirements for and provide notice of
those requirements to health care providers, institutions and
facilities for the purpose of obtaining information directly
related to the public health emergency;
(B) After consultation with appropriate medical experts, create
and require the use of diagnostic and treatment protocols to
respond to the public health emergency and provide notice of
those protocols to health care providers, institutions and
facilities;
(C) Order, or authorize local public health administrators to
order, public health measures appropriate to the public health
threat presented;
(D) Upon approval of the Governor, take other actions necessary
to address the public health emergency and provide notice of
those actions to health care providers, institutions and
facilities, including public health actions authorized by ORS
431.264;
(E) Take any enforcement action authorized by ORS 431.262,
including the imposition of civil penalties of up to $500 per day
against individuals, institutions or facilities that knowingly
fail to comply with requirements resulting from actions taken in
accordance with the powers granted to the Public Health Director
under subparagraphs (A), (B) and (D) of this paragraph; and
(F) The authority granted to the Public Health Director under
this section:
(i) Supersedes any authority granted to a local public health
authority if the local public health authority acts in a manner
inconsistent with guidelines established or rules adopted by the
director under this section; and
(ii) Does not supersede the general authority granted to a
local public health authority or a local public health
administrator except as authorized by law or necessary to respond
to a public health emergency.
(b) The authority of the Public Health Director to take
administrative action, and the effectiveness of any action taken,
under paragraph (a)(A), (B), (D), (E) and (F) of this subsection
terminates upon the expiration of the proclaimed state of public
health emergency, unless the actions are continued under other
applicable law.
(3) Civil penalties under subsection (2) of this section shall
be imposed in the manner provided in ORS 183.745. The Public
Health Director must establish that the individual, institution
or facility subject to the civil penalty had actual notice of the
action taken that is the basis for the penalty. The maximum
aggregate total for penalties that may be imposed against an
individual, institution or facility under subsection (2) of this
section is $500 for each day of violation, regardless of the
number of violations of subsection (2) of this section that
occurred on each day of violation.
(4)(a) During a proclaimed state of public health emergency,
the Public Health Director and local public health administrators
shall be given immediate access to individually identifiable
health information necessary to:
(A) Determine the causes of an illness related to the public
health emergency;
(B) Identify persons at risk;
(C) Identify patterns of transmission;
(D) Provide treatment; and
(E) Take steps to control the disease.
(b) Individually identifiable health information accessed as
provided by paragraph (a) of this subsection may not be used for
conducting nonemergency epidemiologic research or to identify
persons at risk for post-traumatic mental health problems, or for
any other purpose except the purposes listed in paragraph (a) of
this subsection.
(c) Individually identifiable health information obtained by
the Public Health Director or local public health administrators
under this subsection may not be disclosed without written
authorization of the identified individual except:
(A) Directly to the individual who is the subject of the
information or to the legal representative of that individual;
(B) To state, local or federal agencies authorized to receive
such information by state or federal law;
(C) To identify or to determine the cause or manner of death of
a deceased individual; or
(D) Directly to a health care provider for the evaluation or
treatment of a condition that is the subject of a proclamation of
a state of public health emergency issued under ORS 433.441.
(d) Upon expiration of the state of public health emergency,
the Public Health Director or local public health administrators
may not use or disclose any individually identifiable health
information that has been obtained under this section. If a state
of emergency that is related to the state of public health
emergency has been declared under ORS 401.165, the Public Health
Director and local public health administrators may continue to
use any individually identifiable information obtained as
provided under this section until termination of the state of
emergency.
(5) All civil penalties recovered under this section shall be
paid into the State Treasury and credited to the General Fund and
are available for general governmental expenses.
(6) The Public Health Director may request assistance in
enforcing orders issued pursuant to this section from state or
local law enforcement authorities. If so requested by the Public
Health Director, state and local law enforcement authorities, to
the extent resources are available, shall assist in enforcing
orders issued pursuant to this section.
(7) If the Oregon Health Authority adopts temporary rules to
implement the provisions of this section, the rules adopted are
not subject to the provisions of ORS 183.335 (6)(a). The
authority may amend temporary rules adopted pursuant to this
subsection as often as necessary to respond to the public health
emergency.
SECTION 52. ORS 442.015 is amended to read:
442.015. As used in ORS chapter 441 and this chapter, unless
the context requires otherwise:
(1) 'Acquire' or 'acquisition' means obtaining equipment,
supplies, components or facilities by any means, including
purchase, capital or operating lease, rental or donation, with
intention of using such equipment, supplies, components or
facilities to provide health services in Oregon. When equipment
or other materials are obtained outside of this state,
acquisition is considered to occur when the equipment or other
materials begin to be used in Oregon for the provision of health
services or when such services are offered for use in Oregon.
(2) 'Affected persons' has the same meaning as given to '
party' in ORS 183.310.
(3)(a) 'Ambulatory surgical center' means a facility or portion
of a facility that operates exclusively for the purpose of
providing surgical services to patients who do not require
hospitalization and for whom the expected duration of services
does not exceed 24 hours following admission.
(b) 'Ambulatory surgical center' does not mean:
(A) Individual or group practice offices of private physicians
or dentists that do not contain a distinct area used for
outpatient surgical treatment on a regular and organized basis,
or that only provide surgery routinely provided in a physician's
or dentist's office using local anesthesia or conscious sedation;
or
(B) A portion of a licensed hospital designated for outpatient
surgical treatment.
(4) 'Budget' means the projections by the hospital for a
specified future time period of expenditures and revenues with
supporting statistical indicators.
(5) 'Develop' means to undertake those activities that on their
completion will result in the offer of a new institutional health
service or the incurring of a financial obligation, as defined
under applicable state law, in relation to the offering of such a
health service.
(6) 'Expenditure' or 'capital expenditure' means the actual
expenditure, an obligation to an expenditure, lease or similar
arrangement in lieu of an expenditure, and the reasonable value
of a donation or grant in lieu of an expenditure but not
including any interest thereon.
(7) 'Freestanding birthing center' means a facility licensed
for the primary purpose of performing low risk deliveries.
(8) 'Governmental unit' means the state, or any county,
municipality or other political subdivision, or any related
department, division, board or other agency.
(9) 'Gross revenue' means the sum of daily hospital service
charges, ambulatory service charges, ancillary service charges
and other operating revenue. 'Gross revenue' does not include
contributions, donations, legacies or bequests made to a hospital
without restriction by the donors.
(10)(a) 'Health care facility' means:
(A) A hospital;
(B) A long term care facility;
(C) An ambulatory surgical center;
(D) A freestanding birthing center; or
(E) An outpatient renal dialysis center.
(b) 'Health care facility' does not mean:
(A) A residential facility licensed by the Department of Human
Services or the Oregon Health Authority under ORS 443.415;
(B) An establishment furnishing primarily domiciliary care as
described in ORS 443.205;
(C) A residential facility licensed or approved under the rules
of the Department of Corrections;
(D) Facilities established by ORS 430.335 for treatment of
substance abuse disorders; or
(E) Community mental health programs or community developmental
disabilities programs established under ORS 430.620.
(11) 'Health maintenance organization' or 'HMO' means a public
organization or a private organization organized under the laws
of any state that:
(a) Is a qualified HMO under section 1310 (d) of the U.S.
Public Health Services Act; or
(b)(A) Provides or otherwise makes available to enrolled
participants health care services, including at least the
following basic health care services:
(i) Usual physician services;
(ii) Hospitalization;
(iii) Laboratory;
(iv) X-ray;
(v) Emergency and preventive services; and
(vi) Out-of-area coverage;
(B) Is compensated, except for copayments, for the provision of
the basic health care services listed in subparagraph (A) of this
paragraph to enrolled participants on a predetermined periodic
rate basis; and
(C) Provides physicians' services primarily directly through
physicians who are either employees or partners of such
organization, or through arrangements with individual physicians
or one or more groups of physicians organized on a group practice
or individual practice basis.
(12) 'Health services' means clinically related diagnostic,
treatment or rehabilitative services, and includes alcohol, drug
or controlled substance abuse and mental health services that may
be provided either directly or indirectly on an inpatient or
ambulatory patient basis.
(13) 'Hospital' means:
(a) A facility with an organized medical staff and a permanent
building that is capable of providing 24-hour inpatient care to
two or more individuals who have an illness or injury and that
provides at least the following health services:
(A) Medical;
(B) Nursing;
(C) Laboratory;
(D) Pharmacy; and
(E) Dietary; or
(b) A special inpatient care facility as that term is defined
by the Oregon Health Authority by rule.
(14) 'Institutional health services' means health services
provided in or through health care facilities and includes the
entities in or through which such services are provided.
(15) 'Intermediate care facility' means a facility that
provides, on a regular basis, health-related care and services to
individuals who do not require the degree of care and treatment
that a hospital or skilled nursing facility is designed to
provide, but who because of their mental or physical condition
require care and services above the level of room and board that
can be made available to them only through institutional
facilities.
(16) 'Long term care facility' means a facility with permanent
facilities that include inpatient beds, providing medical
services, including nursing services but excluding surgical
procedures except as may be permitted by the rules of the
Director of Human Services, to provide treatment for two or more
unrelated patients. 'Long term care facility' includes skilled
nursing facilities and intermediate care facilities but may not
be construed to include facilities licensed and operated pursuant
to ORS 443.400 to 443.455.
{ - (17) 'New hospital' means a facility that did not offer
hospital services on a regular basis within its service area
within the prior 12-month period and is initiating or proposing
to initiate such services. 'New hospital' also includes any
replacement of an existing hospital that involves a substantial
increase or change in the services offered. - }
{ - (18) 'New skilled nursing or intermediate care service or
facility' means a service or facility that did not offer long
term care services on a regular basis by or through the facility
within the prior 12-month period and is initiating or proposing
to initiate such services. 'New skilled nursing or intermediate
care service or facility' also includes the rebuilding of a long
term care facility, the relocation of buildings that are a part
of a long term care facility, the relocation of long term care
beds from one facility to another or an increase in the number of
beds of more than 10 or 10 percent of the bed capacity, whichever
is the lesser, within a two-year period. - }
{ - (19) - } { + (17) + } 'Offer' means that the health
care facility holds itself out as capable of providing, or as
having the means for the provision of, specified health services.
{ - (20) - } { + (18) + } 'Outpatient renal dialysis
facility' means a facility that provides renal dialysis services
directly to outpatients.
{ - (21) - } { + (19) + } 'Person' means an individual, a
trust or estate, a partnership, a corporation (including
associations, joint stock companies and insurance companies), a
state, or a political subdivision or instrumentality, including a
municipal corporation, of a state.
{ - (22) - } { + (20) + } 'Skilled nursing facility' means
a facility or a distinct part of a facility, that is primarily
engaged in providing to inpatients skilled nursing care and
related services for patients who require medical or nursing
care, or an institution that provides rehabilitation services for
the rehabilitation of individuals who are injured or sick or who
have disabilities.
SECTION 53. ORS 734.790 is amended to read:
734.790. (1) ORS 734.750 to 734.890 provide coverage to the
following persons for policies and contracts specified in
subsection (2) of this section:
(a) To a person who is a resident, if the person is an owner of
or a certificate holder under the policy or contract or, in the
case of an unallocated annuity contract, an employee
participating in a governmental retirement plan established under
section 401, 403(b) or 457 of the United States Internal Revenue
Code or the beneficiaries of each such individual if deceased.
(b) To a person who is not a resident, if the person is an
owner of or a certificate holder under the policy or contract or,
in the case of an unallocated annuity contract, an employee
participating in a governmental retirement plan established under
section 401, 403(b) or 457 of the United States Internal Revenue
Code or the beneficiaries of each such individual if deceased.
This paragraph applies to a person who is not a resident only if
all of the following conditions are met:
(A) The insurer that issued the policy or contract must be a
domestic insurer.
(B) The insurer must never have held a license or certificate
of authority in the state in which the person resides.
(C) The state in which the person resides must have an
association similar to the Oregon Life and Health Insurance
Guaranty Association.
(D) The person must not be eligible for coverage by the
association in the state in which the person resides, as
described in subparagraph (C) of this paragraph.
(c) To a person who, regardless of where the person resides, is
a beneficiary, assignee or payee of the persons covered under
paragraph (a) or (b) of this subsection. This paragraph does not
include a nonresident certificate holder under a group policy or
contract.
(2) ORS 734.750 to 734.890 provide coverage to the persons
specified in subsection (1) of this section for direct life
insurance, including annuity, policies, health insurance
policies, and contracts supplemental to life and health insurance
policies, issued by authorized insurers.
(3) ORS 734.750 to 734.890 do not provide coverage for:
(a) That portion or part of a variable life insurance or
variable annuity policy not guaranteed by an insurer.
(b) That portion or part of any policy or contract under which
the risk is borne by the policyholder.
(c) Any policy or contract or part thereof assumed by the
impaired or insolvent insurer under a contract of reinsurance,
other than reinsurance for which assumption certificates have
been issued.
(d) Any policy or contract issued by a health care service
contractor complying with ORS 750.005 to 750.095.
(e) Any policy or contract issued by a fraternal benefit
society.
(f) Any portion of a policy or contract to the extent that the
rate of interest on which it is based:
(A) Exceeds, when averaged over the period of four years prior
to the date on which the association becomes obligated with
respect to the policy or contract, a rate of interest determined
by subtracting four percentage points from Moody's Corporate Bond
Yield Average averaged for that same four-year period or for a
lesser period if the policy or contract was issued less than four
years before the association became obligated; and
(B) Exceeds, on and after the date on which the association
becomes obligated with respect to the policy or contract, the
rate of interest determined by subtracting three percentage
points from Moody's Corporate Bond Yield Average as most recently
available.
(g) Any plan or program of an employer, association or similar
entity to provide life, health or annuity benefits to its
employees or members to the extent that the plan or program is
self-funded or uninsured, including benefits payable by an
employer, association or similar entity under any of the
following:
(A) A multiple employer welfare arrangement as defined in
section 514 of the Employee Retirement Income Security Act of
1974, as amended.
(B) A minimum premium group insurance plan.
(C) A stop-loss group insurance plan.
(D) An administrative services only contract.
(h) Any portion of a policy or contract to the extent that it
provides dividends or experience rating credits, or provides that
any fees or allowances be paid to any person, including the
policy or contract holder, in connection with the service to or
administration of the policy or contract.
(i) Any policy or contract issued in this state by a member
insurer at a time that it did not have a certificate of authority
to issue the policy or contract in this state.
(j) Any unallocated annuity contract issued to an employee
benefit plan protected under the federal Pension Benefit Guaranty
Corporation.
(k) Any portion of any unallocated annuity contract that is
issued to or in connection with a specific employee, union or
association of natural persons benefit plan, other than a
government retirement plan referred to in subsection (1) of this
section, or a government lottery.
{ - (L) Any coverage issued by the Oregon Medical Insurance
Pool. - }
(4) As used in this section, 'Moody's Corporate Bond Yield
Average' means the Monthly Average Corporates as published by
Moody's Investors Service, Inc., or any successor thereto.
SECTION 54. ORS 743.402 is amended to read:
743.402. Nothing in ORS 743.405 to 743.498, 743A.160 and
743A.164 shall apply to or affect:
(1) Any workers' compensation insurance policy or any liability
insurance policy with or without supplementary expense coverage
therein;
(2) Any policy of reinsurance;
(3) Any blanket or group policy of insurance; or
(4) Any life insurance policy, or policy supplemental thereto
which contains only such provisions relating to health insurance
as:
(a) Provide additional benefits in case of death or
dismemberment or loss of sight by accident; or
(b) Operate to safeguard such policy against lapse, or to give
a special surrender value or special benefit or an annuity in the
event the insured shall become totally and permanently disabled,
as defined by the policy or supplemental policy.
{ - (5) Coverage under ORS 735.600 to 735.650. - }
SECTION 55. ORS 743.730 is amended to read:
743.730. For purposes of ORS 743.730 to 743.773:
(1) 'Actuarial certification' means a written statement by a
member of the American Academy of Actuaries or other individual
acceptable to the Director of the Department of Consumer and
Business Services that a carrier is in compliance with the
provisions of ORS 743.736, 743.760 or 743.761, based upon the
person's examination, including a review of the appropriate
records and of the actuarial assumptions and methods used by the
carrier in establishing premium rates for small employer and
portability health benefit plans.
(2) 'Affiliate' of, or person 'affiliated' with, a specified
person means any carrier who, directly or indirectly through one
or more intermediaries, controls or is controlled by or is under
common control with a specified person. For purposes of this
definition, 'control' has the meaning given that term in ORS
732.548.
(3) 'Affiliation period' means, under the terms of a group
health benefit plan issued by a health care service contractor, a
period:
(a) That is applied uniformly and without regard to any health
status related factors to an enrollee or late enrollee in lieu of
a preexisting conditions provision;
(b) That must expire before any coverage becomes effective
under the plan for the enrollee or late enrollee;
(c) During which no premium shall be charged to the enrollee or
late enrollee; and
(d) That begins on the enrollee's or late enrollee's first date
of eligibility for coverage and runs concurrently with any
eligibility waiting period under the plan.
(4) 'Basic health benefit plan' means a health benefit plan for
small employers that is required to be offered by all small
employer carriers and approved by the Director of the Department
of Consumer and Business Services in accordance with ORS 743.736.
(5) 'Bona fide association' means an association that meets the
requirements of 42 U.S.C. 300gg-11 as amended and in effect on
July 1, 1997.
(6) 'Carrier' means any person who provides health benefit
plans in this state, including a licensed insurance company, a
health care service contractor, a health maintenance
organization, an association or group of employers that provides
benefits by means of a multiple employer welfare arrangement or
any other person or corporation responsible for the payment of
benefits or provision of services.
(7) 'Committee' means the Health Insurance Reform Advisory
Committee created under ORS 743.745.
(8) 'Creditable coverage' means prior health care coverage as
defined in 42 U.S.C. 300gg as amended and in effect on July 1,
1997, and includes coverage remaining in force at the time the
enrollee obtains new coverage.
(9) 'Department' means the Department of Consumer and Business
Services.
(10) 'Dependent' means the spouse or child of an eligible
employee, subject to applicable terms of the health benefit plan
covering the employee.
(11) 'Director' means the Director of the Department of
Consumer and Business Services.
(12) 'Eligible employee' means an employee of a small employer
who works on a regularly scheduled basis, with a normal work week
of 17.5 or more hours. The employer may determine hours worked
for eligibility between 17.5 and 40 hours per week subject to
rules of the carrier. 'Eligible employee' does not include
employees who work on a temporary, seasonal or substitute basis.
Employees who have been employed by the small employer for fewer
than 90 days are not eligible employees unless the small employer
so allows.
(13) 'Employee' means any individual employed by an employer.
(14) 'Enrollee' means an employee, dependent of the employee or
an individual otherwise eligible for a group, individual or
portability health benefit plan who has enrolled for coverage
under the terms of the plan.
(15) 'Exclusion period' means a period during which specified
treatments or services are excluded from coverage.
(16) 'Financially impaired' means a member that is not
insolvent and is:
(a) Considered by the Director of the Department of Consumer
and Business Services to be potentially unable to fulfill its
contractual obligations; or
(b) Placed under an order of rehabilitation or conservation by
a court of competent jurisdiction.
(17)(a) 'Geographic average rate' means the arithmetical
average of the lowest premium and the corresponding highest
premium to be charged by a carrier in a geographic area
established by the director for the carrier's:
(A) Small employer group health benefit plans;
(B) Individual health benefit plans; or
(C) Portability health benefit plans.
(b) 'Geographic average rate' does not include premium
differences that are due to differences in benefit design or
family composition.
(18) 'Group eligibility waiting period' means, with respect to
a group health benefit plan, the period of employment or
membership with the group that a prospective enrollee must
complete before plan coverage begins.
(19)(a) 'Health benefit plan' means any hospital expense,
medical expense or hospital or medical expense policy or
certificate, health care service contractor or health maintenance
organization subscriber contract, any plan provided by a multiple
employer welfare arrangement or by another benefit arrangement
defined in the federal Employee Retirement Income Security Act of
1974, as amended.
(b) 'Health benefit plan' does not include coverage for
accident only, specific disease or condition only, credit,
disability income, coverage of Medicare services pursuant to
contracts with the federal government, Medicare supplement
insurance policies, coverage of CHAMPUS services pursuant to
contracts with the federal government, benefits delivered through
a flexible spending arrangement established pursuant to section
125 of the Internal Revenue Code of 1986, as amended, when the
benefits are provided in addition to a group health benefit plan,
long term care insurance, hospital indemnity only, short term
health insurance policies (the duration of which does not exceed
six months including renewals), student accident and health
insurance policies, dental only, vision only, a policy of
stop-loss coverage that meets the requirements of ORS 742.065,
coverage issued as a supplement to liability insurance, insurance
arising out of a workers' compensation or similar law, automobile
medical payment insurance or insurance under which benefits are
payable with or without regard to fault and that is statutorily
required to be contained in any liability insurance policy or
equivalent self-insurance.
(c) Nothing in this subsection shall be construed to regulate
any employee welfare benefit plan that is exempt from state
regulation because of the federal Employee Retirement Income
Security Act of 1974, as amended.
(20) 'Health statement' means any information that is intended
to inform the carrier or insurance producer of the health status
of an enrollee or prospective enrollee in a health benefit plan.
'Health statement' includes the standard health statement
developed by the Health Insurance Reform Advisory Committee.
(21) 'Implementation of chapter 836, Oregon Laws 1989 ' means
that the Health Services Commission has prepared a priority list,
the Legislative Assembly has enacted funding of the list and all
necessary federal approval, including waivers, has been obtained.
(22) 'Individual coverage waiting period' means a period in an
individual health benefit plan during which no premiums may be
collected and health benefit plan coverage issued is not
effective.
(23) 'Initial enrollment period' means a period of at least 30
days following commencement of the first eligibility period for
an individual.
(24) 'Late enrollee' means an individual who enrolls in a group
health benefit plan subsequent to the initial enrollment period
during which the individual was eligible for coverage but
declined to enroll. However, an eligible individual shall not be
considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg as amended and in effect on July
1, 1997;
(b) The individual applies for coverage during an open
enrollment period;
(c) A court has ordered that coverage be provided for a spouse
or minor child under a covered employee's health benefit plan and
request for enrollment is made within 30 days after issuance of
the court order;
(d) The individual is employed by an employer who offers
multiple health benefit plans and the individual elects a
different health benefit plan during an open enrollment period;
or
(e) The individual's coverage under Medicaid, Medicare,
CHAMPUS, Indian Health Service or a publicly sponsored or
subsidized health plan, including but not limited to the medical
assistance program under ORS chapter 414, has been involuntarily
terminated within 63 days of applying for coverage in a group
health benefit plan.
(25) 'Multiple employer welfare arrangement' means a multiple
employer welfare arrangement as defined in section 3 of the
federal Employee Retirement Income Security Act of 1974, as
amended, 29 U.S.C. 1002, that is subject to ORS 750.301 to
750.341.
{ - (26) 'Oregon Medical Insurance Pool' means the pool
created under ORS 735.610. - }
{ - (27) - } { + (26) + } 'Preexisting conditions
provision' means a health benefit plan provision applicable to an
enrollee or late enrollee that excludes coverage for services,
charges or expenses incurred during a specified period
immediately following enrollment for a condition for which
medical advice, diagnosis, care or treatment was recommended or
received during a specified period immediately preceding
enrollment. For purposes of ORS 743.730 to 743.773:
(a) Pregnancy does not constitute a preexisting condition
except as provided in ORS 743.766;
(b) Genetic information does not constitute a preexisting
condition in the absence of a diagnosis of the condition related
to such information; and
(c) A preexisting conditions provision shall not be applied to
a newborn child or adopted child who obtains coverage in
accordance with ORS 743A.090.
{ - (28) - } { + (27) + } 'Premium' includes insurance
premiums or other fees charged for a health benefit plan,
including the costs of benefits paid or reimbursements made to or
on behalf of enrollees covered by the plan.
{ - (29) - } { + (28) + } 'Rating period' means the
12-month calendar period for which premium rates established by a
carrier are in effect, as determined by the carrier.
{ - (30)(a) - } { + (29)(a) + } 'Small employer' means an
employer that employed an average of at least two but not more
than 50 employees on business days during the preceding calendar
year, the majority of whom are employed within this state, and
that employs at least two eligible employees on the date on which
coverage takes effect under a health benefit plan issued by a
small employer carrier.
(b) Any person that is treated as a single employer under
subsection (b), (c), (m) or (o) of section 414 of the Internal
Revenue Code of 1986 shall be treated as one employer for
purposes of this subsection.
(c) The determination of whether an employer that was not in
existence throughout the preceding calendar year is a small
employer shall be based on the average number of employees that
it is reasonably expected the employer will employ on business
days in the current calendar year.
{ - (31) - } { + (30) + } 'Small employer carrier' means
any carrier that offers health benefit plans covering eligible
employees of one or more small employers. A fully insured
multiple employer welfare arrangement otherwise exempt under ORS
750.303 (4) may elect to be a small employer carrier governed by
the provisions of ORS 743.733 to 743.737.
SECTION 56. ORS 743.748 is amended to read:
743.748. (1) Each carrier offering a health benefit plan shall
submit to the Director of the Department of Consumer and Business
Services on or before April 1 of each year a report that
contains:
(a) The following information for the preceding year that is
derived from the exhibit of premiums, enrollment and utilization
included in the carrier's annual report:
(A) The total number of members;
(B) The total amount of premiums;
(C) The total amount of costs for claims;
(D) The medical loss ratio;
(E) The average amount of premiums per member per month; and
(F) The percentage change in the average premium per member per
month, measured from the previous year.
(b) The following aggregate financial information for the
preceding year that is derived from the carrier's annual report:
(A) The total amount of general administrative expenses,
including identification of the five largest nonmedical
administrative expenses { - and the assessment against the
carrier for the Oregon Medical Insurance Pool - } ;
(B) The total amount of the surplus maintained;
(C) The total amount of the reserves maintained for unpaid
claims;
(D) The total net underwriting gain or loss; and
(E) The carrier's net income after taxes.
(c) The retention rate and claims experience of employer groups
within the plan for the preceding year for association health
plans as described in ORS 743.734 (7). This information is not
subject to public disclosure under ORS chapter 192.
(2) A carrier shall electronically submit the information
described in subsection (1) of this section in a format and
according to instructions prescribed by the Department of
Consumer and Business Services by rule after obtaining a
recommendation from the Health Insurance Reform Advisory
Committee.
(3) The advisory committee shall evaluate the reporting
requirements under subsection (1)(a) of this section by the
following market segments:
(a) Individual health benefit plans;
(b) Health benefit plans for small employers;
(c) Health benefit plans for employers described in ORS
743.733;
(d) Health benefit plans for employers with more than 50
employees; and
(e) Association health plans described in ORS 743.734 (7).
(4) The department shall make the information reported under
this section available to the public through a searchable public
website on the Internet.
SECTION 57. ORS 743.748, as amended by section 10, chapter 752,
Oregon Laws 2007, is amended to read:
743.748. (1) Each carrier offering a health benefit plan shall
submit to the Director of the Department of Consumer and Business
Services on or before April 1 of each year a report that
contains:
(a) The following information for the preceding year that is
derived from the exhibit of premiums, enrollment and utilization
included in the carrier's annual report:
(A) The total number of members;
(B) The total amount of premiums;
(C) The total amount of costs for claims;
(D) The medical loss ratio;
(E) The average amount of premiums per member per month; and
(F) The percentage change in the average premium per member per
month, measured from the previous year.
(b) The following aggregate financial information for the
preceding year that is derived from the carrier's annual report:
(A) The total amount of general administrative expenses,
including identification of the five largest nonmedical
administrative expenses { - and the assessment against the
carrier for the Oregon Medical Insurance Pool - } ;
(B) The total amount of the surplus maintained;
(C) The total amount of the reserves maintained for unpaid
claims;
(D) The total net underwriting gain or loss; and
(E) The carrier's net income after taxes.
(2) A carrier shall electronically submit the information
described in subsection (1) of this section in a format and
according to instructions prescribed by the Department of
Consumer and Business Services by rule after obtaining a
recommendation from the Health Insurance Reform Advisory
Committee.
(3) The advisory committee shall evaluate the reporting
requirements under subsection (1)(a) of this section by the
following market segments:
(a) Individual health benefit plans;
(b) Health benefit plans for small employers;
(c) Health benefit plans for employers described in ORS
743.733; and
(d) Health benefit plans for employers with more than 50
employees.
(4) The department shall make the information reported under
this section available to the public through a searchable public
website on the Internet.
SECTION 58. ORS 743.766 is amended to read:
743.766. (1) All carriers who offer individual health benefit
plans and evaluate the health status of individuals for purposes
of eligibility shall use the standard health statement
established by the Health Insurance Reform Advisory Committee and
may not use any other method to determine the health status of an
individual. Nothing in this subsection shall prevent a carrier
from using health information after enrollment for the purpose of
providing services or arranging for the provision of services
under a health benefit plan.
(2)(a) If an individual is accepted for coverage under an
individual health benefit plan, the carrier shall not impose
exclusions or limitations on coverage greater than:
(A) A preexisting conditions provision that complies with the
following requirements:
(i) The provision shall apply only to a condition for which
medical advice, diagnosis, care or treatment was recommended or
received during the six-month period immediately preceding the
individual's effective date of coverage; and
(ii) The provision shall terminate its effect no later than six
months following the individual's effective date of coverage;
(B) An individual coverage waiting period of 90 days; or
(C) An exclusion period for specified covered services
applicable to all individuals enrolling for the first time in the
individual health benefit plan.
(b) Pregnancy may constitute a preexisting condition for
purposes of this section.
(3) If the carrier elects to restrict coverage through the
application of a preexisting conditions provision or an
individual coverage waiting period provision, the carrier shall
reduce the duration of the provision by an amount equal to the
individual's aggregate periods of creditable coverage if the most
recent period of creditable coverage is ongoing or ended within
63 days of the effective date of coverage in the new individual
health benefit plan. The crediting of prior coverage in
accordance with this subsection shall be applied without regard
to the specific benefits covered during the prior period.
{ - (4) If an eligible prospective enrollee is rejected for
coverage under an individual health benefit plan, the prospective
enrollee shall be eligible to apply for coverage under the Oregon
Medical Insurance Pool. - }
{ - (5) - } { + (4) + } If a carrier accepts an individual
for coverage under an individual health benefit plan, the carrier
shall renew the policy except:
(a) For nonpayment of the required premiums by the
policyholder.
(b) For fraud or misrepresentation by the policyholder.
(c) When the carrier discontinues offering or renewing, or
offering and renewing, all of its individual health benefit plans
in this state or in a specified service area within this state.
In order to discontinue the plans under this paragraph, the
carrier:
(A) Must give notice of the decision to the Director of the
Department of Consumer and Business Services and to all
policyholders covered by the plans;
(B) May not cancel coverage under the plans for 180 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in the entire state or,
except as provided in subparagraph (C) of this paragraph, in a
specified service area;
(C) May not cancel coverage under the plans for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph if coverage is discontinued in a specified service area
because of an inability to reach an agreement with the health
care providers or organization of health care providers to
provide services under the plans within the service area; and
(D) Must discontinue offering or renewing, or offering and
renewing, all health benefit plans issued by the carrier in the
individual market in this state or in the specified service area.
(d) When the carrier discontinues offering and renewing an
individual health benefit plan in a specified service area within
this state because of an inability to reach an agreement with the
health care providers or organization of health care providers to
provide services under the plan within the service area. In order
to discontinue a plan under this paragraph, the carrier:
(A) Must give notice of the decision to the director and to all
policyholders covered by the plan;
(B) May not cancel coverage under the plan for 90 days after
the date of the notice required under subparagraph (A) of this
paragraph; and
(C) Must offer in writing to each policyholder covered by the
plan, all other individual health benefit plans that the carrier
offers in the specified service area. The carrier shall offer the
plans at least 90 days prior to discontinuation.
(e) When the carrier discontinues offering or renewing, or
offering and renewing, an individual health benefit plan for all
individuals in this state or in a specified service area within
this state, other than a plan discontinued under paragraph (d) of
this subsection. With respect to plans that are being
discontinued, the carrier must:
(A) Offer in writing to each policyholder covered by the plan,
one or more individual health benefit plans that the carrier
offers in the specified service area.
(B) Offer the plans at least 90 days prior to discontinuation.
(C) Act uniformly without regard to the claims experience of
the affected policyholders or the health status of any current or
prospective enrollee.
(f) When the director orders the carrier to discontinue
coverage in accordance with procedures specified or approved by
the director upon finding that the continuation of the coverage
would:
(A) Not be in the best interests of the enrollee; or
(B) Impair the carrier's ability to meet its contractual
obligations.
(g) When, in the case of an individual health benefit plan that
delivers covered services through a specified network of health
care providers, the enrollee no longer lives, resides or works in
the service area of the provider network and the termination of
coverage is not related to the health status of any enrollee.
(h) When, in the case of a health benefit plan that is offered
in the individual market only through one or more bona fide
associations, the membership of an individual in the association
ceases and the termination of coverage is not related to the
health status of any enrollee.
(i) For misuse of a provider network provision. As used in this
paragraph, 'misuse of a provider network provision' means a
disruptive, unruly or abusive action taken by an enrollee that
threatens the physical health or well-being of health care staff
and seriously impairs the ability of the carrier or its
participating providers to provide service to an enrollee. An
enrollee under this paragraph retains the rights of an enrollee
under ORS 743.804.
(j) A carrier may modify an individual health benefit plan at
the time of coverage renewal. The modification is not a
discontinuation of the plan under paragraphs (c) and (e) of this
subsection.
{ - (6) - } { + (5) + } Notwithstanding any other provision
of this section, a carrier may rescind an individual health
benefit plan for fraud, material misrepresentation or concealment
by an enrollee.
{ - (7) - } { + (6) + } A carrier that withdraws from the
market for individual health benefit plans must continue to renew
its portability health benefit plans that have been approved
pursuant to ORS 743.761.
{ - (8) - } { + (7) + } A carrier that continues to offer
coverage in the individual market in this state is not required
to offer coverage in all of the carrier's individual health
benefit plans. However, if a carrier elects to continue a plan
that is closed to new individual policyholders instead of
offering alternative coverage in its other individual health
benefit plans, the coverage for all existing policyholders in the
closed plan is renewable in accordance with subsection
{ - (5) - } { + (4) + } of this section.
SECTION 59. ORS 743.767 is amended to read:
743.767. Premium rates for individual health benefit plans
shall be subject to the following provisions:
(1) Each carrier must file the geographic average rate for its
individual health benefit plans for a rating period with the
Director of the Department of Consumer and Business Services on
or before March 15 of each year.
(2) The premium rates charged during a rating period for
individual health benefit plans issued to individuals shall not
vary from the individual geographic average rate, except that the
premium rate may be adjusted to reflect differences in benefit
design, family composition and age. For age adjustments to the
individual plans, a carrier shall apply uniformly its schedule of
age adjustments for individual health benefit plans as approved
by the director.
(3) A carrier may not increase the rates of an individual
health benefit plan more than once in a 12-month period except as
approved by the director. Annual rate increases shall be
effective on the anniversary date of the individual health
benefit plan's issuance. The percentage increase in the premium
rate charged for an individual health benefit plan for a new
rating period may not exceed the sum of the following:
(a) The percentage change in the carrier's geographic average
rate for its individual health benefit plan measured from the
first day of the prior rating period to the first day of the new
period; and
(b) Any adjustment attributable to changes in age and
differences in benefit design and family composition.
(4) Notwithstanding any other provision of this section, a
carrier that imposes an individual coverage waiting period
pursuant to ORS 743.766 may impose a monthly premium rate
surcharge for a period not to exceed six months and in an amount
not to exceed { - the percentage by which the rates for
coverage under the Oregon Medical Insurance Pool exceed the rates
established by the Oregon Medical Insurance Pool Board as
applicable for individual risks under ORS 735.625 - } { + a
percentage adopted by the director by rule + }. The surcharge
{ - shall - } { + must + } be approved by the director
{ - of the Department of Consumer and Business Services - }
and, in combination with the waiting period, shall not exceed the
actuarial value of a six-month preexisting conditions provision.
SECTION 60. ORS 743.769 is amended to read:
743.769. (1) Each carrier shall actively market all individual
health benefit plans sold by the carrier.
(2) Except as provided in subsection (3) of this section, no
carrier or insurance producer shall, directly or indirectly,
discourage an individual from filing an application for coverage
because of the health status, claims experience, occupation or
geographic location of the individual.
(3) Subsection (2) of this section does not apply with respect
to information provided by a carrier to an individual regarding
the established geographic service area or a restricted network
provision of a carrier.
(4) Rejection by a carrier of an application for coverage shall
be in writing and shall state the reason or reasons for the
rejection.
(5) The Director of the Department of Consumer and Business
Services may establish by rule additional standards to provide
for the fair marketing and broad availability of individual
health benefit plans.
(6) A carrier that elects to discontinue offering all of its
individual health benefit plans under ORS 743.766
{ - (5)(c) - } { + (4)(c) + } or to discontinue offering and
renewing all such plans is prohibited from offering and renewing
health benefit plans in the individual market in this state for a
period of five years from the date of notice to the director
pursuant to ORS 743.766
{ - (5)(c) - } { + (4)(c) + } or, if such notice is not
provided, from the date on which the director provides notice to
the carrier that the director has determined that the carrier has
effectively discontinued offering individual health benefit plans
in this state. This subsection does not apply with respect to a
health benefit plan discontinued in a specified service area by a
carrier that covers services provided only by a particular
organization of health care providers or only by health care
providers who are under contract with the carrier.
SECTION 61. ORS 743A.001 is amended to read:
743A.001. (1) { - Except as provided in subsection (4) of
this section, - } Any statute described in subsection (2) of
this section { + :
(a) + } That becomes effective on or after July 13, 1985, { +
except as provided in subsection (4) of this section, + } is
repealed on the sixth anniversary of the effective date of the
statute, unless the Legislative Assembly specifically provides
otherwise { + ; and
(b) Does not apply to any insurer with respect to services
covered in the Affordable Health Care for All Oregon Plan + }.
(2) This section governs any statute that applies to individual
or group health insurance policies and does any of the following:
(a) Requires the insurer to include coverage for specific
physical or mental conditions or specific hospital, medical,
surgical or dental health services.
(b) Requires the insurer to include coverage for specified
persons.
(c) Requires the insurer to provide payment or reimbursement to
specified providers of services if the services are within the
lawful scope of practice of the provider and the insurance policy
provides payment or reimbursement for those services.
(d) Requires the insurer to provide any specific coverage on a
nondiscriminatory basis.
(e) Forbids the insurer to exclude from payment or
reimbursement any covered services.
(f) Forbids the insurer to exclude coverage of a person because
of that person's medical history.
(3) A repeal of a statute under subsection (1) of this section
does not apply to any insurance policy in effect on the effective
date of the repeal. However, the repeal of the statute applies to
a renewal or extension of an existing insurance policy on or
after the effective date of the repealer as well as to a new
policy issued on or after the effective date of the repealer.
(4) { - This section - } { + Subsection (1)(a) of this
section + } does not apply to ORS 743A.020, 743A.080, 743A.100,
743A.104 and 743A.108.
SECTION 62. ORS 744.704 is amended to read:
744.704. (1) The following persons are exempt from the
licensing requirement for third party administrators in ORS
744.702 and from all other provisions of ORS 744.700 to 744.740
applicable to third party administrators:
(a) A person licensed under ORS 744.002 as an adjuster, whose
activities are limited to adjustment of claims and whose
activities do not include the activities of a third party
administrator.
(b) A person licensed as an insurance producer as required by
ORS 744.053 and authorized to transact life or health insurance
in this state, whose activities are limited exclusively to the
sale of insurance and whose activities do not include the
activities of a third party administrator.
(c) An employer acting as a third party administrator on behalf
of:
(A) Its employees;
(B) The employees of one or more subsidiary or affiliated
corporations of the employer; or
(C) The employees of one or more persons with a dealership,
franchise, distributorship or other similar arrangement with the
employers.
(d) A union, or an affiliate thereof, acting as a third party
administrator on behalf of its members.
(e) An insurer that is authorized to transact insurance in this
state with respect to a policy issued and delivered in and
pursuant to the laws of this state or another state.
(f) A creditor acting on behalf of its debtors with respect to
insurance covering a debt between the creditor and its debtors.
(g) A trust and the trustees, agents and employees of the
trust, when acting pursuant to the trust, if the trust is
established in conformity with 29 U.S.C. 186.
(h) A trust exempt from taxation under section 501(a) of the
Internal Revenue Code, its trustees and employees acting pursuant
to the trust, or a voluntary employees beneficiary association
described in section 501(c) of the Internal Revenue Code, its
agents and employees and a custodian and the custodian's agents
and employees acting pursuant to a custodian account meeting the
requirements of section 401(f) of the Internal Revenue Code.
(i) A financial institution that is subject to supervision or
examination by federal or state financial institution regulatory
authorities, or a mortgage lender, to the extent the financial
institution or mortgage lender collects and remits premiums to
licensed insurance producers or authorized insurers in connection
with loan payments.
(j) A company that issues credit cards and advances for and
collects premiums or charges from its credit card holders who
have authorized collection. The exemption under this paragraph
applies only if the company does not adjust or settle claims.
(k) A person who adjusts or settles claims in the normal course
of practice or employment as an attorney at law. The exemption
under this subsection applies only if the person does not collect
charges or premiums in connection with life insurance or health
insurance coverage.
(L) A person who acts solely as an administrator of one or more
bona fide employee benefit plans established by an employer or an
employee organization, or both, for which the Insurance Code is
preempted pursuant to the Employee Retirement Income Security Act
of 1974. A person to whom this paragraph applies must comply with
the requirements of ORS 744.714.
{ - (m) The Oregon Medical Insurance Pool Board, established
under ORS 735.600 to 735.650, and the administering insurer or
insurers for the board, for services provided pursuant to ORS
735.600 to 735.650. - }
{ - (n) - } { + (m) + } An entity or association owned by
or composed of like employers who administer partially or fully
self-insured plans for employees of the employers or association
members.
{ - (o) - } { + (n) + } A trust established by a
cooperative body formed between cities, counties, districts or
other political subdivisions of this state, or between any
combination of such entities, and the trustees, agents and
employees acting pursuant to the trust.
{ - (p) - } { + (o) + } Any person designated by the
Director of the Department of Consumer and Business Services by
rule.
(2) A third party administrator is not required to be licensed
as a third party administrator in this state if the following
conditions are met:
(a) The third party administrator has its principal place of
business in another state;
(b) The third party administrator is not soliciting business as
a third party administrator in this state; and
(c) In the case of any group policy or plan of insurance
serviced by the third party administrator, the lesser of five
percent or 100 certificate holders reside in this state.
SECTION 63. ORS 746.600 is amended to read:
746.600. As used in ORS 746.600 to 746.690:
(1)(a) 'Adverse underwriting decision' means any of the
following actions with respect to insurance transactions
involving insurance coverage that is individually underwritten:
(A) A declination of insurance coverage.
(B) A termination of insurance coverage.
(C) Failure of an insurance producer to apply for insurance
coverage with a specific insurer that the insurance producer
represents and that is requested by an applicant.
(D) In the case of life or health insurance coverage, an offer
to insure at higher than standard rates.
(E) In the case of insurance coverage other than life or health
insurance coverage:
(i) Placement by an insurer or insurance producer of a risk
with a residual market mechanism, an unauthorized insurer or an
insurer that specializes in substandard risks.
(ii) The charging of a higher rate on the basis of information
that differs from that which the applicant or policyholder
furnished.
(iii) An increase in any charge imposed by the insurer for any
personal insurance in connection with the underwriting of
insurance. For purposes of this sub-subparagraph, the imposition
of a service fee is not a charge.
(b) 'Adverse underwriting decision' does not mean any of the
following actions, but the insurer or insurance producer
responsible for the occurrence of the action must nevertheless
provide the applicant or policyholder with the specific reason or
reasons for the occurrence:
(A) The termination of an individual policy form on a class or
statewide basis.
(B) A declination of insurance coverage solely because the
coverage is not available on a class or statewide basis.
(C) The rescission of a policy.
(2) 'Affiliate of' a specified person or 'person affiliated
with' a specified person means a person who directly, or
indirectly, through one or more intermediaries, controls, or is
controlled by, or is under common control with, the person
specified.
(3) 'Applicant' means a person who seeks to contract for
insurance coverage, other than a person seeking group insurance
coverage that is not individually underwritten.
(4) 'Consumer' means an individual, or the personal
representative of the individual, who seeks to obtain, obtains or
has obtained one or more insurance products or services from a
licensee that are to be used primarily for personal, family or
household purposes, and about whom the licensee has personal
information.
(5) 'Consumer report' means any written, oral or other
communication of information bearing on a natural person's
creditworthiness, credit standing, credit capacity, character,
general reputation, personal characteristics or mode of living
that is used or expected to be used in connection with an
insurance transaction.
(6) 'Consumer reporting agency' means a person that, for
monetary fees or dues, or on a cooperative or nonprofit basis:
(a) Regularly engages, in whole or in part, in assembling or
preparing consumer reports;
(b) Obtains information primarily from sources other than
insurers; and
(c) Furnishes consumer reports to other persons.
(7) 'Control' means, and the terms 'controlled by' or ' under
common control with' refer to, the possession, directly or
indirectly, of the power to direct or cause the direction of the
management and policies of a person, whether through the
ownership of voting securities, by contract other than a
commercial contract for goods or nonmanagement services, or
otherwise, unless the power of the person is the result of a
corporate office held in, or an official position held with, the
controlled person.
(8) 'Covered entity' means:
(a) A health insurer;
(b) A health care provider that transmits any health
information in electronic form to carry out financial or
administrative activities in connection with a transaction
covered by ORS 746.607 or by rules adopted under ORS 746.608; or
(c) A health care clearinghouse.
(9) 'Credit history' means any written or other communication
of any information by a consumer reporting agency that:
(a) Bears on a consumer's creditworthiness, credit standing or
credit capacity; and
(b) Is used or expected to be used, or collected in whole or in
part, as a factor in determining eligibility, premiums or rates
for personal insurance.
(10) 'Customer' means a consumer who has a continuing
relationship with a licensee under which the licensee provides
one or more insurance products or services to the consumer that
are to be used primarily for personal, family or household
purposes.
(11) 'Declination of insurance coverage' or 'decline coverage'
means a denial, in whole or in part, by an insurer or insurance
producer of an application for requested insurance coverage.
(12) 'Health care' means care, services or supplies related to
the health of an individual.
(13) 'Health care operations' includes but is not limited to:
(a) Quality assessment, accreditation, auditing and improvement
activities;
(b) Case management and care coordination;
(c) Reviewing the competence, qualifications or performance of
health care providers or health insurers;
(d) Underwriting activities;
(e) Arranging for legal services;
(f) Business planning;
(g) Customer services;
(h) Resolving internal grievances;
(i) Creating de-identified information; and
(j) Fundraising.
(14) 'Health care provider' includes but is not limited to:
(a) A psychologist, occupational therapist, regulated social
worker, professional counselor or marriage and family therapist
licensed or otherwise authorized to practice under ORS chapter
675 or an employee of the psychologist, occupational therapist,
regulated social worker, professional counselor or marriage and
family therapist;
(b) A physician, podiatric physician and surgeon, physician
assistant or acupuncturist licensed under ORS chapter 677 or an
employee of the physician, podiatric physician and surgeon,
physician assistant or acupuncturist;
(c) A nurse or nursing home administrator licensed under ORS
chapter 678 or an employee of the nurse or nursing home
administrator;
(d) A dentist licensed under ORS chapter 679 or an employee of
the dentist;
(e) A dental hygienist or denturist licensed under ORS chapter
680 or an employee of the dental hygienist or denturist;
(f) A speech-language pathologist or audiologist licensed under
ORS chapter 681 or an employee of the speech-language pathologist
or audiologist;
(g) An emergency medical technician certified under ORS chapter
682;
(h) An optometrist licensed under ORS chapter 683 or an
employee of the optometrist;
(i) A chiropractic physician licensed under ORS chapter 684 or
an employee of the chiropractic physician;
(j) A naturopathic physician licensed under ORS chapter 685 or
an employee of the naturopathic physician;
(k) A massage therapist licensed under ORS 687.011 to 687.250
or an employee of the massage therapist;
(L) A direct entry midwife licensed under ORS 687.405 to
687.495 or an employee of the direct entry midwife;
(m) A physical therapist licensed under ORS 688.010 to 688.201
or an employee of the physical therapist;
(n) A medical imaging licensee under ORS 688.405 to 688.605 or
an employee of the medical imaging licensee;
(o) A respiratory care practitioner licensed under ORS 688.800
to 688.840 or an employee of the respiratory care practitioner;
(p) A pharmacist licensed under ORS chapter 689 or an employee
of the pharmacist;
(q) A dietitian licensed under ORS 691.405 to 691.585 or an
employee of the dietitian;
(r) A funeral service practitioner licensed under ORS chapter
692 or an employee of the funeral service practitioner;
(s) A health care facility as defined in ORS 442.015;
(t) A home health agency as defined in ORS 443.005;
(u) A hospice program as defined in ORS 443.850;
(v) A clinical laboratory as defined in ORS 438.010;
(w) A pharmacy as defined in ORS 689.005;
(x) A diabetes self-management program as defined in ORS
743.694; and
(y) Any other person or entity that furnishes, bills for or is
paid for health care in the normal course of business.
(15) 'Health information' means any oral or written information
in any form or medium that:
(a) Is created or received by a covered entity, a public health
authority, a life insurer, a school, a university or a health
care provider that is not a covered entity; and
(b) Relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(16) 'Health insurer' means { - : - }
{ - (a) - } an insurer who offers:
{ - (A) - } { + (a) + } A health benefit plan as defined in
ORS 743.730;
{ - (B) - } { + (b) + } A short term health insurance
policy, the duration of which does not exceed six months
including renewals;
{ - (C) - } { + (c) + } A student health insurance policy;
{ - (D) - } { + (d) + } A Medicare supplemental policy; or
{ - (E) - } { + (e) + } A dental only policy.
{ - (b) The Oregon Medical Insurance Pool operated by the
Oregon Medical Insurance Pool Board under ORS 735.600 to
735.650. - }
(17) 'Homeowner insurance' means insurance for residential
property consisting of a combination of property insurance and
casualty insurance that provides coverage for the risks of owning
or occupying a dwelling and that is not intended to cover an
owner's interest in rental property or commercial exposures.
(18) 'Individual' means a natural person who:
(a) In the case of life or health insurance, is a past, present
or proposed principal insured or certificate holder;
(b) In the case of other kinds of insurance, is a past, present
or proposed named insured or certificate holder;
(c) Is a past, present or proposed policyowner;
(d) Is a past or present applicant;
(e) Is a past or present claimant; or
(f) Derived, derives or is proposed to derive insurance
coverage under an insurance policy or certificate that is subject
to ORS 746.600 to 746.690.
(19) 'Individually identifiable health information' means any
oral or written health information that is:
(a) Created or received by a covered entity or a health care
provider that is not a covered entity; and
(b) Identifiable to an individual, including demographic
information that identifies the individual, or for which there is
a reasonable basis to believe the information can be used to
identify an individual, and that relates to:
(A) The past, present or future physical or mental health or
condition of an individual;
(B) The provision of health care to an individual; or
(C) The past, present or future payment for the provision of
health care to an individual.
(20) 'Institutional source' means a person or governmental
entity that provides information about an individual to an
insurer, insurance producer or insurance-support organization,
other than:
(a) An insurance producer;
(b) The individual who is the subject of the information; or
(c) A natural person acting in a personal capacity rather than
in a business or professional capacity.
(21) 'Insurance producer' or 'producer' means a person licensed
by the Director of the Department of Consumer and Business
Services as a resident or nonresident insurance producer.
(22) 'Insurance score' means a number or rating that is derived
from an algorithm, computer application, model or other process
that is based in whole or in part on credit history.
(23)(a) 'Insurance-support organization' means a person who
regularly engages, in whole or in part, in assembling or
collecting information about natural persons for the primary
purpose of providing the information to an insurer or insurance
producer for insurance transactions, including:
(A) The furnishing of consumer reports to an insurer or
insurance producer for use in connection with insurance
transactions; and
(B) The collection of personal information from insurers,
insurance producers or other insurance-support organizations for
the purpose of detecting or preventing fraud, material
misrepresentation or material nondisclosure in connection with
insurance underwriting or insurance claim activity.
(b) 'Insurance-support organization' does not mean insurers,
insurance producers, governmental institutions or health care
providers.
(24) 'Insurance transaction' means any transaction that
involves insurance primarily for personal, family or household
needs rather than business or professional needs and that
entails:
(a) The determination of an individual's eligibility for an
insurance coverage, benefit or payment; or
(b) The servicing of an insurance application, policy or
certificate.
(25) 'Insurer' has the meaning given that term in ORS 731.106.
(26) 'Investigative consumer report' means a consumer report,
or portion of a consumer report, for which information about a
natural person's character, general reputation, personal
characteristics or mode of living is obtained through personal
interviews with the person's neighbors, friends, associates,
acquaintances or others who may have knowledge concerning such
items of information.
(27) 'Licensee' means an insurer, insurance producer or other
person authorized or required to be authorized, or licensed or
required to be licensed, pursuant to the Insurance Code.
(28) 'Loss history report' means a report provided by, or a
database maintained by, an insurance-support organization or
consumer reporting agency that contains information regarding the
claims history of the individual property that is the subject of
the application for a homeowner insurance policy or the consumer
applying for a homeowner insurance policy.
(29) 'Nonaffiliated third party' means any person except:
(a) An affiliate of a licensee;
(b) A person that is employed jointly by a licensee and by a
person that is not an affiliate of the licensee; and
(c) As designated by the director by rule.
(30) 'Payment' includes but is not limited to:
(a) Efforts to obtain premiums or reimbursement;
(b) Determining eligibility or coverage;
(c) Billing activities;
(d) Claims management;
(e) Reviewing health care to determine medical necessity;
(f) Utilization review; and
(g) Disclosures to consumer reporting agencies.
(31)(a) 'Personal financial information' means:
(A) Information that is identifiable with an individual,
gathered in connection with an insurance transaction from which
judgments can be made about the individual's character, habits,
avocations, finances, occupations, general reputation, credit or
any other personal characteristics; or
(B) An individual's name, address and policy number or similar
form of access code for the individual's policy.
(b) 'Personal financial information' does not mean information
that a licensee has a reasonable basis to believe is lawfully
made available to the general public from federal, state or local
government records, widely distributed media or disclosures to
the public that are required by federal, state or local law.
(32) 'Personal information' means:
(a) Personal financial information;
(b) Individually identifiable health information; or
(c) Protected health information.
(33) 'Personal insurance' means the following types of
insurance products or services that are to be used primarily for
personal, family or household purposes:
(a) Private passenger automobile coverage;
(b) Homeowner, mobile homeowners, manufactured homeowners,
condominium owners and renters coverage;
(c) Personal dwelling property coverage;
(d) Personal liability and theft coverage, including excess
personal liability and theft coverage; and
(e) Personal inland marine coverage.
(34) 'Personal representative' includes but is not limited to:
(a) A person appointed as a guardian under ORS 125.305,
419B.370, 419C.481 or 419C.555 with authority to make medical and
health care decisions;
(b) A person appointed as a health care representative under
ORS 127.505 to 127.660 or 127.700 to 127.737 to make health care
decisions or mental health treatment decisions;
(c) A person appointed as a personal representative under ORS
chapter 113; and
(d) A person described in ORS 746.611.
(35) 'Policyholder' means a person who:
(a) In the case of individual policies of life or health
insurance, is a current policyowner;
(b) In the case of individual policies of other kinds of
insurance, is currently a named insured; or
(c) In the case of group policies of insurance under which
coverage is individually underwritten, is a current certificate
holder.
(36) 'Pretext interview' means an interview wherein the
interviewer, in an attempt to obtain personal information about a
natural person, does one or more of the following:
(a) Pretends to be someone the interviewer is not.
(b) Pretends to represent a person the interviewer is not in
fact representing.
(c) Misrepresents the true purpose of the interview.
(d) Refuses upon request to identify the interviewer.
(37) 'Privileged information' means information that is
identifiable with an individual and that:
(a) Relates to a claim for insurance benefits or a civil or
criminal proceeding involving the individual; and
(b) Is collected in connection with or in reasonable
anticipation of a claim for insurance benefits or a civil or
criminal proceeding involving the individual.
(38)(a) 'Protected health information' means individually
identifiable health information that is transmitted or maintained
in any form of electronic or other medium by a covered entity.
(b) 'Protected health information' does not mean individually
identifiable health information in:
(A) Education records covered by the federal Family Educational
Rights and Privacy Act (20 U.S.C. 1232g);
(B) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); or
(C) Employment records held by a covered entity in its role as
employer.
(39) 'Residual market mechanism' means an association,
organization or other entity involved in the insuring of risks
under ORS 735.005 to 735.145, 737.312 or other provisions of the
Insurance Code relating to insurance applicants who are unable to
procure insurance through normal insurance markets.
(40) 'Termination of insurance coverage' or 'termination of an
insurance policy' means either a cancellation or a nonrenewal of
an insurance policy, in whole or in part, for any reason other
than the failure of a premium to be paid as required by the
policy.
(41) 'Treatment' includes but is not limited to:
(a) The provision, coordination or management of health care;
and
(b) Consultations and referrals between health care providers.
SECTION 64. ORS 748.603 is amended to read:
748.603. (1) Societies are governed by this chapter and are
exempt from all other provisions of the insurance laws of this
state unless expressly designated therein, or unless specifically
made applicable by this chapter.
(2) ORS 705.137, 705.139, 731.004 to 731.026, 731.036 to
731.136, 731.146 to 731.156, 731.162, 731.166, 731.170, 731.216
to 731.268, 731.296, 731.324, 731.328, 731.354, 731.356, 731.358,
731.378, 731.380, 731.381, 731.382, 731.385, 731.386, 731.390,
731.394, 731.396, 731.398, 731.402, 731.406, 731.410, 731.422 to
731.434, 731.446 to 731.454, 731.488, 731.504, 731.508, 731.509,
731.510, 731.511, 731.512, 731.592, 731.594, 731.730, 731.731,
731.735, 731.737, 731.750, 731.804, 731.844 to 731.992, 731.870,
732.245, 732.250, 732.320, 732.325, 733.010 to 733.050, 733.080,
733.140 to 733.210, 733.220, 733.510, 733.652 to 733.658, 733.730
to 733.750, { - 735.600 to 735.650, - } 742.001, 742.003,
742.005, 742.007, 742.009, 742.013 to 742.021, 742.028, 742.038,
742.041, 742.046, 742.051, 742.150 to 742.162 and 744.700 to
744.740 and ORS chapters 734, 743 and 743A apply to fraternal
benefit societies to the extent not inconsistent with the express
provisions of this chapter.
(3) For the purposes of this subsection and subsection (2) of
this section, fraternal benefit societies shall be deemed
insurers, and benefit certificates issued by fraternal benefit
societies shall be deemed policies.
(4) Every society authorized to do business in this state shall
be subject to the provisions of ORS chapter 746 relating to
unfair trade practices. However, nothing in ORS chapter 746 shall
be construed as applying to or affecting the right of any society
to determine its eligibility requirements for membership, or be
construed as applying to or affecting the offering of benefits
exclusively to members or persons eligible for membership in the
society by a subsidiary corporation or affiliated organization of
the society.
SECTION 65. 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.
(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) - } { + (i) + } ORS 743.680 to 743.689.
{ - (k) - } { + (j) + } ORS 744.700 to 744.740.
{ - (L) - } { + (k) + } ORS 743.730 to 743.773.
{ - (m) - } { + (L) + } 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 66. ORS 705.145 is amended to read:
705.145. (1) There is created in the State Treasury a fund to
be known as the Consumer and Business Services Fund, separate and
distinct from the General Fund. All moneys collected or received
by the Department of Consumer and Business Services, except
moneys
{ - collected pursuant to ORS 735.612 and those moneys
required - } to be paid into the Workers' Benefit Fund, shall be
paid into the State Treasury and credited to the Consumer and
Business Services Fund. Moneys in the fund may be invested in the
same manner as other state moneys and any interest earned shall
be credited to the fund.
(2) The department shall keep a record of all moneys deposited
in the Consumer and Business Services Fund that shall indicate,
by separate account, the source from which the moneys are
derived, the interest earned and the activity or program against
which any withdrawal is charged.
(3) If moneys credited to any one account are withdrawn,
transferred or otherwise used for purposes other than the program
or activity for which the account is established, interest shall
accrue on the amount withdrawn from the date of withdrawal and
until such funds are restored.
(4) Moneys in the fund are continuously appropriated to the
department for its administrative expenses and for its expenses
in carrying out its functions and duties under any provision of
law.
(5) Except as provided in ORS 705.165, it is the intention of
the Legislative Assembly that the performance of the various
duties and functions of the department in connection with each of
its programs shall be financed by the fees, assessments and
charges established and collected in connection with those
programs.
(6) There is created by transfer from the Consumer and Business
Services Fund a revolving administrative account in the amount of
$100,000. The revolving account shall be disbursed by checks or
orders issued by the director or the Workers' Compensation Board
and drawn upon the State Treasury, to carry on the duties and
functions of the department and the board. All checks or orders
paid from the revolving account shall be reimbursed by a warrant
drawn in favor of the department charged against the Consumer and
Business Services Fund and recorded in the appropriate subsidiary
record.
(7) For the purposes of ORS chapter 656, the revolving account
created pursuant to subsection (6) of this section may also be
used to:
(a) Pay compensation benefits; and
(b) Refund to employers amounts paid to the Consumer and
Business Services Fund in excess of the amounts required by ORS
chapter 656.
(8) Notwithstanding subsections (2), (3) and (5) of this
section and except as provided in ORS 455.220 (1), the moneys
derived pursuant to ORS 446.003 to 446.200, 446.210, 446.225 to
446.285, 446.395 to 446.420, 446.566 to 446.646, 446.666 to
446.756 and 455.220 (1) and deposited to the fund, interest
earned on those moneys and withdrawals of moneys for activities
or programs under ORS 446.003 to 446.200, 446.210, 446.225 to
446.285, 446.395 to 446.420, 446.566 to 446.646 and 446.666 to
446.756, or education and training programs pertaining thereto,
must be assigned to a single account within the fund.
(9) Notwithstanding subsections (2), (3) and (5) of this
section, the moneys derived pursuant to ORS 455.240 or 460.370 or
from state building code or specialty code program fees for which
the amount is established by department rule pursuant to ORS
455.020 (2) and deposited to the fund, interest earned on those
moneys and withdrawals of moneys for activities or programs
described under ORS 455.240 or 446.566 to 446.646, 446.666 to
446.756 and 460.310 to 460.370, structural or mechanical
specialty code programs or activities for which a fee is
collected under ORS 455.020 (2), or programs described under
subsection (10) of this section that provide training and
education for persons employed in producing, selling, installing,
delivering or inspecting manufactured structures or manufactured
dwelling parks or recreation parks, must be assigned to a single
account within the fund.
(10) Notwithstanding ORS 279.835 to 279.855 and ORS chapters
279A and 279B, the department may, after consultation with the
appropriate specialty code advisory boards established under ORS
455.132, 455.135, 455.138, 480.535 and 693.115, contract for
public or private parties to develop or provide training and
education programs relating to the state building code and
associated licensing or certification programs.
SECTION 67. 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
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
743.951 and former enrollees shall be eligible for portability
coverage in accordance with ORS 735.616; - }
{ - (h) - } { + (g) + } 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) - } { + (h) + } Each public body in a joint
insurance program is liable only to its own employees and no
others for benefits under the 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 self-insurance program for tort liability or property
damage that is established by two or more affordable housing
entities and that complies with the same requirements that public
bodies must meet under ORS 30.282 (6). As used in this
subsection:
(a) 'Affordable housing' means housing projects in which some
of the dwelling units may be purchased or rented, with or without
government assistance, on a basis that is affordable to
individuals of low income.
(b) 'Affordable housing entity' means any of the following:
(A) A housing authority created under the laws of this state or
another jurisdiction and any agency or instrumentality of a
housing authority, including but not limited to a legal entity
created to conduct a self-insurance program for housing
authorities that complies with ORS 30.282 (6).
(B) A nonprofit corporation that is engaged in providing
affordable housing.
(C) A partnership or limited liability company that is engaged
in providing affordable housing and that is affiliated with a
housing authority described in subparagraph (A) of this paragraph
or a nonprofit corporation described in subparagraph (B) of this
paragraph if the housing authority or nonprofit corporation:
(i) Has, or has the right to acquire, a financial or ownership
interest in the partnership or limited liability company;
(ii) Has the power to direct the management or policies of the
partnership or limited liability company;
(iii) Has entered into a contract to lease, manage or operate
the affordable housing owned by the partnership or limited
liability company; or
(iv) Has any other material relationship with the partnership
or limited liability company.
(11) A community-based health care initiative approved by the
Administrator of the Office for Oregon Health Policy and Research
under ORS 735.723 operating a community-based health care
improvement program approved by the administrator.
{ +
APPROPRIATION + }
SECTION 68. { + There is appropriated to the Oregon Health
Authority for deposit in the Affordable Health Care for All
Oregon Fund established by section 21 of this 2011 Act, for the
biennium beginning July 1, 2011, out of the General Fund, the
amount of $_______ for the purpose of establishing the Affordable
Health Care for All Oregon Board and developing the Affordable
Health Care for All Oregon Plan. + }
{ +
REPEALS + }
SECTION 69. { + ORS 413.064 and 413.075 and section 17,
chapter 595, Oregon Laws 2009, are repealed. + }
SECTION 70. { + ORS 414.825, 414.826, 414.828, 414.831,
414.839, 414.841, 414.842, 414.844, 414.846, 414.848, 414.851,
414.852, 414.854, 414.856, 414.858, 414.861, 414.862, 414.864,
414.866, 414.868, 414.870, 414.872, 735.600, 735.605, 735.610,
735.612, 735.614, 735.615, 735.616, 735.620, 735.625, 735.630,
735.635, 735.640, 735.645, 735.650, 735.700, 735.701, 735.702,
735.703, 735.705, 735.707, 735.709, 735.710, 735.711, 735.712,
735.714 and 746.222 and sections 1, 2, 3, 4 and 5, chapter 47,
Oregon Laws 2010, are repealed. + }
{ +
CAPTIONS + }
SECTION 71. { + The unit captions used in this 2011 Act are
provided only for the convenience of the reader and do not become
part of the statutory law of this state or express any
legislative intent in the enactment of this 2011 Act. + }
{ +
OPERATIVE DATE + }
SECTION 72. { + Sections 1 and 25 to 37 of this 2011 Act, the
amendments to ORS 65.957, 192.519, 243.105, 243.125, 243.135,
243.215, 243.860, 243.864, 243.866, 243.868, 291.055, 413.032,
413.201, 414.041, 414.231, 705.145, 731.036, 734.790, 743.402,
743.730, 743.748, 743.766, 743.767, 743.769, 743A.001, 744.704,
746.600, 748.603 and 750.055 and section 1, chapter 867, Oregon
Laws 2009, by sections 13 to 20, 38 to 40, 44, 46 to 49 and 53 to
67 of this 2011 Act and the repeal of ORS 414.825, 414.826,
414.828, 414.831, 414.839, 414.841, 414.842, 414.844, 414.846,
414.848, 414.851, 414.852, 414.854, 414.856, 414.858, 414.861,
414.862, 414.864, 414.866, 414.868, 414.870, 414.872, 735.600,
735.605, 735.610, 735.612, 735.614, 735.615, 735.616, 735.620,
735.625, 735.630, 735.635, 735.640, 735.645, 735.650, 735.700,
735.701, 735.702, 735.703, 735.705, 735.707, 735.709, 735.710,
735.711, 735.712, 735.714 and 746.222 and sections 1, 2, 3, 4 and
5, chapter 47, Oregon Laws 2010, by section 70 of this 2011 Act
become operative January 2, 2014. + }
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