76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
Enrolled
Senate Bill 104
Printed pursuant to Senate Interim Rule 213.28 by order of the
President of the Senate in conformance with presession filing
rules, indicating neither advocacy nor opposition on the part
of the President (at the request of Governor John A. Kitzhaber
for Oregon Health Authority)
CHAPTER ................
AN ACT
Relating to functions of the Oregon Health Authority; creating
new provisions; amending ORS 414.841, 414.842, 414.844,
414.864, 414.866, 414.868, 431.385, 433.815, 433.820, 443.005,
443.019, 443.035, 443.045, 443.085, 443.100, 443.105, 443.355,
735.610, 735.615, 735.700, 735.702 and 735.710 and section 1,
chapter 803, Oregon Laws 2009, and section 2, chapter 47,
Oregon Laws 2010; repealing ORS 735.714; and declaring an
emergency.
Be It Enacted by the People of the State of Oregon:
{ +
FAMILY HEALTH INSURANCE ASSISTANCE PROGRAM + }
SECTION 1. ORS 414.841 is amended to read:
414.841. For purposes of ORS 414.841 to 414.864:
(1) 'Carrier' has the meaning given that term in ORS 735.700.
(2) 'Eligible individual' means an individual who:
(a) Is a resident of the State of Oregon;
(b) Is not eligible for Medicare;
(c) Either has been without health benefit plan coverage for a
period of time established by the Office of Private Health
Partnerships, or meets exception criteria established by the
office;
(d) Except as otherwise provided by the office, has family
income { - less than - } { + that is at or below + }200
percent of the federal poverty level; { + and + }
{ - (e) Has investments and savings less than the limit
established by the office; and - }
{ - (f) - } { + (e) + } Meets other eligibility criteria
established by the office.
{ - (3)(a) - } { + (3) + } 'Family' means { - : - }
{ + an eligible individual and all other related individuals, as
prescribed by the office by rule. + }
{ - (A) A single individual; - }
{ - (B) An adult and the adult's spouse; - }
{ - (C) An adult and the adult's spouse, all unmarried,
dependent children under 23 years of age, including adopted
children, children placed for adoption and children under the
Enrolled Senate Bill 104 (SB 104-INTRO) Page 1
legal guardianship of the adult or the adult's spouse, and all
dependent children of a dependent child; or - }
{ - (D) An adult and the adult's unmarried, dependent
children under 23 years of age, including adopted children,
children placed for adoption and children under the legal
guardianship of the adult, and all dependent children of a
dependent child. - }
{ - (b) A family includes a dependent elderly relative or a
dependent adult child with a disability who meets the criteria
established by the office and who lives in the home of the adult
described in paragraph (a) of this subsection. - }
(4)(a) 'Health benefit plan' means a policy or certificate of
group or individual health insurance, as defined in ORS 731.162,
providing payment or reimbursement for hospital, medical and
surgical expenses { + or for dental care expenses + }. 'Health
benefit plan' includes a health care service contractor or health
maintenance organization subscriber contract, the Oregon Medical
Insurance Pool and any plan provided by a less than fully insured
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, student accident and health insurance, long term care
insurance, hospital indemnity only, { - dental only, - }
vision only, coverage issued as a supplement to liability
insurance, insurance arising out of a workers' compensation or
similar law, automobile medical payment insurance, insurance
under which the benefits are payable with or without regard to
fault and that is legally required to be contained in any
liability insurance policy or equivalent self-insurance or
coverage obtained or provided in another state but not available
in Oregon.
(5) 'Income' means gross income in cash or kind available to
the applicant or the applicant's family. Income does not include
earned income of the applicant's children or income earned by a
spouse if there is a legal separation.
{ - (6) 'Investment and savings' means cash, securities as
defined in ORS 59.015, negotiable instruments as defined in ORS
73.0104 and such similar investments or savings as the office may
establish that are available to the applicant or the applicant's
family to contribute toward meeting the needs of an applicant or
eligible individual. - }
{ - (7) 'Medicaid' means medical assistance provided under 42
U.S.C. section 1396a (section 1902 of the Social Security
Act). - }
{ - (8) - } { + (6) + } 'Resident' means an individual who
meets the residency requirements established by rule by the
office.
{ - (9) - } { + (7) + } 'Subsidy' means payment or
reimbursement to an eligible individual toward the purchase of a
health benefit plan, and may include a net billing arrangement
with carriers or a prospective or retrospective payment for
health benefit plan premiums and eligible copayments or
deductible expenses directly related to the eligible individual.
{ - (10) - } { + (8) + } ' { - Third-party - } { + Third
party + } administrator' means any insurance company or other
Enrolled Senate Bill 104 (SB 104-INTRO) Page 2
entity licensed under the Insurance Code to administer health
insurance benefit programs.
SECTION 2. ORS 414.842 is amended to read:
414.842. (1) There is established the Family Health Insurance
Assistance Program in the Office of Private Health Partnerships.
The purpose of the program is to remove economic barriers to
health insurance coverage for residents of the State of Oregon
with family income { - less than - } { + that is at or below
+ }200 percent of the federal poverty level { - , and
investment and savings less than the limit established by the
office, - } while encouraging individual responsibility,
promoting health benefit plan coverage of children, building on
the private sector health benefit plan system and encouraging
employer and employee participation in employer-sponsored health
benefit plan coverage.
(2) The Office of Private Health Partnerships shall be
responsible for the implementation and operation of the Family
Health Insurance Assistance Program. The Administrator of the
Office for Oregon Health Policy and Research, in consultation
with the Oregon Health Policy Board, shall make recommendations
to the Office of Private Health Partnerships regarding program
policy, including but not limited to eligibility requirements,
assistance levels, benefit criteria and carrier participation.
(3) The Office of Private Health Partnerships may contract with
one or more { - third-party - } { + third party + }
administrators to administer one or more components of the Family
Health Insurance Assistance Program. Duties of a
{ - third-party - } { + third party + } administrator may
include but are not limited to:
(a) Eligibility determination;
(b) Data collection;
(c) Assistance payments;
(d) Financial tracking and reporting; and
(e) Such other services as the office may deem necessary for
the administration of the program.
(4) If the office decides to enter into a contract with a
{ - third-party - } { + third party + } administrator
pursuant to subsection (3) of this section, the office shall
engage in competitive bidding. The office shall evaluate bids
according to criteria established by the office, including but
not limited to:
(a) The bidder's proven ability to administer a program of the
size of the Family Health Insurance Assistance Program;
(b) The efficiency of the bidder's payment procedures;
(c) The estimate provided of the total charges necessary to
administer the program; and
(d) The bidder's ability to operate the program in a
cost-effective manner.
SECTION 3. ORS 414.844 is amended to read:
414.844. (1) To enroll in the Family Health Insurance
Assistance Program established in ORS 414.841 to 414.864, an
applicant shall submit a written application to the Office of
Private Health Partnerships or to the { - third-party - } { +
third party + } administrator contracted by the office to
administer the program pursuant to ORS 414.842 in the form and
manner prescribed by the office. Except as provided in ORS
414.848, if the applicant qualifies as an eligible individual,
the applicant shall either be enrolled in the program or placed
on a waiting list for enrollment.
Enrolled Senate Bill 104 (SB 104-INTRO) Page 3
(2) After an eligible individual has enrolled in the program,
the individual shall remain eligible for enrollment for the
period of time established by the office.
(3) After an eligible individual has enrolled in the program,
the office or { - third-party - } { + third party + }
administrator shall issue subsidies in an amount determined
pursuant to ORS 414.846 to either the eligible individual or to
the carrier designated by the eligible individual, subject to the
following restrictions:
(a) Subsidies may not be issued to an eligible individual
unless all eligible children, if any, in the eligible
individual's family are covered under a health benefit plan or
{ - Medicaid - } { + medical assistance + }.
(b) Subsidies may not be used to subsidize premiums on a health
benefit plan whose premiums are wholly paid by the eligible
individual's employer without contribution from the employee.
(c) Such other restrictions as the office may adopt.
(4) The office may issue subsidies to an eligible individual in
advance of a purchase of a health benefit plan { + or a dental
plan + }.
(5) To remain eligible for a subsidy, an eligible individual
must enroll in a group health benefit plan if a plan is available
to the eligible individual through the individual's employment
and the employer makes a monetary contribution toward the cost of
the plan, unless the office implements specific cost or benefit
structure criteria that make enrollment in an individual health
insurance plan more advantageous for the eligible individual.
(6) { - Notwithstanding ORS 414.841 (4)(b), if an eligible
individual is enrolled in a group health benefit plan available
to the eligible individual through the individual's employment
and the employer requires enrollment in both a health benefit
plan and a dental plan, the - } { + An + } individual is
eligible for a subsidy for both { - the - } { + a + } health
benefit plan and { - the - } { + a + } dental plan { + ,
regardless of whether the health benefit plan provides dental
coverage + }.
SECTION 4. ORS 414.864 is amended to read:
414.864. (1) The Office of Private Health Partnerships
{ - may impose sanctions against an individual who violates - }
{ + shall adopt by rule criteria for the recovery of an
overpayment as described in ORS 411.640 of a subsidy incorrectly
paid.
(2) The office may suspend or terminate an enrollee's
participation in the Family Health Insurance Assistance Program
as a sanction for violating + }any provision of ORS 414.841 to
414.864 or rules adopted pursuant thereto { - , including but
not limited to suspension or termination from the Family Health
Insurance Assistance Program and repayment of any subsidy amounts
paid due to the omission or misrepresentation of an applicant or
enrolled individual. Sanctions allowed under this subsection
shall be imposed in the manner prescribed in ORS chapter 183 - }
.
{ - (2) - } { + (3) + } In addition to the sanctions
available pursuant to subsection { - (1) - } { + (2) + } of
this section, the office may impose a civil penalty not to exceed
$1,000 against any individual who violates any provision of ORS
414.841 to 414.864 or rules adopted pursuant thereto.
{ + (4) Sanctions and + }civil penalties imposed pursuant to
this section shall be imposed pursuant to ORS { - 183.745 - }
{ + chapter 183 + }.
Enrolled Senate Bill 104 (SB 104-INTRO) Page 4
SECTION 5. ORS 414.866 is amended to read:
414.866. As used in ORS 414.866 to 414.872:
(1) 'Benefits plan' has the meaning given that term in ORS
735.605.
(2) 'Other costs' means costs incurred by the Oregon Medical
Insurance Pool that are not covered by the premiums received by
the pool for a subsidized member.
{ - (3) 'Premium' has the meaning given that term in ORS
735.700. - }
{ - (4) - } { + (3) + } 'Subsidized member' means a medical
assistance program client who is enrolled in a benefits plan and
who is receiving a subsidy from the Family Health Insurance
Assistance Program established in ORS 414.841 to 414.864.
{ - (5) - } { + (4) + } 'Subsidy' has the meaning given
that term in ORS 414.841.
SECTION 6. ORS 414.868 is amended to read:
414.868. Notwithstanding ORS 735.615 { - (3)(a) and (f) - }
{ + (3)(b) and (g) + }, a subsidized member is eligible for
coverage under ORS 735.600 to 735.650.
{ +
PUBLIC HEALTH + }
SECTION 7. ORS 431.385 is amended to read:
431.385. (1) The local public health authority shall submit an
annual plan to the Oregon Health Authority for performing
services pursuant to ORS 431.375 to 431.385 and 431.416. The
annual plan shall be submitted { - no later than May 1 of each
year or - } on a date { + established by the Oregon Health
Authority by rule or on a date + } mutually agreeable to the
authority and the local public health authority.
(2) If the local public health authority decides not to submit
an annual plan under the provisions of ORS 431.375 to 431.385 and
431.416, the authority shall become the local public health
authority for that county or health district.
(3) The authority shall review and approve or disapprove each
plan. Variances to the local public health plan must be approved
by the authority. In consultation with the Conference of Local
Health Officials, the authority shall establish the elements of a
plan and an appeals process whereby a local health authority may
obtain a hearing if its plan is disapproved.
(4) Each local commission on children and families shall
reference the local public health plan in the local coordinated
comprehensive plan created pursuant to ORS 417.775.
SECTION 8. ORS 433.815 is amended to read:
433.815. { + (1) + } Educational training { + on the
treatment of allergic responses, as + } required by ORS 433.800
to 433.830 { + , + } shall be conducted under the supervision of
a physician licensed under ORS chapter 677 or a nurse
practitioner licensed under ORS chapter 678 to practice in this
state. The training may be conducted by a health care
professional licensed under ORS chapter 678 as delegated by a
supervising professional { + or by an emergency medical
technician meeting the requirements established by the Oregon
Health Authority by rule + }. The curricula shall
{ - minimally - } include { + , at a minimum, + } the following
subjects:
{ - (1) - } { + (a) + } Recognition of the symptoms of
systemic allergic responses to insect stings and other allergens;
{ - (2) Recognition of the symptoms of hypoglycemia; - }
Enrolled Senate Bill 104 (SB 104-INTRO) Page 5
{ - (3) - } { + (b) + } Familiarity with common factors
that are likely to elicit systemic allergic responses { - and
common factors that may induce hypoglycemia - } ;
{ - (4) - } { + (c) + } Proper administration of
{ - a - } { + an intramuscular or + } subcutaneous injection
of epinephrine for severe allergic responses to insect stings and
other specific allergens; { + and + }
{ - (5) Proper administration of a subcutaneous injection of
glucagon for severe hypoglycemia when other treatment has failed
or cannot be initiated; and - }
{ - (6) - } { + (d) + } Necessary follow-up treatment.
{ +
(2) Educational training on the treatment of hypoglycemia, as
required by ORS 433.800 to 433.830, shall be conducted under the
supervision of a physician licensed under ORS chapter 677 or a
nurse practitioner licensed under ORS chapter 678 to practice in
this state. The training may be conducted by a health care
professional licensed under ORS chapter 678 as delegated by a
supervising professional. The curricula shall include, at a
minimum, the following subjects:
(a) Recognition of the symptoms of hypoglycemia;
(b) Familiarity with common factors that may induce
hypoglycemia;
(c) Proper administration of a subcutaneous injection of
glucagon for severe hypoglycemia when other treatment has failed
or cannot be initiated; and
(d) Necessary follow-up treatment. + }
SECTION 9. ORS 433.820 is amended to read:
433.820. A person eligible to receive the training described in
ORS 433.815 must meet the following requirements:
(1) Be { - 21 - } { + 18 + } years of age or older; and
(2) Have, or reasonably expect to have, responsibility for or
contact with at least one other person as a result of the
eligible person's occupational or volunteer status, such as camp
counselors, scout leaders, school personnel, forest rangers, tour
guides or chaperones.
SECTION 10. ORS 443.005 is amended to read:
443.005. As used in ORS 443.005 to 443.105:
{ - (1) 'Authority' means the Oregon Health Authority. - }
{ - (2) - } { + (1) + } 'Caregiver registry' means { - an
agency - } { + a person + } that prequalifies, establishes and
maintains a { - list - } { + roster + } of qualified private
contractor caregivers that is provided to a client { + or the
client's representative + } for { + consideration in the hiring
of an individual to provide + } caregiver services within the
client's place of residence.
{ - (3) - } { + (2) + } 'Home health agency' means a public
or private agency providing coordinated home health services on a
home visiting basis. 'Home health agency' does not include:
(a) Any visiting nurse service or home health service conducted
by and for those who rely upon spiritual means through prayer
alone for healing in accordance with the tenets and practices of
a recognized church or religious denomination.
(b) Those home health services offered by county health
departments outside, and in addition to, programs formally
designated and funded as home health agencies.
{ - (4) - } { + (3) + } 'Home health services' means items
and services furnished to an individual by a home health agency,
or by others under arrangements with such agency, on a visiting
basis, in a place of temporary or permanent residence used as the
Enrolled Senate Bill 104 (SB 104-INTRO) Page 6
individual's home for the purpose of maintaining that individual
at home.
{ - (5) 'Referral agency' means an agency that prequalifies,
coordinates and arranges for home health services within a
client's place of residence. - }
SECTION 11. ORS 443.019 is amended to read:
443.019. (1) The Oregon Health Authority shall conduct an
on-site inspection of a home health agency { - , referral
agency - } and { + a + } caregiver registry prior to licensure
and at least once every three years thereafter.
(2) In lieu of an on-site inspection, the authority may accept
a certification or accreditation from a federal agency or an
accrediting body approved by the authority that the state
licensing standards have been met, if:
(a) The certification or accreditation is recognized by the
authority as addressing the standards and conditions of
participation requirements of the Centers for Medicare and
Medicaid Services and any additional standards set by the
authority;
(b) The agency or registry notifies the authority to
participate in any exit interview conducted by the federal agency
or accrediting body; and
(c) The agency or registry provides copies of all documentation
concerning the certification or accreditation requested by the
authority.
SECTION 12. ORS 443.035 is amended to read:
443.035. (1) The Oregon Health Authority may grant a license to
a home health agency { - , referral agency - } or caregiver
registry for a calendar year, may annually renew a license and
may allow for a change of ownership, upon payment of a fee as
follows:
(a) For a new home health agency:
(A) $1,600; and
(B) An additional $1,600 for each subunit of a parent home
health agency.
(b) For renewal of a home health agency license:
(A) $850; and
(B) An additional $850 for each subunit of a parent home health
agency.
(c) For a change of ownership of a home health agency at a time
other than the annual renewal date:
(A) $500; and
(B) An additional $500 for each subunit of a parent home health
agency.
(d) For a new { - referral agency or - } caregiver registry:
(A) $1,500; and
(B) An additional $750 for each subunit of a { - referral
agency or - } caregiver registry.
(e) For renewal of a { - referral agency or - } caregiver
registry license:
(A) $750; and
(B) An additional $750 for each subunit of a { - referral
agency or - } caregiver registry.
(f) For a change of ownership of a { - referral agency or - }
caregiver registry at a time other than the annual renewal date:
(A) $350; and
(B) An additional $350 for each subunit of a { - referral
agency or - } caregiver registry.
Enrolled Senate Bill 104 (SB 104-INTRO) Page 7
(2) Notwithstanding subsection (1)(c) or (f) of this section,
the fee for a change in ownership shall be $100 if a change in
ownership does not involve:
(a) The majority owner or partner; or
(b) The administrator operating the agency or registry.
(3) All fees received pursuant to subsection (1) of this
section shall be paid over to the State Treasurer and credited to
the Public Health Account. Such moneys are appropriated
continuously to the Oregon Health Authority for the
administration of ORS 443.005 to 443.105.
SECTION 13. ORS 443.045 is amended to read:
443.045. (1) The Oregon Health Authority may deny, suspend or
revoke the license of, or assess a civil penalty against, any
individual, home health agency { - , referral agency - } or
caregiver registry for failure to comply with ORS 443.004 or
443.005 to 443.105, or with the rules of the authority as
authorized by ORS 443.085.
(2) License denials, suspensions and revocations, assessment of
civil penalties, adoption of rules and judicial review thereof
shall be in accordance with ORS chapter 183.
(3) A civil penalty imposed under this section may not exceed
$1,000 per violation and may not total more than $2,000.
(4) All civil penalties recovered under this section shall be
paid into the State Treasury and credited to the Oregon Health
Authority Fund. Moneys credited to the fund under this section
are continuously appropriated to the authority for the
administration of ORS 443.005 to 443.105 and 443.305 to 443.350.
SECTION 14. ORS 443.085 is amended to read:
443.085. The Oregon Health Authority shall adopt rules to
implement ORS 443.005 to 443.105 including, but not limited to:
(1) The qualifications of professional and ancillary personnel
in order to adequately furnish home health services;
(2) Standards for the organization and quality of
{ - patient - } { + client + } care;
(3) Procedures for maintaining records;
(4) Provision for contractual arrangements for professional and
ancillary health services; and
(5) Complaint and inspection procedures.
SECTION 15. ORS 443.100 is amended to read:
443.100. A person may not establish, conduct or maintain a
{ - referral agency or - } caregiver registry, or represent to
the public that the person is a { - referral agency or - }
caregiver registry, without first obtaining a { - referral
agency license or - } caregiver registry license from the Oregon
Health Authority.
SECTION 16. ORS 443.105 is amended to read:
443.105. The Oregon Health Authority may adopt rules governing
{ - referral agencies and - } caregiver registries, including
but not limited to:
(1) The minimum qualifications of individuals whose services
are offered through a { - referral agency or - } caregiver
registry;
(2) Standards for the organization and quality of
{ - patient - } { + client + } care;
(3) Procedures for maintaining records;
(4) Requirements for contractual arrangements for professional
and ancillary services;
(5) Requiring criminal background checks on individuals placed
on a { - caregiver or referral list by a referral agency or - }
{ + roster by a + } caregiver registry { - or on individuals
Enrolled Senate Bill 104 (SB 104-INTRO) Page 8
placed in a client's place of residence by a referral agency or
caregiver registry - } ;
(6) Procedures for complaints against { - referral agencies
and - } caregiver registries; and
(7) Procedures for inspection of { - referral agencies
and - } caregiver registries.
SECTION 17. ORS 443.355 is amended to read:
443.355. (1) Rules adopted by the Oregon Health Authority
pursuant to ORS 443.085 and 443.340 shall include procedures for
the filing of complaints as to the care or services provided by
home health agencies, in-home care agencies { - , referral
agencies - } or caregiver registries that ensure the
confidentiality of the identity of the complainant.
(2) An employee or contract provider with knowledge of a
violation of law or rules of the authority shall use the
reporting procedures established by the home health agency,
in-home care agency { - , referral agency - } or caregiver
registry before notifying the authority or other state agency of
the inappropriate care or violation, unless the employee or
contract provider:
(a) Believes a { - patient's - } { + client's + } health or
safety is in immediate jeopardy; or
(b) Files a complaint in accordance with rules adopted under
subsection (1) of this section.
(3) Information obtained by the authority during an
investigation of a complaint or reported violation under this
section is confidential and not subject to public disclosure
under ORS 192.410 to 192.505. Upon the conclusion of the
investigation, the authority may publicly release a report of its
findings but may not include information in the report that could
be used to identify the complainant or any client of the home
health agency, in-home care agency { - , referral agency - } or
caregiver registry. The authority may use any information
obtained during an investigation in an administrative or judicial
proceeding concerning the licensing of a home health agency,
in-home care agency { - , referral agency - } or caregiver
registry.
(4) As used in this section:
(a) 'Caregiver registry' has the meaning given that term in ORS
443.005.
(b) 'Home health agency' has the meaning given that term in ORS
443.005.
(c) 'In-home care agency' has the meaning given that term in
ORS 443.305.
{ - (d) 'Referral agency' has the meaning given that term in
ORS 443.005. - }
SECTION 18. { + ORS 431.925 to 431.955 are added to and made a
part of ORS 453.605 to 453.800. + }
{ +
OREGON MEDICAL INSURANCE POOL BOARD + }
SECTION 19. ORS 735.610 is amended to read:
735.610. (1) There is created in the Oregon Health Authority
the Oregon Medical Insurance Pool Board. The board shall
establish the Oregon Medical Insurance Pool and otherwise carry
out the responsibilities of the board under ORS 735.600 to
735.650.
(2) The board shall consist of { - nine - } { + 10 + }
individuals, { - seven - } { + eight + } of whom shall be
Enrolled Senate Bill 104 (SB 104-INTRO) Page 9
appointed by the Director of the Oregon Health Authority. The
Director of the Department of Consumer and Business Services or
the director's designee and the Director of the Oregon Health
Authority or the director's designee shall be members of the
board. The chair of the board shall be elected from among the
members of the board. The board shall at all times, to the extent
possible, include at least one representative of a domestic
insurance company licensed to transact health insurance, one
representative of a domestic not-for-profit health care service
contractor, one representative of a health maintenance
organization, one representative of reinsurers and two members of
the general public who are not associated with the medical
profession, a hospital or an insurer. A majority of the voting
members of the board constitutes a quorum for the transaction of
business. An act by a majority of a quorum is an official act of
the board.
(3) The Director of the Oregon Health Authority may fill any
vacancy on the board by appointment.
(4) The board shall have the general powers and authority
{ - granted - } under the laws of this state { + granted + }
to insurance companies with a certificate of authority to
transact health insurance and the specific authority to:
(a) Enter into such contracts as are necessary or proper to
carry out the provisions and purposes of ORS 735.600 to 735.650
including the authority to enter into contracts with similar
pools of other states for the joint performance of common
administrative functions, or with persons or other organizations
for the performance of administrative functions;
(b) Recover any assessments for, on behalf of, or against
insurers;
(c) Take such legal action as is necessary to avoid the payment
of improper claims against the pool or the coverage provided by
or through the pool;
(d) Establish appropriate rates, rate schedules, rate
adjustments, expense allowances, insurance producers' referral
fees, claim reserves or formulas and perform any other actuarial
function appropriate to the operation of the pool. Rates may not
be unreasonable in relation to the coverage provided, the risk
experience and expenses of providing the coverage. Rates and rate
schedules may be adjusted for appropriate risk factors such as
age and area variation in claim costs and shall take into
consideration appropriate risk factors in accordance with
established actuarial and underwriting practices;
(e) Issue policies of insurance in accordance with the
requirements of ORS 735.600 to 735.650;
(f) Appoint from among insurers appropriate actuarial and other
committees as necessary to provide technical assistance in the
operation of the pool, policy and other contract design, and any
other function within the authority of the board;
(g) Seek advances to effect the purposes of the pool; and
(h) Establish rules, conditions and procedures for reinsuring
risks under ORS 735.600 to 735.650.
(5) Each member of the board is entitled to compensation and
expenses as provided in ORS 292.495.
(6) The Director of the Oregon Health Authority shall adopt
rules, as provided under ORS chapter 183, implementing policies
recommended by the board for the purpose of carrying out ORS
735.600 to 735.650.
(7) In consultation with the board, the Director of the Oregon
Health Authority shall employ such staff and consultants as may
Enrolled Senate Bill 104 (SB 104-INTRO) Page 10
be necessary for the purpose of carrying out responsibilities
under ORS 735.600 to 735.650.
SECTION 20. ORS 735.615 is amended to read:
735.615. (1) Except as provided in subsection (3) of this
section, a person who is a resident of this state, as defined by
the Oregon Medical Insurance Pool Board, is eligible for medical
pool coverage if:
(a) An insurer, or an insurance company with a certificate of
authority in any other state, has made within a time frame
established by the board an adverse underwriting decision, as
defined in ORS 746.600 (1)(a)(A), (B) or (D), on individual
medical insurance for health reasons while the person was a
resident;
(b) The person has a history of any medical or health
conditions on the list adopted by the board under subsection (2)
of this section;
(c) The person is a spouse or dependent of a person described
in paragraph (a) or (b) of this subsection; or
(d) The person is eligible for the credit for health insurance
costs under section 35 of the federal Internal Revenue Code, as
amended and in effect on December 31, 2004.
(2) The board may adopt a list of medical or health conditions
for which a person is eligible for pool coverage without applying
for individual medical insurance pursuant to this section.
(3) A person is not eligible for coverage under ORS 735.600 to
735.650 if:
(a) { - Except as provided in ORS 735.625 (3)(c), the person
is eligible to receive health services as defined in ORS 414.705
that meet or exceed those adopted by the board or - } { +
Except as provided in ORS 735.625 (3) and subsection (5) of this
section, the person + } is eligible for Medicare;
{ + (b) The person is eligible to receive health services as
defined in ORS 414.705 that meet or exceed those adopted by the
board; + }
{ - (b) - } { + (c) + } The person has terminated coverage
in the pool within the last 12 months and the termination was
for:
(A) A reason other than becoming eligible to receive health
services as defined in ORS 414.705; or
(B) A reason that does not meet exception criteria established
by the board;
{ - (c) - } { + (d) + } The person has exceeded the maximum
lifetime benefit established by the board;
{ - (d) - } { + (e) + } The person is an inmate of or a
patient in a public institution named in ORS 179.321;
{ - (e) - } { + (f) + } The person has, on the date of
issue of coverage by the board, coverage under health insurance
or a self-insurance arrangement that is substantially equivalent
to coverage under ORS 735.625; or
{ - (f) - } { + (g) + } The person has the premiums paid or
reimbursed by a public entity or a health care provider, reducing
the financial loss or obligation of the payer.
(4) A person applying for coverage shall establish initial
eligibility by providing evidence that the board requires.
(5)(a) Notwithstanding ORS 735.625 (4)(c) { - and subsection
(3)(a) of this section - } , if a person { + :
(A) + } Becomes eligible for Medicare after being enrolled in
the pool for a period of time as determined by the board by rule,
that person may continue coverage within the pool as secondary
coverage to Medicare.
Enrolled Senate Bill 104 (SB 104-INTRO) Page 11
{ + (B) Is eligible for Medicare but is not yet eligible to
enroll in Medicare Parts B and D, the individual may receive
coverage under the pool until enrolled in Medicare Parts B and
D. + }
(b) The board may adopt rules concerning the terms and
conditions for the coverage provided under paragraph (a) of this
subsection.
(6) The board may adopt rules to establish additional
eligibility requirements for a person described in subsection
{ - (1)(d) - } { + (1)(e) + } of this section.
SECTION 21. Section 1, chapter 803, Oregon Laws 2009, is
amended to read:
{ + Sec. 1. + } Notwithstanding ORS 735.620, the Oregon
Medical Insurance Pool Board is authorized to extend the
three-year period of service for no more than an additional
{ - 24 - } { + 36 + } months, on terms mutually agreed upon
with an insurer that is administering the insurance program or
components of the insurance program pursuant to ORS 735.620 on
{ - the effective date of this 2009 Act - } { + July 23,
2009 + }.
SECTION 22. Section 2, chapter 47, Oregon Laws 2010, is amended
to read:
{ + Sec. 2. + } (1) The Temporary High Risk Pool Program is
established to ensure health insurance coverage for individuals
who are uninsured and are not enrolled in the Oregon Medical
Insurance Pool or other publicly funded medical assistance.
(2) The program shall be administered by the Oregon Medical
Insurance Pool Board created by ORS 735.610. The board shall
adopt rules for the program that are designed to obtain the
maximum level of federal funding. The rules shall establish:
(a) Eligibility criteria for enrollment in the program;
(b) Health care benefits available through the program;
(c) The cost of premiums for participation in the program; and
(d) Other enrollment or benefit coverage conditions for the
program.
(3) The board may limit enrollment in the program based on the
anticipated federal funding and enrollee premium payments.
{ + (4) The board has the authority to enter into contracts
as necessary or proper to carry out this section. + }
{ +
OFFICE OF PRIVATE HEALTH PARTNERSHIPS + }
SECTION 23. ORS 735.700 is amended to read:
735.700. As used in ORS 735.700 to 735.714, unless the context
requires otherwise:
(1) '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.
{ - (2) 'Eligible employee' means an employee of an employer
who is employed by the employer for an average of at least 17.5
hours per week who elects to participate in one of the group
benefit plans provided through action of the Office of Private
Health Partnerships, and sole proprietors, business partners, and
limited partners. The term does not include individuals: - }
{ - (a) Engaged as independent contractors. - }
{ - (b) Whose periods of employment are on an intermittent or
irregular basis. - }
Enrolled Senate Bill 104 (SB 104-INTRO) Page 12
{ - (c) Who have been employed by the employer for a period
of time established by the employer or for fewer than 90 days,
whichever is less. - }
{ - (3) - } { + (2) + } 'Family member' { - means an
eligible employee's spouse, any unmarried child or stepchild
within age limits and other conditions imposed by the office with
regard to unmarried children or stepchildren, or any other
dependents eligible under the terms of the health benefit plan
selected by the employee's employer - } { + means one of the
related individuals within a family as defined in ORS
414.841 + }.
{ - (4) - } { + (3) + } 'Health benefit plan' { - means a
contract for group medical, surgical, hospital or any other
remedial care recognized by state law and related services and
supplies - } { + has the meaning given that term in ORS
414.841 + }.
{ - (5) 'Premium' means the monthly or other periodic charge
for a health benefit plan. - }
{ - (6) 'Small employer' means a person, firm, corporation,
partnership or association actively engaged in business that, on
at least 50 percent of its working days during the preceding
year, employed no more than 50 eligible employees and no fewer
than two eligible employees, the majority of whom are employed
within this state, and in which a bona fide partnership or
employer-employee relationship exists. 'Small employer' includes
corporations that are eligible to file a consolidated tax return
pursuant to ORS 317.715. - }
SECTION 24. ORS 735.702 is amended to read:
735.702. To increase access to health insurance and health
care, the Office of Private Health Partnerships shall provide:
(1) Information about health benefit plans and the premiums
charged for those plans to self-employed individuals and
{ - small - } employers in Oregon;
(2) Direct assistance to health insurance producers and health
insurance consumers regarding health benefit plans; { + and + }
(3) A central source for information about resources for health
care and health insurance { + . + } { - ; and - }
{ - (4) Health benefit plans for small employers that have
not provided a group health benefit plan for eligible employees
for a period of at least one year. - }
SECTION 25. ORS 735.710 is amended to read:
735.710. (1) In carrying out its duties under ORS 414.841 to
414.864 and 735.700 to 735.714, the Office of Private Health
Partnerships { - shall - } { + may + }:
(a) Enter into contracts for administration of ORS 414.841 to
414.864 and 735.700 to 735.714, including collection of premiums
and paying carriers.
(b) Retain consultants and employ staff.
(c) Enter into contracts with carriers or health care providers
for health benefit plans { + for individuals and employers + },
including contracts where final payment may be reduced if usage
is below a level fixed in the contract.
{ - (d) Set premium rates for eligible employees and small
employers. - }
{ - (e) - } { + (d) + } Perform other duties to provide
low-cost health benefit plans of types likely to be purchased by
{ + individuals and + }
{ - small - } employers.
Enrolled Senate Bill 104 (SB 104-INTRO) Page 13
{ - (f) Establish contributions to be paid by small employers
toward the premiums incurred on behalf of covered eligible
employees. - }
{ - (g) - } { + (2) The office shall + } establish
procedures by rule for the publication or release of aggregate
data relating to:
{ - (A) - } { + (a) + } Applicants for enrollment and
persons enrolled in the Family Health Insurance Assistance
Program;
{ - (B) - } { + (b) + } Health benefit plans for
{ - small - } { + individuals and + } employers offered by the
office; and
{ - (C) - } { + (c) + } Other programs operated by the
office.
{ + (3) With respect to health benefit plans contracted for
or certified by the office under ORS 414.841 to 414.864 or
735.700 to 735.714, the office: + }
{ - (2) - } { + (a) + } { - Notwithstanding any other
health benefit plan contracted for and offered by the office, the
office - } Shall contract for { - a - } { + or certify + }
health benefit { - plan or - } plans best designed to meet the
needs and provide for the welfare of { + individuals, + }
{ - eligible - } employees and { - small - } employers.
{ - (3) - } { + (b) + } { - The office - } May approve
more than one carrier for each type of plan contracted for
{ - and offered - } { + or certified + }, but the number of
carriers shall be held to a number consistent with adequate
service to { - eligible employees and family members - } { +
enrollees + }.
{ + (c) May approve premium rates for health benefit plans
for individuals and employers and may establish contributions to
be paid by employers toward the premiums incurred on behalf of
covered employees. + }
{ - (4) - } { + (d) Shall, + } where appropriate for a
contracted and offered health benefit plan, { - the office
shall - } provide options under which an { - eligible - }
employee may arrange coverage for family members of the employee.
{ - (5) - } { + (e) + } { - In developing any health
benefit plan, the office - } May provide an option of additional
coverage for { - eligible - } employees and family members at
an additional cost or premium.
{ - (6) - } { + (f) Shall, by rule, establish a method for
all enrollees to + }transfer { - of - } enrollment from one
health benefit plan to another { - shall be open to all
eligible employees and family members under rules adopted by the
office - } .
{ - (7) - } { + (g) + } { - If the office requests less
health care service or benefit - } { + May require coverage of
fewer health care services or benefits + } than is otherwise
required by state law { - , a carrier is not required to offer
such service or benefit - } .
{ - (8) - } { + (h) Shall require + } health benefit plans
{ - for small employers contracted for and offered - } { +
certified + } by the office { + for the Family Health Insurance
Assistance Program or offered in the private health option under
ORS 414.826 to + } { - must - } { + + }provide a sufficient
level of benefits to be eligible for a subsidy under ORS 414.844.
{ - (9) - } { + (4) + } The office may employ whatever
means are reasonably necessary to carry out the purposes of ORS
414.841 to 414.864 and 735.700 to 735.714. Such authority
Enrolled Senate Bill 104 (SB 104-INTRO) Page 14
includes but is not limited to authority to seek clarification,
amendment, modification, suspension or termination of any
agreement { + , + } { - or - } contract { + or
certification + } that in the office's judgment requires such
action.
SECTION 26. { + ORS 735.714 is repealed. + }
{ +
UNIT CAPTIONS + }
SECTION 27. { + 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. + }
{ +
EMERGENCY CLAUSE + }
SECTION 28. { + This 2011 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2011 Act takes effect on
its passage. + }
----------
Passed by Senate February 10, 2011
.............................................................
Robert Taylor, Secretary of Senate
.............................................................
Peter Courtney, President of Senate
Passed by House May 11, 2011
.............................................................
Bruce Hanna, Speaker of House
.............................................................
Arnie Roblan, Speaker of House
Enrolled Senate Bill 104 (SB 104-INTRO) Page 15
Received by Governor:
......M.,............., 2011
Approved:
......M.,............., 2011
.............................................................
John Kitzhaber, Governor
Filed in Office of Secretary of State:
......M.,............., 2011
.............................................................
Kate Brown, Secretary of State
Enrolled Senate Bill 104 (SB 104-INTRO) Page 16