68th OREGON LEGISLATIVE ASSEMBLY--1995 Regular Session
SA to SB 979
LC 1591
SENATE AMENDMENTS TO
SENATE BILL 979
By COMMITTEE ON HEALTH AND HUMAN SERVICES
May 18
On ****************************page 1 of the printed bill, line
2, before the period insert '; creating new provisions; and
amending ORS 750.055 and 750.333'.
Delete lines 4 through 31 and ****************************pages
2 through 4 and insert:
' **************************** { + SECTION 1. + } { + As
used in sections 1 to 7 of this Act:
' (1) 'Independent practice association' means a corporation
wholly owned by providers, or whose membership consists entirely
of providers, formed for the sole purpose of contracting with
insurers for the provision of health care services to enrollees,
or with employers for the provision of health care services to
employees, or with a group, as described in ORS 743.522, to
provide health care services to group members.
' (2) 'Insurer' means an insurer, as defined in ORS 731.106,
providing health insurance, as defined in ORS 731.162. For
purposes of this Act, 'insurer' also includes a health care
service contractor as defined in ORS 750.005.
' (3) 'Medical services contract' means a contract between an
insurer and an independent practice association, between an
insurer and a provider, between an independent practice
association and a provider or organization of providers, between
medical or mental health clinics, and between a medical or mental
health clinic and a provider to provide medical or mental health
services. 'Medical services contract' does not include a contract
of employment or a contract creating legal entities and ownership
thereof that are authorized under ORS chapters 58, 60 or 70, or
other similar professional organizations permitted by statute.
' (4) 'Provider' means a person licensed, certified or
otherwise authorized or permitted by laws of this state to
administer medical or mental health services in the ordinary
course of business or practice of a profession. + }
' **************************** { + SECTION 2. + } { + (1) No
medical services contract may require the provider, as an element
of the contract or as a condition of compensation for services,
to agree:
' (a) In the event of alleged improper medical treatment of a
patient, to indemnify the other party to the medical services
contract for any damages, awards or liabilities including but not
limited to judgments, settlements, attorney fees, court costs and
any associated charges incurred for any reason other than the
negligence or intentional act of the provider or the provider's
employees;
' (b) To charge the other party to the medical services
contract a rate for services rendered pursuant to the medical
services contract that is no greater than the lowest rate that
the provider charges for the same service to any other person;
' (c) To deny care to a patient because of a determination made
pursuant to the medical services contract that the care is not
covered or is experimental, or to deny referral of a patient to
another provider for the provision of such care, if the patient
is informed that the patient will be responsible for the payment
of such noncovered, experimental or referral care and the patient
nonetheless desires to obtain such care or referral; or
' (d) Upon the provider's withdrawal from or termination or
nonrenewal of the medical services contract, not to treat or
solicit a patient even at that patient's request and expense.
' (2) All medical services contracts shall:
' (a) Grant to the provider adequate notice and hearing
procedures, or such other procedures as are fair to the provider
under the circumstances, prior to termination or nonrenewal of
the medical services contract when such termination or nonrenewal
is based upon issues relating to the quality of patient care
rendered by the provider.
' (b) Set forth generally the criteria used by the other party
to the medical services contract for the termination or
nonrenewal of the medical services contract.
' (c) Entitle the provider to an annual accounting accurately
summarizing the financial transactions between the parties to the
medical services contract for that year.
' (d) Allow the provider to withdraw from the care of a patient
when, in the professional judgment of the provider, it is in the
best interest of the patient to do so.
' (e) Provide that a doctor of medicine or osteopathy licensed
under ORS chapter 677 shall be retained by the other party to the
medical services contract and shall be responsible for all final
medical and mental health decisions relating to coverage or
payment made pursuant to the medical services contract.
' (f) Provide that a physician who is practicing in conformity
with ORS 677.095 may advocate a decision, policy or practice
without being subject to termination or penalty for the sole
reason of such advocacy.
' (3) The other party to a medical services contract shall not:
' (a) Refer to other documents or instruments in a contract
unless the nonprovider party agrees to make available to the
provider for review a copy of the documents or instruments within
72 hours of request; or
' (b) Provide as an element of a contract with a third party
relating to the provision of medical services to a patient of the
provider that the provider's patient may not sue or otherwise
recover from the nonprovider party, or must hold the nonprovider
party harmless for, any and all expenses, damages, awards or
liabilities that arise from the management decisions, utilization
review provisions or other policies or determinations of the
nonprovider party that have an impact on the provider's treatment
decisions and actions with regard to the patient.
' (4) An insurer, independent practice association, medical or
mental health clinic or other party to a medical services
contract shall provide the criteria for selection of parties to
future medical services contracts upon the request of current or
prospective parties. + }
' **************************** { + SECTION 3. + }
{ + Sections 4 and 5 of this Act are added to and made a part of
ORS chapter 743. + }
' **************************** { + SECTION 4. + } { + (1)
All insurers offering a policy of health insurance in this state
that requires an enrollee to designate a participating primary
care physician shall:
' (a) Permit the enrollee to change participating primary care
physicians at will, except that the enrollee may be restricted to
making changes no more frequently than two times in any 12-month
period and may be limited to designating only those participating
primary care physicians accepting new patients.
' (b) Have available for employer purchasers of group health
plans with more than 25 employees a point-of-service benefit plan
providing for payment for the services of a provider on a
discounted fee-for-service basis with reasonable access to a
broad array of licensed providers in the insurer's geographic
service area. Any higher premium for the point-of-service benefit
plan may not exceed true actuarial cost, including administrative
costs, to the insurer.
' (c) Have a written policy that recognizes the rights of
enrollees:
' (A) To voice grievances about the organization or health care
provided;
' (B) To be provided with information about the organization,
its services, the practitioners providing care, and enrollees'
rights and responsibilities;
' (C) To participate in decision-making regarding their health
care; and
' (D) To be treated with respect and recognition of their
dignity and need for privacy.
' (d) Provide a copy of policies on enrollees' rights and
responsibilities to all participating providers and directly to
enrollees.
' (e) Have a timely and organized system for resolving enrollee
complaints and formal grievances, including:
' (A) Procedures for registering and responding to complaints
and grievances in a timely fashion;
' (B) Documentation of the substance of complaints, grievances
and actions taken; and
' (C) An appeal process for grievances that includes at least
the following:
' (i) The enrollee has a right to a review by a grievance
panel.
' (ii) The enrollee has a right to a second review with
different individuals.
' (iii) At least one of the levels of review permits the
enrollee to appear before the panel.
' (iv) There is an expedited procedure for emergency cases.
' (f) Inform enrollees about services provided, access to
services, charges and scheduling, including:
' (A) Benefits and services included and excluded and how to
obtain them;
' (B) The organization's policy on referrals for specialty
care;
' (C) Provisions for after-hours and emergency care;
' (D) Charges to enrollees, if applicable, including policy on
payment of charges, copayments and fees for which the enrollee is
responsible;
' (E) Procedures for notifying enrollees affected by
termination or change in any benefits, termination of any
services or termination of any service delivery office or site;
' (F) Procedures for appealing decisions adversely affecting
the enrollee's coverage, benefits or relationship to the
organization;
' (G) Procedures for changing practitioners;
' (H) Procedures for voicing complaints or grievances; and
' (I) Procedures for recommending changes in policies and
services.
' (g) Take steps to ensure that the points of access to primary
care, specialty care and hospital services are identified for
enrollees, and that enrollees are provided information about how
to obtain the names, qualifications and titles of the
practitioners providing or responsible for their care.
' (h) Ensure that confidentiality of specified patient
information and records is protected.
' (2) Insurers that have been accredited by the National
Committee for Quality Assurance are deemed to have met the
requirements of subsection (1)(c) to (h) of this section.
' (3) A health maintenance organization that is exempt from
federal income tax under Internal Revenue Code Section 501(c)(3)
or (4) shall not be required to offer a point-of-service benefit
plan as required by subsection (1)(b) of this section if offering
such plan could result in loss of federal tax-exempt status.
Until such time as the Federal Government establishes guidelines
for health maintenance organizations exempt from federal income
tax that offer point-of-service benefit plans, such a health
maintenance organization shall not be required to offer a
point-of-service benefit plan if:
' (a) Enrollment in Internal Revenue Code Section 501(m)
coverages exceeds five percent of its business; or
' (b) Revenue from Internal Revenue Code Section 501(m)
coverages exceeds five percent of its revenue.
' (4) A health maintenance organization that is federally
qualified under 42 U.S.C. Ý300e et seq. shall not be required to
offer a point-of-service benefit plan in a manner or to an extent
that is inconsistent with federal law and regulation. + }
' { + **************************** SECTION 5. + } { + All
insurers offering a policy of health insurance in this state
shall include a provision in the policy that all subscribers or
enrollees, by acceptance of the benefits of the policy, shall be
deemed to have consented to the examination of medical records
for purposes of utilization review, quality assurance and peer
review by the insurer or its designee. + }
' **************************** { + SECTION 6. + } { + All
utilization review performed pursuant to a medical services
contract shall comply with the following:
' (1) The criteria used in the review process and the method of
development of the criteria shall be made available for review to
a party to such medical services contract upon request.
' (2) A doctor of medicine or osteopathy licensed under ORS
chapter 677 shall be responsible for all final recommendations
regarding the necessity or appropriateness of services or the
site at which the services are provided and shall consult as
appropriate with medical and mental health specialists in making
such recommendations.
' (3) Any patient or provider who has had a request for
treatment or payment for services denied as not medically
necessary or as experimental shall be provided an opportunity for
a timely appeal before an appropriate medical consultant or peer
review committee.
' (4) A provider request for prior authorization of
nonemergency service must be answered within two business days,
and qualified health care personnel must be available for
same-day telephone responses to inquiries concerning
certification of continued length of stay.
' (5) When prior approval for a service or other covered item
is required and obtained, unless there is misrepresentation, the
approval shall be final and may not be rescinded after the
service or other covered item has been provided. + }
' **************************** { + SECTION 7. + } { + An
insurer shall make the point-of-service benefit required by
section 4 (1)(b) of this Act available no later than the
effective date of this Act unless, upon application of an insurer
to the Director of the Department of Consumer and Business
Services, the director finds that the insurer cannot make the
benefit available without endangering the insurer's financial
solvency. If the director so finds, the insurer may delay making
the point-of-service benefit available until January 1, 1997. + }
' **************************** { + SECTION 8. + } ORS 750.055
is amended to read:
' 750.055. (1) The following provisions of the Insurance Code
shall apply to health care service contractors to the extent so
applicable and not inconsistent with the express provisions of
ORS 750.005 to 750.095:
' (a) ORS 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, 731.450,
731.454, 731.488, 731.504, 731.508, 731.509, 731.510, 731.511,
731.512, 731.574 to 731.620, 731.640 to 731.652, 731.730,
731.731, 731.735, 731.737, 731.804 and 731.844 to 731.992.
' (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 732.549 and
732.574 to 732.592.
' (c)(A) ORS 733.010 to 733.050, 733.080, 733.140 to 733.170,
733.210, 733.510 to 733.620, 733.635 to 733.680 and 733.695 to
733.780 apply to not-for-profit health care service contractors.
' (B) ORS chapter 733, not including ORS 733.630, applies to
for-profit health care service contractors.
' (d) ORS chapter 734.
' (e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065,
742.400, 742.520 to 742.540, 743.010, 743.013, 743.018 to
743.030, 743.050, 743.055, 743.100 to 743.109, 743.402, 743.412,
743.472, 743.492, 743.495, 743.498, 743.523 to 743.527, 743.529,
743.549 to 743.555, 743.556, 743.560, 743.600 to 743.622, 743.650
to 743.656, 743.701, 743.704, 743.706 to 743.712, 743.721,
743.722, 743.727, 743.728 { + , + } { - and - } 743.729 { +
and sections 4 and 5 of this 1995 Act + }.
' (f) ORS 743.522 and 743.528, except that individual policies
may be issued to the persons or families insured in lieu of
issuance of a single group policy as referred to in ORS 743.522.
An individual policy issued under this paragraph shall be
considered the statement of the essential features of the
insurance coverage required under ORS 743.528 (2).
' (g) The provisions of ORS chapter 744 relating to the
regulation of agents.
' (h) ORS 746.005 to 746.140, 746.160, 746.180, 746.220 to
746.370 and 746.600 to 746.690.
' (i) ORS 743.714, 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.
' (j) ORS 735.600 to 735.650.
' (k) ORS 743.680 to 743.689.
' (L) ORS 744.700 to 744.740.
' (m) ORS 743.730 to 743.745.
' (n) 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 only, health care
service contractors shall be deemed insurers.
' (3) Any for-profit health care service contractor organized
under the laws of any other state which is not governed by the
insurance laws of such state, will be subject to all requirements
of ORS chapter 732.
' (4) The director 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 9. + } ORS 750.333
is amended to read:
' 750.333. (1) The following provisions of the Insurance Code
apply to trusts carrying out a multiple employer welfare
arrangement:
' (a) ORS 731.004 to 731.150, 731.162, 731.216 to 731.268,
731.296 to 731.316, 731.324, 731.328, 731.378, 731.386, 731.390,
731.398, 731.406, 731.410, 731.414, 731.418 to 731.434, 731.454,
731.484, 731.486, 731.488, 731.512, 731.574 to 731.620, 731.640
to 731.652, 731.804 to 731.992.
' (b) ORS 733.010 to 733.050, 733.140 to 733.170, 733.210,
733.510 to 733.680 and 733.695 to 733.780.
' (c) ORS chapter 734.
' (d) ORS 742.001 to 742.009, 742.013, 742.061 and 742.400.
' (e) ORS 743.028, 743.053, 743.055, 743.524, 743.526, 743.527,
743.528, 743.529, 743.530, 743.560, 743.562, 743.600, 743.601,
743.602, 743.610, 743.611, 743.613, 743.614 { + , + }
{ - and - } 743.730 to 743.745 { + and sections 4 and 5 of this
1995 Act + }.
' (f) ORS 743.556, 743.701, 743.703, 743.704, 743.706, 743.707,
743.709, 743.710, 743.712, 743.713, 743.714, 743.716, 743.717,
743.718, 743.719, 743.721, 743.722 and 743.724. Multiple employer
welfare arrangements to which ORS 743.730 to 743.745 apply are
subject to the sections referred to in this paragraph only as
provided in ORS 743.730 to 743.745.
' (g) Provisions of ORS chapter 744 relating to the regulation
of agents and insurance consultants, and ORS 744.700 to 744.740.
' (h) ORS 746.005 to 746.140, 746.160, 746.180 and 746.220 to
746.370.
' (2) For the purposes of this section:
' (a) A trust carrying out a multiple employer welfare
arrangement shall be considered an insurer.
' (b) References to certificates of authority shall be
considered references to certificates of multiple employer
welfare arrangement.
' (c) Contributions shall be considered premiums.
' (3) The provision of health benefits under ORS 750.301 to
750.341 shall be considered to be the transaction of health
insurance.'.
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