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LC 1914 2013 Regular Session 11/14/12 (LHF/ps)

DRAFT SUMMARY

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 1, 2017. Makes provisions establishing board operative on January 1, 2016. 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 and coordinated care organizations. 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 1, 2017. Appropriates moneys from General Fund to authority for purposes of plan. Declares emergency, effective on passage. 1

A BILL FOR AN ACT

2

Relating to statewide coverage of health care; creating new provisions;

3

amending ORS 65.957, 192.556, 243.105, 243.125, 243.135, 243.160, 243.215,

4

243.275, 243.860, 243.864, 243.866, 243.868, 243.886, 291.055, 411.402, 413.011,

5

413.017, 413.032, 413.037, 413.201, 414.041, 414.231, 430.315, 433.443, 442.015,

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442.315, 442.325, 705.145, 731.036, 734.790, 743.402, 743.730, 743.748, 743.766,

7

743.767, 743.769, 743A.001, 743A.012, 743A.070, 743A.080, 743A.100, 743A.104,

8

743A.105, 743A.108, 743A.110, 743A.120, 743A.124, 743A.141, 743A.144,

9

743A.148, 743A.160, 743A.168, 743A.170, 743A.175, 743A.184, 743A.188, NOTE: Matter in boldfaced type in an amended section is new; matter [italic and bracketed] is existing law to be omitted. New sections are in boldfaced type.


LC 1914 11/14/12 1

743A.190, 743A.192, 744.704, 746.600, 748.603 and 750.055 and section 1,

2

chapter 867, Oregon Laws 2009, and section 1, chapter 101, Oregon Laws

3

2012; repealing ORS 414.825, 414.826, 414.828, 414.831, 414.839, 414.841,

4

414.842, 414.844, 414.846, 414.848, 414.851, 414.852, 414.854, 414.856, 414.858,

5

414.861, 414.862, 414.864, 414.866, 414.868, 414.870, 414.872, 735.600, 735.605,

6

735.610, 735.612, 735.614, 735.615, 735.616, 735.620, 735.625, 735.630, 735.635,

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735.640, 735.645, 735.650, 735.700, 735.701, 735.702, 735.703, 735.705, 735.707,

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735.709, 735.710, 735.712, 741.001, 741.002, 741.025, 741.027, 741.029, 741.031,

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741.101, 741.105, 741.201, 741.220, 741.222, 741.250, 741.255, 741.300, 741.310,

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741.340, 741.381, 741.390, 741.500, 741.510, 741.520, 741.540, 741.900, 743.822,

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743.826 and 746.222 and sections 1, 2, 3, 4 and 5, chapter 47, Oregon Laws

12

2010; appropriating money; and declaring an emergency.

13

Be It Enacted by the People of the State of Oregon:

14 15

ESTABLISHMENT OF THE AFFORDABLE HEALTH CARE

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FOR ALL OREGON PLAN

17 18

SECTION 1. (1) The Affordable Health Care for All Oregon Plan is

19

established to ensure access to quality, patient-centered and affordable

20

health care for all individuals living or working in Oregon, to improve

21

the public’s health and to control the cost of health care for the ben-

22

efit of individuals, families, businesses and society.

23

(2) The plan shall pay the costs of medically necessary health ser-

24

vices in the following categories within the scope prescribed by the

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Affordable Health Care for All Oregon Board, excluding health services

26

provided only for cosmetic purposes:

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(a) Primary and preventive care, including health education;

28

(b) Specialty care;

29

(c) Inpatient and outpatient hospital care;

30

(d) Emergency care;

31

(e) Home health care; [2]


LC 1914 11/14/12 1

(f) Prescription drugs according to a drug formulary;

2

(g) Durable medical equipment;

3

(h) Mental health services;

4

(i) Substance abuse treatment;

5

(j) Dental services;

6

(k) Chiropractic and naturopathic services;

7

(L) Certified nurse midwife services;

8

(m) Basic vision and vision correction;

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(n) Diagnostic imaging, laboratory services and other diagnostic

10

and evaluation services;

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(o) Inpatient and outpatient rehabilitative services;

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(p) Emergency transportation;

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(q) Translation of spoken and written language;

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(r) Hospice care;

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(s) Podiatry;

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(t) Acupuncture; and

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(u) Dialysis.

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(3) A person and the immediate family members of a person are

19

eligible to enroll in the plan if the person:

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(a) Resides in this state; or

21

(b) Is employed in this state.

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(4) Copayments, deductibles or other forms of cost sharing may not

23

be imposed on enrollees under the plan.

24

(5) Enrollees in the plan may choose any health care provider li-

25

censed or certified in this state or in another state for services within

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the scope of the provider’s license or certification.

27

(6) Within the scope of services covered within each category,

28

enrollees and their health care providers shall determine what treat-

29

ment is medically necessary.

30

(7) A health care provider may not discriminate against any

31

enrollee on the basis of race, religion, nationality, sex, sexual orien[3]


LC 1914 11/14/12 1

tation, age, wealth or any basis prohibited by the civil rights laws of

2

this state.

3

(8) A health care provider must accept payment from the plan as

4

payment in full and may not bill a patient for an amount exceeding

5

the payment made by the plan.

6

(9) A payment under the plan to a health care facility for opera-

7

tional expenses may not be used by the facility to pay for or to replace

8

other funds used to pay for capital expenditures.

9 10 11 12 13 14 15

(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.

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(11) Loss of eligibility due to no longer meeting the criteria in sub-

17

section (3) of this section shall be considered a qualifying event. The

18

Oregon Health Authority shall be considered to be a plan sponsor of

19

a group health plan for purposes of continuation coverage required by

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29 U.S.C. 1161 and shall notify the enrollee losing coverage and the

21

immediate family members of the enrollee losing coverage of the op-

22

tion to continue coverage at the enrollee’s own expense.

23

SECTION 2. No later than January 1, 2019, the Affordable Health

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Care for All Oregon Board established under section 5 of this 2013 Act

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shall develop and submit to the Legislative Assembly a recommen-

26

dation for the coverage of long term care services by the Affordable

27

Health Care for All Oregon Plan.

28

SECTION 3. Notwithstanding any other provision of law, an insurer

29

with a certificate of authority to transact insurance issued by the

30

Department of Consumer and Business Services may not offer in this

31

state a policy or certificate of health insurance that covers the health [4]


LC 1914 11/14/12 1

services provided under the Affordable Health Care for All Oregon

2

Plan.

3

SECTION 4. Actions taken by insurers may not be considered to be

4

the transaction of insurance for purposes of the Insurance Code if the

5

actions are:

6 7 8 9

(1) Taken in accordance with the requirements adopted pursuant to sections 1, 7 and 10 of this 2013 Act; and (2) Approved by the Oregon Health Authority or the Affordable Health Care for All Oregon Board.

10 11

AFFORDABLE HEALTH CARE FOR ALL OREGON BOARD

12 13

SECTION 5. (1) There is established the Affordable Health Care for

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All Oregon Board, consisting of nine members who represent each

15

congressional district in the state. The Governor shall appoint the

16

members of the board subject to confirmation by the Senate in the

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manner prescribed by ORS 171.562 and 171.565. The membership must

18

include:

19

(a) A licensed or certified health care provider;

20

(b) A public health official;

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(c) A representative of organized labor; and

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(d) A representative of business who is not employed by a health

23

care provider, pharmaceutical company, health insurer or medical

24

supply company.

25

(2) The term of office of each member is four years and begins on

26

the January 2 following appointment. A new term begins on the expi-

27

ration of the previous term. A member is eligible for reappointment.

28

The Governor shall appoint a person to fill any vacancy, subject to

29

confirmation by the Senate. Any appointment to a vacant position

30

shall become immediately effective for the unexpired term.

31

(3) The board shall select one of its members as chairperson and [5]


LC 1914 11/14/12 1

another as vice chairperson, for such terms and with duties and pow-

2

ers necessary for the performance of the functions of such offices as

3

the board determines.

4 5

(4) A majority of the members of the board constitutes a quorum for the transaction of business.

6

(5) The board shall meet at least once every three months at a

7

place, day and hour determined by the chairperson. The board may

8

also meet at other times and places specified by the call of the chair-

9

person or of a majority of the members of the board.

10

(6) Consistent with ORS chapter 244, the board shall adopt rules of

11

ethics and definitions of conflicts of interest for determining the cir-

12

cumstances under which members of the board must recuse them-

13

selves from voting.

14 15

(7) The Oregon Health Authority shall provide staff support for the board.

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(8) A member of the board is entitled to compensation and expenses

17

as provided in ORS 292.495 for participation in board and any subcom-

18

mittee meetings.

19

(9) In accordance with applicable provisions of ORS chapter 183, the

20

board may adopt rules necessary for the administration of the laws

21

that the board is charged with administering.

22

SECTION 6. Notwithstanding section 5 of this 2013 Act, of the

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members first appointed to the Affordable Health Care for All Oregon

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Board:

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(1) Three shall serve for terms ending December 31, 2017.

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(2) Three shall serve for terms ending December 31, 2018.

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(3) Three shall serve for terms ending December 31, 2019.

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SECTION 7. The Affordable Health Care for All Oregon Board is

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responsible for the development, implementation, management and

30

oversight of the Affordable Health Care for All Oregon Plan estab-

31

lished in section 1 of this 2013 Act, including but not limited to all of [6]


LC 1914 11/14/12 1

the following duties:

2

(1) Determining and regularly updating the scope of coverage within

3

each category described in section 1 (2) of this 2013 Act in consultation

4

with enrollees and guided by evidence-based practices that integrate

5

clinical expertise, patient values and current research.

6

(2) Approving the package of benefits covered in the plan.

7

(3) Overseeing management of the Affordable Health Care for All

8 9 10 11 12 13 14

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;

15

(c) Ensuring that the plan covers health services that:

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(A) Are evidence-based and cost-effective in promoting health; and

17

(B) Emphasize disease prevention and health promotion;

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(d) Developing quality of care indicators;

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(e) Establishing policies regarding conflicts of interest for health

20

care providers and health care facilities;

21

(f) Regularly soliciting input from the public, including individuals

22

with specialized health service needs, through district advisory com-

23

mittees appointed under section 9 of this 2013 Act, and other means;

24 25 26 27 28 29

(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;

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(j) Seeking all waivers, exemptions and agreements from federal,

31

state and local government sources that are necessary to provide [7]


LC 1914 11/14/12 1

funding for the plan; and

2

(k) Ensuring that implementation of the plan affects all individuals

3

equitably, regardless of health status, age, disability, employment

4

status or income.

5 6 7

(5) Partnering with public health agencies to improve the public’s health. (6) Reporting, at least annually, to the Legislative Assembly on the

8

performance

9

changes.

of

the

plan

and recommending needed legislative

10

(7) Establishing an appeal process, in accordance with ORS chapter

11

183, and an ombudsman office for both health care providers and

12

enrollees to appeal adverse determinations by the board or the Oregon

13

Health Authority and to resolve complaints.

14 15 16 17

(8) Submitting to the Legislative Assembly an estimate of the funding needed to operate the plan. (9) Ensuring an annual audit is conducted of the revenue and expenses of the plan.

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(10) Establishing procedures and terms for payments to in-state and

19

out-of-state health care providers for covered services provided under

20

the plan.

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(11) Establishing policies for the certificate of need process under ORS 442.315. (12) Seeking federal certification of the plan as a Medicare Advantage plan.

25

SECTION 8. (1) The Affordable Health Care for All Oregon Board

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shall establish a program to operate during the first four years of op-

27

eration of the Affordable Health Care for All Oregon Plan to pay for

28

or to reimburse the costs of retraining for workers who are displaced

29

by the implementation of the plan. The Oregon Health Authority shall

30

administer the program.

31

(2) The board shall apply for federal and private gifts and grants [8]


LC 1914 11/14/12 1 2 3

available to operate the program. (3) A worker is eligible for no more than 24 months of retraining under this section.

4

SECTION 9. (1) The Affordable Health Care for All Oregon Board

5

shall appoint for each congressional district in this state a district

6

advisory committee consisting of residents of the district. Each advi-

7

sory committee shall solicit input, receive complaints, conduct public

8

hearings, facilitate accountability or assist the board in any manner

9

deemed appropriate by the board to meet the health service needs of

10 11 12

residents of the congressional district. (2) The Oregon Health Authority shall provide staff support to each district advisory committee.

13 14

DUTIES OF THE OREGON HEALTH AUTHORITY IN ADMINISTER-

15

ING THE AFFORDABLE HEALTH CARE FOR ALL OREGON PLAN

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SECTION 10. The Oregon Health Authority, under the direction,

18

policies and oversight of the Affordable Health Care for All Oregon

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Board, shall:

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(1) Adopt rules approved by the board necessary for carrying out the authority’s duties under this section;

22

(2) Propose goals, objectives and standards to achieve quality and

23

affordable health care accessible to all Oregonians and propose major

24

policy changes to the board;

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(3) Establish systems to monitor and evaluate access, quality and cost of health services provided to Oregonians;

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(4) Direct research to improve health and health services;

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(5) Identify legislation needed to improve health services covered

29

under the Affordable Health Care for All Oregon Plan;

30

(6) Establish collaborative partnerships with public health agencies;

31

(7) Make recommendations to the board for ensuring equity in the [9]


LC 1914 11/14/12 1

delivery of culturally sensitive health care to all Oregon populations;

2

(8) Develop a biennial budget for board and legislative approval;

3

(9) Administer the legislatively approved budget for the plan;

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(10) Report periodically to the board, the Governor and the Legis-

5

lative Assembly on the progress of implementing the plan and on the

6

financial status of the plan;

7 8 9

(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;

10

(13) Contract with health care providers, insurers and health care

11

service contractors to provide or administer health services under the

12

plan and contract for actuarial, legal, technical or other professional

13

services as needed;

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(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;

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(17) Provide prompt responses to suggestions, complaints and

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grievances submitted by health care providers and enrollees under the

22

process established by the board in section 7 (7) of this 2013 Act; and

23 24

(18) Perform other functions delegated by the board to the authority.

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CERTIFICATES OF NEED

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SECTION 11. ORS 442.015 is amended to read:

29

442.015. As used in ORS chapter 441 and this chapter, unless the context

30 31

requires otherwise: (1) “Acquire” or “acquisition” means obtaining equipment, supplies, com[10]


LC 1914 11/14/12 1

ponents or facilities by any means, including purchase, capital or operating

2

lease, rental or donation, with intention of using such equipment, supplies,

3

components or facilities to provide health services in Oregon. When equip-

4

ment or other materials are obtained outside of this state, acquisition is

5

considered to occur when the equipment or other materials begin to be used

6

in Oregon for the provision of health services or when such services are of-

7

fered for use in Oregon.

8 9

(2) “Affected persons” has the same meaning as given to “party” in ORS 183.310.

10

(3)(a) “Ambulatory surgical center” means a facility or portion of a fa-

11

cility that operates exclusively for the purpose of providing surgical services

12

to patients who do not require hospitalization and for whom the expected

13

duration of services does not exceed 24 hours following admission.

14

(b) “Ambulatory surgical center” does not mean:

15

(A) Individual or group practice offices of private physicians or dentists

16

that do not contain a distinct area used for outpatient surgical treatment

17

on a regular and organized basis, or that only provide surgery routinely

18

provided in a physician’s or dentist’s office using local anesthesia or con-

19

scious sedation; or

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(B) A portion of a licensed hospital designated for outpatient surgical treatment. [(4) “Budget” means the projections by the hospital for a specified future

23

time

24

indicators.]

25 26

period

of

expenditures

and revenues with supporting statistical

(4) “Coordinated care organization” has the meaning given that term in ORS 414.025.

27

(5) “Develop” means to undertake those activities that on their com-

28

pletion will result in the offer of a new institutional health service or the

29

incurring of a financial obligation, as defined under applicable state law, in

30

relation to the offering of such a health service.

31

(6) “Expenditure” or “capital expenditure” means the actual expenditure, [11]


LC 1914 11/14/12 1

an obligation to an expenditure, lease or similar arrangement in lieu of an

2

expenditure, and the reasonable value of a donation or grant in lieu of an

3

expenditure but not including any interest thereon.

4 5

(7) “Freestanding birthing center” means a facility licensed for the primary purpose of performing low risk deliveries.

6

(8) “Governmental unit” means the state, or any county, municipality or

7

other political subdivision, or any related department, division, board or

8

other agency.

9

(9) “Gross revenue” means the sum of daily hospital service charges,

10

ambulatory service charges, ancillary service charges and other operating

11

revenue. “Gross revenue” does not include contributions, donations, legacies

12

or bequests made to a hospital without restriction by the donors.

13

(10)(a) “Health care facility” means:

14

(A) A hospital;

15

(B) A long term care facility;

16

(C) An ambulatory surgical center;

17

(D) A freestanding birthing center; or

18

(E) An outpatient renal dialysis center.

19

(b) “Health care facility” does not mean:

20

(A) A residential facility licensed by the Department of Human Services

21 22 23 24 25 26 27 28 29

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.

30

(11) “Health maintenance organization” or “HMO” means a public or-

31

ganization or a private organization organized under the laws of any state [12]


LC 1914 11/14/12 1 2 3

that: (a) Is a qualified HMO under section 1310 (d) of the U.S. Public Health Services Act; or

4

(b)(A) Provides or otherwise makes available to enrolled participants

5

health care services, including at least the following basic health care ser-

6

vices:

7

(i) Usual physician services;

8

(ii) Hospitalization;

9

(iii) Laboratory;

10

(iv) X-ray;

11

(v) Emergency and preventive services; and

12

(vi) Out-of-area coverage;

13

(B) Is compensated, except for copayments, for the provision of the basic

14

health care services listed in subparagraph (A) of this paragraph to enrolled

15

participants on a predetermined periodic rate basis; and

16

(C) Provides physicians’ services primarily directly through physicians

17

who are either employees or partners of such organization, or through ar-

18

rangements with individual physicians or one or more groups of physicians

19

organized on a group practice or individual practice basis.

20

(12) “Health services” means clinically related diagnostic, treatment or

21

rehabilitative services, and includes alcohol, drug or controlled substance

22

abuse and mental health services that may be provided either directly or

23

indirectly on an inpatient or ambulatory patient basis.

24

(13) “Hospital” means:

25

(a) A facility with an organized medical staff and a permanent building

26

that is capable of providing 24-hour inpatient care to two or more individuals

27

who have an illness or injury and that provides at least the following health

28

services:

29

(A) Medical;

30

(B) Nursing;

31

(C) Laboratory; [13]


LC 1914 11/14/12 1

(D) Pharmacy; and

2

(E) Dietary; or

3

(b) A special inpatient care facility as that term is defined by the Oregon

4

Health Authority by rule.

5

(14) “Institutional health services” means health services provided in or

6

through health care facilities and includes the entities in or through which

7

such services are provided.

8

(15) “Intermediate care facility” means a facility that provides, on a reg-

9

ular basis, health-related care and services to individuals who do not require

10

the degree of care and treatment that a hospital or skilled nursing facility

11

is designed to provide, but who because of their mental or physical condition

12

require care and services above the level of room and board that can be made

13

available to them only through institutional facilities.

14

(16) “Long term care facility” means a facility with permanent facilities

15

that include inpatient beds, providing medical services, including nursing

16

services but excluding surgical procedures except as may be permitted by the

17

rules of the Director of Human Services, to provide treatment for two or

18

more unrelated patients. “Long term care facility” includes skilled nursing

19

facilities and intermediate care facilities but may not be construed to include

20

facilities licensed and operated pursuant to ORS 443.400 to 443.455.

21

[(17) “New hospital” means a facility that did not offer hospital services on

22

a regular basis within its service area within the prior 12-month period and

23

is initiating or proposing to initiate such services. “New hospital” also in-

24

cludes any replacement of an existing hospital that involves a substantial in-

25

crease or change in the services offered.]

26

[(18) “New skilled nursing or intermediate care service or facility” means

27

a service or facility that did not offer long term care services on a regular basis

28

by or through the facility within the prior 12-month period and is initiating

29

or proposing to initiate such services. “New skilled nursing or intermediate

30

care service or facility” also includes the rebuilding of a long term care facil-

31

ity, the relocation of buildings that are a part of a long term care facility, the [14]


LC 1914 11/14/12 1

relocation of long term care beds from one facility to another or an increase

2

in the number of beds of more than 10 or 10 percent of the bed capacity,

3

whichever is the lesser, within a two-year period.]

4

[(19)] (17) “Offer” means that the health care facility holds itself out as

5

capable of providing, or as having the means for the provision of, specified

6

health services.

7 8

[(20)] (18) “Outpatient renal dialysis facility” means a facility that provides renal dialysis services directly to outpatients.

9

[(21)] (19) “Person” means an individual, a trust or estate, a partnership,

10

a corporation (including associations, joint stock companies and insurance

11

companies), a state, or a political subdivision or instrumentality, including

12

a municipal corporation, of a state.

13

[(22)] (20) “Skilled nursing facility” means a facility or a distinct part of

14

a facility, that is primarily engaged in providing to inpatients skilled nursing

15

care and related services for patients who require medical or nursing care,

16

or an institution that provides rehabilitation services for the rehabilitation

17

of individuals who are injured or sick or who have disabilities.

18

SECTION 12. ORS 442.315 is amended to read:

19

442.315. (1) Any [new hospital or new skilled nursing or intermediate care

20

service or] health care facility not excluded pursuant to ORS 441.065

21

[shall] must obtain a certificate of need from the Oregon Health Authority

22

prior to an offering or development.

23

(2) The authority shall adopt rules, in compliance with policies devel-

24

oped and subject to approval by the Affordable Health Care for All

25

Oregon Board, specifying criteria and procedures for [making decisions as

26

to the need for the new] approving certificates of need for services or fa-

27

cilities.

28 29

(3)(a) An applicant for a certificate of need shall apply to the authority on forms provided for this purpose by the authority by rule.

30

(b) An applicant shall pay a fee prescribed as provided in this section.

31

Subject to the approval of the [Oregon Department of Administrative [15]


LC 1914 11/14/12 1

Services] board, the authority shall prescribe application fees, based on the

2

complexity and scope of the proposed project.

3

(4) The authority shall [be the decision-making authority for the purpose

4

of certificates] issue a proposed order with respect to an application for

5

a certificate of need.

6

(5)(a) An applicant or any affected person who is dissatisfied with the

7

proposed [decision] order of the authority is entitled to an informal hearing

8

[in the course of review and] before a final [decision is rendered] order is

9

issued.

10

(b) [Following a final decision being rendered by the authority,] The au-

11

thority shall prescribe by rule a time frame within which an applicant

12

or any affected person may request a reconsideration [hearing pursuant to

13

ORS chapter 183] of or a rehearing on a final order.

14

(c) [In any proceeding brought by an affected person or an applicant chal-

15

lenging an authority decision under this subsection, the authority shall follow

16

procedures] All proceedings under this subsection shall be conducted

17

consistent with the provisions of ORS chapter 183 relating to [a] contested

18

case procedures.

19

(6) Once a certificate of need has been issued, it may not be revoked or

20

rescinded unless it was acquired by fraud or deceit.

However, if the au-

21

thority finds that a person is offering or developing a project that is not

22

within the scope of the certificate of need, the authority may limit the

23

project as specified in the issued certificate of need or reconsider the appli-

24

cation. A certificate of need is not transferable.

25

(7) Nothing in this section applies to any [hospital, skilled nursing or

26

intermediate care service or] health care facility that seeks to replace

27

equipment with equipment of similar basic technological function or an up-

28

grade that improves the quality or cost-effectiveness of the service provided.

29

Any person acquiring such replacement or upgrade shall file a letter of in-

30

tent for the project in accordance with the rules of the authority if the price

31

of the replacement equipment or upgrade exceeds $1 million. [16]


LC 1914 11/14/12 1

(8) [Except as required in subsection (1) of this section for a new hospital

2

or new skilled nursing or intermediate care service or facility not operating

3

as a Medicare swing bed program, nothing in] This section [requires] does

4

not require a rural hospital as defined in ORS 442.470 (5)(a)(A) and (B) to

5

obtain a certificate of need.

6

(9) [Nothing in this section applies to basic health services, but basic health

7

services do not include] This section applies to:

8

(a) Magnetic resonance imaging scanners;

9

(b) Positron emission tomography scanners;

10

(c) Cardiac catheterization equipment;

11

(d) Megavoltage radiation therapy equipment;

12

(e) Extracorporeal shock wave lithotriptors;

13

(f) Neonatal intensive care;

14

(g) Burn care;

15

(h) Trauma care;

16

(i) Inpatient psychiatric services;

17

(j) Inpatient chemical dependency services;

18

(k) Inpatient rehabilitation services;

19

(L) Open heart surgery; or

20

(m) Organ transplant services.

21

(10) This section does not apply to health services offered in or

22 23 24

through a hospital licensed under ORS chapter 441 except for: (a) Skilled or intermediate care nursing services offered in a hospital; and

25

(b) The services specified in section (9) of this section.

26

[(10)] (11) In addition to any other remedy provided by law, whenever it

27

appears that any person is engaged in, or is about to engage in, any acts that

28

constitute a violation of this section, or any rule adopted or order issued

29

by the authority under this section, the authority may institute proceedings

30

in the circuit courts to enforce obedience to [such] the statute, rule or order

31

by injunction or by other processes, mandatory or otherwise. [17]


LC 1914 11/14/12 1

[(11) As used in this section, “basic health services� means health services

2

offered in or through a hospital licensed under ORS chapter 441, except skilled

3

nursing or intermediate care nursing facilities or services and those services

4

specified in subsection (9) of this section.]

5

SECTION 13. ORS 442.325 is amended to read:

6

442.325. (1) A certificate of need shall be required for the development or

7

establishment of a health care facility of any [new] health maintenance or-

8

ganization or coordinated care organization.

9

(2) Any activity of a health maintenance organization or coordinated

10

care organization that [which] does not involve the direct delivery of

11

health services, as distinguished from arrangements for indirect delivery of

12

health services through contracts with providers, shall be exempt from cer-

13

tificate of need review.

14

(3) [Nothing in ORS 244.050, 431.250,] ORS 441.015 to 441.087[,] and

15

442.015 to 442.420 [and 442.450 applies] do not apply to any decision of a

16

health maintenance organization or coordinated care organization involv-

17

ing its organizational structure, its arrangements for financing health ser-

18

vices, the terms of its contracts with enrolled beneficiaries or its scope of

19

benefits.

20 21

(4) With the exception of certificate of need requirements, when applicable[,]:

22

(a) The licensing and regulation of health maintenance organizations

23

shall be controlled by ORS 750.005 to 750.095 and statutes incorporated by

24

reference therein.

25 26

(b) The certification of coordinated care organizations shall be controlled by ORS 414.625.

27

(5) It is the policy of ORS [244.050, 431.250,] 414.620, 414.625, 441.015 to

28

441.087[,] and 442.015 to 442.420 [and 442.450] to encourage the growth of

29

health maintenance organizations [as an] and coordinated care organiza-

30

tions as alternative delivery [system] systems and to provide the facilities

31

for the provision of quality health care to the present and future members [18]


LC 1914 11/14/12 1

who may enroll within their defined service area.

2

(6)(a) It is also the policy of ORS [244.050, 431.250,] 414.620, 414.625,

3

441.015 to 441.087[,] and 442.015 to 442.420 [and 442.450] to consider the spe-

4

cial needs and circumstances of health maintenance organizations and co-

5

ordinated care organizations. Such needs and circumstances include the

6

needs of and costs to members and projected members of [the health mainte-

7

nance] each organization in obtaining health services and the potential for

8

a reduction in the use of inpatient care in the community through an ex-

9

tension of preventive health services and the provision of more systematic

10

and comprehensive health services. The consideration of a new health service

11

proposed by a health maintenance organization or a coordinated care or-

12

ganization shall also address the availability and cost of obtaining the

13

proposed new health service from the existing providers in the area that are

14

not part of the health maintenance [organizations] organization or coor-

15

dinated care organization.

16

(b) The Oregon Health Authority shall issue a certificate of need for beds,

17

services or equipment to meet the needs or reasonably anticipated needs of

18

members of health maintenance organizations and coordinated care or-

19

ganizations when beds, services or equipment are not available from [non-

20

plan] providers outside of the organization.

21 22

PUBLIC EMPLOYEE PARTICIPATION IN

23

THE AFFORDABLE HEALTH CARE FOR ALL OREGON PLAN

24

(Public Employees’ Benefit Board)

25 26 27

SECTION 14. ORS 243.105 is amended to read:

28

243.105. As used in ORS 243.105 to 243.285, unless the context requires

29

otherwise:

30

(1) “Benefit plan” includes, but is not limited to:

31

(a) Contracts for insurance or other benefits, including supplemental [19]


LC 1914 11/14/12 1

medical, dental[,] or vision, life[,] or disability [and other health care recog-

2

nized by state law, and related services and supplies]; and

3 4 5 6 7 8 9

[(b) Comparable benefits for employees who rely on spiritual means of healing; and] [(c) Self-insurance programs managed by the Public Employees’ Benefit Board.] (b) The Affordable Health Care for All Oregon Plan or comparable benefits for employees who rely on spiritual means of healing. (2) “Board” means the Public Employees’ Benefit Board.

10

(3) “Carrier” means an insurance company or health care service con-

11

tractor holding a valid certificate of authority from the Director of the De-

12

partment of Consumer and Business Services, or two or more companies or

13

contractors acting together pursuant to a joint venture, partnership or other

14

joint means of operation, or a board-approved guarantor of benefit plan

15

coverage and compensation.

16

(4)(a) “Eligible employee” means an officer or employee of a state agency

17

who elects to participate in one of the group benefit plans described in ORS

18

243.135. The term includes state officers and employees in the exempt, un-

19

classified and classified service, and state officers and employees, whether

20

or not retired, who:

21

(A) Are receiving a service retirement allowance, a disability retirement

22

allowance or a pension under the Public Employees Retirement System or

23

are receiving a service retirement allowance, a disability retirement allow-

24

ance or a pension under any other retirement or disability benefit plan or

25

system offered by the State of Oregon for its officers and employees;

26

(B) Are eligible to receive a service retirement allowance under the Pub-

27

lic Employees Retirement System and have reached earliest retirement age

28

under ORS chapter 238;

29 30 31

(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 un[20]


LC 1914 11/14/12 1

der another retirement benefit plan or system offered by the State of Oregon

2

and have attained earliest retirement age under the plan or system.

3

(b) “Eligible employee” does not include individuals:

4

(A) Engaged as independent contractors;

5

(B) Whose periods of employment in emergency work are on an intermit-

6

tent or irregular basis;

7

(C) Who are employed on less than half-time basis unless the individuals

8

are employed in positions classified as job-sharing positions, unless the in-

9

dividuals are defined as eligible under rules of the board;

10

(D) Appointed under ORS 240.309;

11

(E) Provided sheltered employment or make-work by the state in an em-

12

ployment or industries program maintained for the benefit of such individ-

13

uals; or

14 15

(F) Provided student health care services in conjunction with their enrollment as students at a public university listed in ORS 352.002.

16

(5) “Family member” means an eligible employee’s spouse and any un-

17

married child or stepchild within age limits and other conditions imposed

18

by the board with regard to unmarried children or stepchildren.

19

(6) “Payroll disbursing officer” means the officer or official authorized to

20

disburse moneys in payment of salaries and wages of employees of a state

21

agency.

22 23 24 25

(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.

26

SECTION 15. ORS 243.125 is amended to read:

27

243.125. (1) The Public Employees’ Benefit Board shall prescribe rules for

28

the conduct of its business and for carrying out ORS 243.256. The board shall

29

study all matters connected with the providing of adequate benefit plan

30

coverage for eligible state employees on the best basis possible with relation

31

both to the welfare of the employees and to the state. The board shall design [21]


LC 1914 11/14/12 1

benefits, devise specifications, analyze carrier responses to advertisements

2

for bids and decide on the award of contracts. Contracts shall be signed by

3

the chairperson on behalf of the board.

4

(2) In carrying out its duties under subsection (1) of this section, the goal

5

of the board shall be to provide a high quality plan of health and other

6

benefits for state employees at a cost affordable to both the employer and the

7

employees.

8

(3) Subject to ORS chapter 183, the board may make rules not inconsistent

9

with ORS 243.105 to 243.285 and 292.051 to determine the terms and condi-

10

tions of eligible employee participation and coverage.

11

(4) The board shall prepare specifications, invite bids and do acts neces-

12

sary to award contracts for [health benefit plan and dental] benefit plan

13

coverage of eligible employees in accordance with the criteria set forth in

14

ORS 243.135 [(1)] (2).

15

(5) The board may retain consultants, brokers or other advisory personnel

16

when necessary and, subject to the State Personnel Relations Law, shall

17

employ such personnel as are required to perform the functions of the board.

18

SECTION 16. ORS 243.135 is amended to read:

19

243.135. (1) Any person who is eligible to participate in a health

20

benefit plan available to state employees pursuant to ORS 243.105 to

21

243.285 shall enroll in the Affordable Health Care for All Oregon Plan.

22

(1) (2) [Notwithstanding any other benefit plan contracted for and offered

23

by the Public Employees’ Benefit Board] If the Public Employees’ Benefit

24

Board contracts for health benefit plans to supplement coverage pro-

25

vided in the Affordable Health Care for All Oregon Plan, the board shall

26

contract for a supplemental health benefit plan or plans best designed to

27

meet the needs and provide for the welfare of eligible employees and the

28

state. In considering whether to enter into a contract for a supplemental

29

health benefit plan, the board shall place emphasis on:

30

(a) Employee choice among high quality plans;

31

(b) A competitive marketplace; [22]


LC 1914 11/14/12 1

(c) Plan performance and information;

2

(d) Employer flexibility in plan design and contracting;

3

(e) Quality customer service;

4

(f) Creativity and innovation;

5

(g) Plan benefits as part of total employee compensation; and

6

(h) The improvement of employee health.

7

[(2)] (3) The board may approve more than one carrier for each type of

8

supplemental health benefit plan contracted for and offered but the num-

9

ber of carriers shall be held to a number consistent with adequate service

10

to eligible employees and their family members.

11

[(3)] (4) Where appropriate for a contracted and offered supplemental

12

health benefit plan, the board shall provide options under which an eligible

13

employee may arrange coverage for family members.

14

[(4)] (5) Payroll deductions for such costs as are not payable by the state

15

may be made upon receipt of a signed authorization from the employee in-

16

dicating an election to participate in the supplemental health benefit plan

17

or plans selected and the deduction of a certain sum from the employee’s pay.

18

[(5)] (6) In developing any supplemental health benefit plan, the board

19

may provide an option of additional coverage for eligible employees and their

20

family members at an additional cost or premium.

21

[(6)] (7) Transfer of enrollment from one supplemental health benefit

22

plan to another shall be open to all eligible employees and their family

23

members under rules adopted by the board. [Because of the special problems

24

that may arise in individual instances under comprehensive group practice

25

plan coverage involving acceptable physician-patient relations between a par-

26

ticular panel of physicians and particular eligible employees and their family

27

members, the board shall provide a procedure under which any eligible em-

28

ployee may apply at any time to substitute a health service benefit plan for

29

participation in a comprehensive group practice benefit plan.]

30

[(7)] (8) The board shall evaluate a supplemental health benefit plan

31

that serves a limited geographic region of this state according to the criteria [23]


LC 1914 11/14/12 1

described in subsection [(1)] (2) of this section.

2

SECTION 17. ORS 243.160 is amended to read:

3

243.160. A retired state officer or employee is not required to participate

4

in one of the group benefit plans described in ORS 243.135 in order to obtain

5

supplemental dental benefit plan coverage. The Public Employees’ Benefit

6

Board shall establish by rule standards of eligibility for retired officers or

7

employees to participate in a supplemental dental benefit plan.

8

SECTION 18. ORS 243.215 is amended to read:

9

243.215. Any eligible employee unable to participate in one or more of the

10

plans described in ORS 243.135 [(1)] solely because the employee is assigned

11

to perform duties outside the state may be eligible to receive the monthly

12

state contribution, less administrative expenses, as payment of all or part

13

of the cost of a [health] benefit plan of choice, subject to the approval of the

14

Public Employees’ Benefit Board and such rules as the board may adopt.

15

SECTION 19. ORS 243.275 is amended to read:

16

243.275. (1) [In addition to contracting for health and dental benefit

17

plans,] The Public Employees’ Benefit Board may contract with carriers to

18

provide at the expense of participating eligible employees and with or with-

19

out state participation for coverage, including but not limited to, insurance

20

or other benefit based on life, supplemental medical, supplemental dental,

21

[optical] vision, accidental death or disability insurance plans.

22

(2) The monthly contribution of each eligible employee for other benefit

23

plan or plans coverage, as described in subsection (1) of this section, shall

24

be the total cost per month of the benefit coverage afforded the employee

25

under the plan or plans, for which the employee exercises an option, in-

26

cluding the cost of enrollment of such eligible employees and administrative

27

expenses therefor.

28

(3) For any benefit plan or plans described in subsection (1) of this section

29

in which the state participates, the monthly contribution of each eligible

30

employee for the benefit plan, for which the employee exercises an option

31

and there is state participation, shall be reduced by an amount equal to the [24]


LC 1914 11/14/12 1

portion thereof contributed by the state, including the cost of enrollment of

2

the eligible employee and the administrative expenses therefor.

3

(4) The board may withdraw approval of any such additional benefit plan

4

coverage in the same manner as it withdraws approval of [health] benefit

5

plans as described and authorized by ORS 243.145.

6

(5) If any state agency contracts for any of the benefits described in sub-

7

section (1) of this section on behalf of any state employees, the administra-

8

tive expenses thereof shall be paid by assessment of the participating

9

employees. Such contracts are subject to approval of the board before they

10

become operative. The board may withdraw approval for any such benefit in

11

the same manner as it withdraws approval under ORS 243.145.

12

(Oregon Educators Benefit Board)

13 14 15

SECTION 20. ORS 243.860 is amended to read:

16

243.860. As used in ORS 243.860 to 243.886, unless the context requires

17

otherwise:

18

(1) “Benefit plan” includes but is not limited to:

19

(a) Contracts for insurance or other benefits, including supplemental

20

medical, dental[,] or vision, life[,] or disability [and other health care recog-

21

nized by state law, and related services and supplies]; and

22 23 24 25 26 27

[(b) Self-insurance programs managed by the Oregon Educators Benefit Board; and] [(c) Comparable benefits for employees who rely on spiritual means of healing] (b) The Affordable Health Care for All Oregon Plan or comparable benefits for employees who rely on spiritual means of healing.

28

(2) “Carrier” means an insurance company or health care service con-

29

tractor holding a valid certificate of authority from the Director of the De-

30

partment of Consumer and Business Services, or two or more companies or

31

contractors acting together pursuant to a joint venture, partnership or other [25]


LC 1914 11/14/12 1

joint means of operation, or a board-approved provider or guarantor of ben-

2

efit plan coverage and compensation.

3

(3) “District” means a common school district, a union high school dis-

4

trict, an education service district, as defined in ORS 334.003, or a commu-

5

nity college district, as defined in ORS 341.005.

6

(4)(a) “Eligible employee” includes:

7

(A) An officer or employee of a district who elects to participate in one

8 9

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:

10

(i) Is receiving a service retirement allowance, a disability retirement al-

11

lowance or a pension under the Public Employees Retirement System or is

12

receiving a service retirement allowance, a disability retirement allowance

13

or a pension under any other retirement or disability benefit plan or system

14

offered by the district for its officers and employees;

15

(ii) Is eligible to receive a service retirement allowance under the Public

16

Employees Retirement System and has reached earliest service retirement

17

age under ORS chapter 238;

18 19

(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

20

(iv) Is eligible to receive a service retirement allowance or pension under

21

any other retirement benefit plan or system offered by the district and has

22

attained earliest retirement age under the plan or system.

23 24

(b) Except as provided in paragraph (a)(B) of this subsection, “eligible employee” does not include an individual:

25

(A) Engaged as an independent contractor;

26

(B) Whose periods of employment in emergency work are on an intermit-

27

tent or irregular basis; or

28

(C) Who is employed on less than a half-time basis unless the individual

29

is employed in a position classified as a job-sharing position or unless the

30

individual is defined as eligible under rules of the Oregon Educators Benefit

31

Board or under a collective bargaining agreement. [26]


LC 1914 11/14/12 1

(5) “Family member” means an eligible employee’s spouse or domestic

2

partner and any unmarried child or stepchild of an eligible employee within

3

age limits and other conditions imposed by the Oregon Educators Benefit

4

Board with regard to unmarried children or stepchildren.

5

(6) “Payroll disbursing officer” means the officer or official authorized to

6

disburse moneys in payment of salaries and wages of officers and employees

7

of a district.

8

(7) “Premium” means the monthly or other periodic charge, including

9

administrative fees of the Oregon Educators Benefit Board, for a benefit

10

plan.

11

SECTION 21. ORS 243.864 is amended to read:

12

243.864. (1) The Oregon Educators Benefit Board:

13

(a) Shall adopt rules for the conduct of its business and for carrying out

14

ORS 243.879; and

15

(b) May adopt rules not inconsistent with ORS 243.860 to 243.886 to de-

16

termine the terms and conditions of eligible employee participation in and

17

coverage under benefit plans.

18

(2) The board shall study all matters connected with the provision of ad-

19

equate benefit plan coverage for eligible employees on the best basis possible

20

with regard to the welfare of the employees and affordability for the dis-

21

tricts. The board shall design benefits, prepare specifications, analyze carrier

22

responses to advertisements for bids and award contracts. Contracts shall

23

be signed by the chairperson on behalf of the board.

24

(3) In carrying out its duties under subsections (1) and (2) of this section,

25

the goal of the board is to provide high-quality [health, dental and other]

26

benefit plans for eligible employees at a cost affordable to the districts, the

27

employees and the taxpayers of Oregon.

28

(4) The board shall prepare specifications, invite bids and take actions

29

necessary to award contracts for [health and dental] benefit plan coverage

30

of eligible employees in accordance with the criteria set forth in ORS 243.866

31

[(1)] (2). The Public Contracting Code does not apply to contracts for benefit [27]


LC 1914 11/14/12 1

plans provided under ORS 243.860 to 243.886. The board may not exclude from

2

competition to contract for a benefit plan an Oregon carrier solely because

3

the carrier does not serve all counties in Oregon.

4

(5) The board may retain consultants, brokers or other advisory personnel

5

when necessary and shall employ such personnel as are required to perform

6

the functions of the board.

7

SECTION 22. ORS 243.866 is amended to read:

8

243.866. (1) Any person who is eligible to participate in a health

9

benefit plan under ORS 243.860 to 243.886 shall enroll in the Affordable

10

Health Care for All Oregon Plan.

11

[(1)] (2) If the Oregon Educators Benefit Board contracts for health

12

benefit plans to supplement coverage provided in the Affordable Health

13

Care for All Oregon Plan, the board shall contract for supplemental

14

health benefit plans best designed to meet the needs and provide for the

15

welfare of eligible employees and the districts. In considering whether to

16

enter into a contract for a supplemental health benefit plan, the board

17

shall place emphasis on:

18

(a) Employee choice among high-quality plans;

19

(b) Encouragement of a competitive marketplace;

20

(c) Plan performance and information;

21

(d) District flexibility in plan design and contracting;

22

(e) Quality customer service;

23

(f) Creativity and innovation;

24

(g) Plan benefits as part of total employee compensation; and

25

(h) Improvement of employee health.

26

[(2)] (3) The board may approve more than one carrier for each type of

27

supplemental health benefit plan offered, but the board shall limit the

28

number of carriers to a number consistent with adequate service to eligible

29

employees and family members.

30

[(3)] (4) When appropriate, the board shall provide options under which

31

an eligible employee may arrange coverage for family members under a [28]


LC 1914 11/14/12 1

supplemental health benefit plan.

2

[(4)] (5) A district shall provide that payroll deductions for supplemental

3

health benefit plan costs that are not payable by the district may be made

4

upon receipt of a signed authorization from the employee indicating an

5

election to participate in the supplemental health benefit plan or plans

6

selected and allowing the deduction of those costs from the employee’s pay.

7

[(5)] (6) In developing any supplemental health benefit plan, the board

8

may provide an option of additional coverage for eligible employees and

9

family members at an additional premium.

10

[(6)] (7) The board shall adopt rules providing that transfer of enrollment

11

from one supplemental health benefit plan to another is open to all eligible

12

employees and family members. [Because of the special problems that may

13

arise involving acceptable physician-patient relations between a particular

14

panel of physicians and a particular eligible employee or family member under

15

a comprehensive group practice benefit plan, the board shall provide a proce-

16

dure under which any eligible employee may apply at any time to substitute

17

another benefit plan for participation in a comprehensive group practice benefit

18

plan.]

19

[(7) An eligible employee who is retired is not required to participate in a

20

health benefit plan offered under this section in order to obtain dental benefit

21

plan coverage. The board shall establish by rule standards of eligibility for

22

retired employees to participate in a dental benefit plan.]

23

(8) The board shall evaluate a supplemental health benefit plan that

24

serves a limited geographic region of this state according to the criteria de-

25

scribed in subsection [(1)] (2) of this section.

26

SECTION 23. ORS 243.868 is amended to read:

27

243.868. (1) [In addition to contracting for health and dental benefit

28

plans,] The Oregon Educators Benefit Board may contract with carriers to

29

provide [other] benefit plans including, but not limited to, insurance or other

30

benefits based on life, supplemental medical, supplemental dental, supple-

31

mental vision, accidental death or disability insurance plans. [29]


LC 1914 11/14/12 1

(2) The premium for each eligible employee for coverage under a benefit

2

plan [other than a health or dental benefit plan] described in subsection (1)

3

of this section shall be the total cost per month of the coverage afforded the

4

employee under the plan for which the employee exercises an option, in-

5

cluding the cost of enrollment of the eligible employee and administrative

6

expenses for the plan.

7

(3) The board may withdraw approval of any additional benefit plan in

8

the same manner as it withdraws approval of a health or dental benefit plan

9

as described and authorized by ORS 243.878.

10

(4) If the board does not contract for a benefit plan described in sub-

11

section (1) of this section, a district may contract for the benefit plan on

12

behalf of any district employees.

13

shall be paid in accordance with the district’s negotiated agreement with the

14

employees. Benefit plans entered into by a district are subject to approval

15

by the board before they become operative. The board may withdraw ap-

16

proval of any such benefit plan in the same manner as it withdraws approval

17

of a benefit plan under ORS 243.878.

The administrative expenses of the plan

18 19

AFFORDABLE HEALTH CARE FOR ALL OREGON FUND

20 21

SECTION 24. (1) The Affordable Health Care for All Oregon Fund

22

is established in the State Treasury, separate and distinct from the

23

General Fund, consisting of moneys received under ORS 243.185 and

24

243.882 and sections 8, 26 and 27 of this 2013 Act, moneys appropriated

25

by the Legislative Assembly and moneys received from federal, state,

26

county and local governments and private sources to pay for health

27

care services covered by the Affordable Health Care for All Oregon

28

Plan. Moneys in the Affordable Health Care for All Oregon Fund are

29

continuously appropriated to the Oregon Health Authority to admin-

30

ister the Affordable Health Care for All Oregon Plan and to carry out

31

ORS 442.315 and 442.325 and sections 1, 5, 7, 8, 9, 10, 26 and 27 of this [30]


LC 1914 11/14/12 1

2013 Act.

2

(2) The Affordable Health Care for All Oregon Reserve Account is

3

established in the Affordable Health Care for All Oregon Fund and

4

consists of moneys transferred from the fund to the reserve account.

5

The board shall determine the minimum and maximum amounts of

6

moneys to be maintained in the reserve account.

7

(3) The Affordable Health Care for All Oregon Excess Funds Ac-

8

count is established in the Affordable Health Care for All Oregon Fund

9

and consists of moneys transferred from the fund to the excess funds

10

account under section 25 of this 2013 Act.

Notwithstanding ORS

11

293.190, any moneys remaining in the excess funds account at the end

12

of a biennium that were appropriated from the General Fund do not

13

revert to the General Fund.

14

SECTION 25. (1) Whenever the amount of moneys in the Affordable

15

Health Care for All Oregon Fund exceeds the amount obligated for the

16

remainder of the biennium, the Oregon Health Authority shall trans-

17

fer the excess amount to the Affordable Health Care for All Oregon

18

Excess Funds Account. Moneys in the excess funds account may be

19

transferred to the fund as necessary to carry out the provisions spec-

20

ified in section 24 of this 2013 Act.

21

(2) The Affordable Health Care for All Oregon Board shall establish

22

the maximum amount of moneys to be maintained in the excess funds

23

account. Moneys in the excess funds account may be transferred to

24

the Affordable Health Care for All Oregon Reserve Account.

25

SECTION 26. (1) The Affordable Health Care for All Oregon Plan

26

shall be the primary payer of reimbursement for health services pro-

27

vided through the plan, including but not limited to compensable

28

medical expenses covered by workers’ compensation insurance.

29

(2) The Oregon Health Authority is subrogated to the rights of any

30

person that has a claim against an insurer, tortfeasor, employer, third

31

party administrator, pension manager, public or private corporation, [31]


LC 1914 11/14/12 1

government entity or any other person that may be liable for the cost

2

of health services paid for by the Affordable Health Care for All

3

Oregon Plan.

4

(3) The authority may enter into an agreement with any person for

5

the prepayment of claims anticipated to arise under subsection (2) of

6

this section during a biennium. At the end of the biennium, the au-

7

thority shall appropriately charge or refund to the payer the difference

8

between the amount prepaid and the amount due.

9

(4) All moneys recovered pursuant to this section shall be deposited

10

in the Affordable Health Care for All Oregon Fund established in sec-

11

tion 24 of this 2013 Act.

12 13

FINANCING OF THE AFFORDABLE HEALTH CARE

14

FOR ALL OREGON PLAN

15 16

SECTION 27. (1) The Affordable Health Care for All Oregon Board

17

shall develop recommendations for dedicated funding mechanisms to

18

finance the Affordable Health Care for All Oregon Plan. In lieu of

19

premiums, copayments, coinsurance and deductibles, the plan must

20

be funded by a system of dedicated, progressive taxes that are based

21

on the payer’s ability to pay.

22

payroll tax, a graduated personal income tax, a transaction tax on

23

stocks and bonds, other taxes on unearned income, a progressive

24

surtax on higher incomes, a progressive tax on gross business receipts

25

divided by full-time equivalent employment and any other possible

26

sources of funding.

27

capacity of the source to generate sufficient revenue to fund the plan

28

and maintain an adequate reserve as specified by the board under

29

section 24 (2) of this 2013 Act. The burden of the assessments must be

30

distributed according to ability to pay.

31

The board shall consider an employer

Funding sources must be assessed based on the

(2) The board shall report its recommendations to the appropriate [32]


LC 1914 11/14/12 1

committees of the Seventy-eighth Legislative Assembly in the 2015

2

regular session in the manner provided by ORS 192.245.

3 4

ABOLISHMENT OF OREGON MEDICAL

5

INSURANCE POOL PROGRAM

6 7

SECTION 28. (1) The Oregon Medical Insurance Pool Board is

8

abolished. On the operative date of this section, the tenure of office

9

of the members of the Oregon Medical Insurance Pool Board ceases.

10

(2) All moneys remaining in the Oregon Medical Insurance Pool

11

Account and the Temporary High Risk Pool Program Fund on the op-

12

erative date of this section are transferred for deposit in the Afforda-

13

ble Health Care for All Oregon Fund.

14

SECTION 29. The abolishment of the Oregon Medical Insurance

15

Pool Board by section 28 of this 2013 Act does not affect any action,

16

proceeding or prosecution involving or with respect to the duties,

17

functions and powers of the board begun before and pending at the

18

time of the abolishment, except that the Oregon Health Authority is

19

substituted for the board in the action, proceeding or prosecution.

20

SECTION 30. (1) Nothing in sections 28 and 29 of this 2013 Act, the

21

amendments to statutes and session law by sections 47 to 98 of this

22

2013 Act or the repeal of statutes and session law by section 100 of this

23

2013 Act relieves a person of a liability, duty or obligation accruing

24

under or with respect to the duties, functions and powers of the

25

Oregon Medical Insurance Pool Board that accrues before the opera-

26

tive date of section 28 of this 2013 Act. The Oregon Health Authority

27

may undertake the collection or enforcement of any such liability,

28

duty or obligation.

29

(2) The rights and obligations of the board legally incurred under

30

contracts, leases and business transactions executed, entered into or

31

begun before the operative date of section 28 of this 2013 Act are [33]


LC 1914 11/14/12 1

transferred to the authority. For the purpose of succession to these

2

rights and obligations, the Oregon Health Authority is a continuation

3

of the board.

4

SECTION 31. The rules of the Oregon Medical Insurance Pool Board

5

in effect on the operative date of section 28 of this 2013 Act continue

6

in effect until superseded or repealed by rules of the Oregon Health

7

Authority. References in rules of the board to the board or an officer

8

or employee of the board are considered to be references to the au-

9

thority or an officer or employee of the authority.

10

SECTION 32. Whenever, in any uncodified law or resolution of the

11

Legislative Assembly or in any rule, document, record or proceeding

12

authorized by the Legislative Assembly, reference is made to the

13

Oregon Medical Insurance Pool Board or an officer or employee of the

14

board, the reference is considered to be a reference to the Oregon

15

Health Authority or an officer or employee of the authority.

16

SECTION 33. For the purpose of harmonizing and clarifying statu-

17

tory law, the Legislative Counsel may substitute for words designating

18

the “Oregon Medical Insurance Pool Board” or its officers, wherever

19

they occur in statutory law, words designating the “Oregon Health

20

Authority” or its officers.

21

SECTION 34. For the purpose of harmonizing and clarifying statu-

22

tory law, the Legislative Counsel may substitute for words designating

23

the “Oregon Medical Insurance Pool Account” or “Temporary High

24

Risk Pool Program Fund,” wherever they occur in statutory law,

25

words designating the “Affordable Health Care for All Oregon Fund.”

26 27

ABOLISHMENT OF OFFICE OF

28

PRIVATE HEALTH PARTNERSHIPS

29 30

SECTION 35. The Office of Private Health Partnerships is abolished.

31

On the operative date of this section, the tenure of the Administrator [34]


LC 1914 11/14/12 1

of the Office of Private Health Partnerships ceases.

2

SECTION 36. The abolishment of the Office of Private Health

3

Partnerships by section 35 of this 2013 Act does not affect any action,

4

proceeding or prosecution involving or with respect to the duties,

5

functions and powers of the office begun before and pending at the

6

time of the abolishment, except that the Oregon Health Authority is

7

substituted for the Office of Private Health Partnerships in the action,

8

proceeding or prosecution.

9

SECTION 37. (1) Nothing in sections 35 and 36 of this 2013 Act, the

10

amendments to statutes and session law by sections 47 to 98 of this

11

2013 Act or the repeal of statutes and session law by section 100 of this

12

2013 Act relieves a person of a liability, duty or obligation accruing

13

under or with respect to the duties, functions and powers of the Office

14

of Private Health Partnerships that accrues before the operative date

15

of section 35 of this 2013 Act. The Oregon Health Authority may

16

undertake the collection or enforcement of any such liability, duty or

17

obligation.

18

(2) The rights and obligations of the Office of Private Health Part-

19

nerships legally incurred under contracts, leases and business trans-

20

actions executed, entered into or begun before the operative date of

21

section 35 of this 2013 Act are transferred to the authority. For the

22

purpose of succession to these rights and obligations, the Oregon

23

Health Authority is a continuation of the office.

24

SECTION 38. The rules of the Office of Private Health Partnerships

25

in effect on the operative date of section 35 of this 2013 Act continue

26

in effect until superseded or repealed by rules of the Oregon Health

27

Authority. References in rules of the office to the office or an admin-

28

istrator or employee of the office are considered to be references to

29

the authority or an administrator or employee of the authority.

30

SECTION 39. Whenever, in any uncodified law or resolution of the

31

Legislative Assembly or in any rule, document, record or proceeding [35]


LC 1914 11/14/12 1

authorized by the Legislative Assembly, reference is made to the Office

2

of Private Health Partnerships or to an administrator or employee of

3

the office, the reference is considered to be a reference to the Oregon

4

Health Authority or an administrator or employee of the authority.

5

SECTION 40. For the purpose of harmonizing and clarifying statu-

6

tory law, the Legislative Counsel may substitute for words designating

7

the “Office of Private Health Partnerships” or its administrator,

8

wherever they occur in statutory law, words designating the “Oregon

9

Health Authority” or its director.

10 11

ABOLISHMENT OF OREGON HEALTH INSURANCE EXCHANGE

12 13

SECTION 41. The Oregon Health Insurance Exchange Corporation

14

is abolished. On the operative date of this section, the tenure of the

15

board of directors and the executive director of the Oregon Health

16

Insurance Exchange Corporation ceases.

17

SECTION 42. The abolishment of the Oregon Health Insurance Ex-

18

change Corporation by section 41 of this 2013 Act does not affect any

19

action, proceeding or prosecution involving or with respect to the du-

20

ties, functions and powers of the corporation begun before and pending

21

at the time of the abolishment, except that the Oregon Health Au-

22

thority is substituted for the Oregon Health Insurance Exchange Cor-

23

poration in the action, proceeding or prosecution.

24

SECTION 43. (1) Nothing in sections 41 and 42 of this 2013 Act, the

25

amendments to statutes and session law by sections 47 to 98 of this

26

2013 Act or the repeal of statutes and session law by section 100 of this

27

2013 Act relieves a person of a liability, duty or obligation accruing

28

under or with respect to the duties, functions and powers of the

29

Oregon Health Insurance Exchange Corporation that accrues before

30

the operative date of section 41 of this 2013 Act. The Oregon Health

31

Authority may undertake the collection or enforcement of any such [36]


LC 1914 11/14/12 1

liability, duty or obligation.

2

(2) The rights and obligations of the Oregon Health Insurance Ex-

3

change Corporation legally incurred under contracts, leases and busi-

4

ness transactions executed, entered into or begun before the operative

5

date of section 41 of this 2013 Act are transferred to the authority. For

6

the purpose of succession to these rights and obligations, the Oregon

7

Health Authority is a continuation of the corporation.

8

SECTION 44. The rules of the Oregon Health Insurance Exchange

9

Corporation in effect on the operative date of section 41 of this 2013

10

Act continue in effect until superseded or repealed by rules of the

11

Oregon Health Authority. References in rules of the corporation to the

12

corporation or an administrator or employee of the corporation are

13

considered to be references to the authority or an administrator or

14

employee of the authority.

15

SECTION 45. Whenever, in any uncodified law or resolution of the

16

Legislative Assembly or in any rule, document, record or proceeding

17

authorized by the Legislative Assembly, reference is made to the

18

Oregon Health Insurance Exchange Corporation or to an administrator

19

or employee of the corporation, the reference is considered to be a

20

reference to the Oregon Health Authority or an administrator or em-

21

ployee of the authority.

22

SECTION 46. For the purpose of harmonizing and clarifying statu-

23

tory law, the Legislative Counsel may substitute for words designating

24

the “Oregon Health Insurance Exchange Corporation” or its executive

25

director, wherever they occur in statutory law, words designating the

26

“Oregon Health Authority” or its director.

27 28

CONFORMING AMENDMENTS

29 30

SECTION 47. ORS 65.957 is amended to read:

31

65.957. (1) This chapter applies to all domestic corporations in existence [37]


LC 1914 11/14/12 1

on October 3, 1989, that were incorporated under any general statute of this

2

state providing for incorporation of nonprofit corporations if power to amend

3

or repeal the statute under which the corporation was incorporated was re-

4

served.

5

(2) Without limitation as to any other corporations that may be outside

6

the scope of subsection (1) of this section, this chapter does not apply to the

7

following:

8 9 10 11

(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;

12

(c) The Oregon Insurance Guaranty Association and the Oregon Life and

13

Health Insurance Guaranty Association created under ORS chapter 734; and

14

(d) The Oregon FAIR Plan Association [and the Oregon Medical Insurance

15

Pool] created under ORS chapter 735.

16

SECTION 48. ORS 192.556 is amended to read:

17

192.556. As used in ORS 192.553 to 192.581:

18

(1) “Authorization� means a document written in plain language that

19 20 21 22 23 24 25

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;

26

(d) A description of each purpose of the requested use or disclosure, in-

27

cluding but not limited to a statement that the use or disclosure is at the

28

request of the individual;

29 30 31

(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 indi[38]


LC 1914 11/14/12 1 2 3

vidual and the date; (g) A description of the authority of the personal representative, if applicable; and

4

(h) Statements adequate to place the individual on notice of the following:

5

(A) The individual’s right to revoke the authorization in writing;

6

(B) The exceptions to the right to revoke the authorization;

7

(C) The ability or inability to condition treatment, payment, enrollment

8

or eligibility for benefits on whether the individual signs the authorization;

9

and

10 11

(D) The potential for information disclosed pursuant to the authorization to be subject to redisclosure by the recipient and no longer protected.

12

(2) “Covered entity” means:

13

(a) A state health plan;

14

(b) A health insurer;

15

(c) A health care provider that transmits any health information in elec-

16

tronic form to carry out financial or administrative activities in connection

17

with a transaction covered by ORS 192.553 to 192.581; or

18

(d) A health care clearinghouse.

19

(3) “Health care” means care, services or supplies related to the health

20

of an individual.

21

(4) “Health care operations” includes but is not limited to:

22

(a) Quality assessment, accreditation, auditing and improvement activ-

23

ities;

24

(b) Case management and care coordination;

25

(c) Reviewing the competence, qualifications or performance of health

26

care providers or health insurers;

27

(d) Underwriting activities;

28

(e) Arranging for legal services;

29

(f) Business planning;

30

(g) Customer services;

31

(h) Resolving internal grievances; [39]


LC 1914 11/14/12 1

(i) Creating deidentified information; and

2

(j) Fundraising.

3

(5) “Health care provider� includes but is not limited to:

4

(a) A psychologist, occupational therapist, regulated social worker, pro-

5

fessional counselor or marriage and family therapist licensed or otherwise

6

authorized to practice under ORS chapter 675 or an employee of the psy-

7

chologist, occupational therapist, regulated social worker, professional

8

counselor or marriage and family therapist;

9

(b) A physician, podiatric physician and surgeon, physician assistant or

10

acupuncturist licensed under ORS chapter 677 or an employee of the physi-

11

cian, podiatric physician and surgeon, physician assistant or acupuncturist;

12 13 14 15 16 17

(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;

18

(f) A speech-language pathologist or audiologist licensed under ORS

19

chapter 681 or an employee of the speech-language pathologist or audiologist;

20

(g) An emergency medical services provider licensed under ORS chapter

21 22 23 24 25 26 27 28 29 30 31

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; [40]


LC 1914 11/14/12 1 2 3 4 5 6 7 8 9 10 11 12 13 14

(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 688.815 or an employee of the respiratory care practitioner; (p) A polysomnographic technologist licensed under ORS 688.819 or an employee of the polysomnographic technologist; (q) A pharmacist licensed under ORS chapter 689 or an employee of the pharmacist; (r) A dietitian licensed under ORS 691.405 to 691.485 or an employee of the dietitian; (s) A funeral service practitioner licensed under ORS chapter 692 or an employee of the funeral service practitioner;

15

(t) A health care facility as defined in ORS 442.015;

16

(u) A home health agency as defined in ORS 443.005;

17

(v) A hospice program as defined in ORS 443.850;

18

(w) A clinical laboratory as defined in ORS 438.010;

19

(x) A pharmacy as defined in ORS 689.005;

20

(y) A diabetes self-management program as defined in ORS 743A.184; and

21

(z) Any other person or entity that furnishes, bills for or is paid for health

22 23 24

care in the normal course of business. (6) “Health information� means any oral or written information in any form or medium that:

25

(a) Is created or received by a covered entity, a public health authority,

26

an employer, a life insurer, a school, a university or a health care provider

27

that is not a covered entity; and

28

(b) Relates to:

29

(A) The past, present or future physical or mental health or condition of

30 31

an individual; (B) The provision of health care to an individual; or [41]


LC 1914 11/14/12 1 2

(C) The past, present or future payment for the provision of health care to an individual.

3

(7) “Health insurer” means[:]

4

[(a)] an insurer as defined in ORS 731.106 who offers:

5

[(A)] (a) A health benefit plan as defined in ORS 743.730;

6

[(B)] (b) A short term health insurance policy, the duration of which does

7

not exceed six months including renewals;

8

[(C)] (c) A student health insurance policy;

9

[(D)] (d) A Medicare supplemental policy; or

10

[(E)] (e) A dental only policy.

11

[(b) The Oregon Medical Insurance Pool operated by the Oregon Medical

12 13 14 15 16

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

17

(b) Identifiable to an individual, including demographic information that

18

identifies the individual, or for which there is a reasonable basis to believe

19

the information can be used to identify an individual, and that relates to:

20 21

(A) The past, present or future physical or mental health or condition of an individual;

22

(B) The provision of health care to an individual; or

23

(C) The past, present or future payment for the provision of health care

24

to an individual.

25

(9) “Payment” includes but is not limited to:

26

(a) Efforts to obtain premiums or reimbursement;

27

(b) Determining eligibility or coverage;

28

(c) Billing activities;

29

(d) Claims management;

30

(e) Reviewing health care to determine medical necessity;

31

(f) Utilization review; and [42]


LC 1914 11/14/12 1

(g) Disclosures to consumer reporting agencies.

2

(10) “Personal representative” includes but is not limited to:

3

(a) A person appointed as a guardian under ORS 125.305, 419B.370,

4

419C.481 or 419C.555 with authority to make medical and health care deci-

5

sions;

6

(b) A person appointed as a health care representative under ORS 127.505

7

to 127.660 or a representative under ORS 127.700 to 127.737 to make health

8

care decisions or mental health treatment decisions;

9 10

(c) A person appointed as a personal representative under ORS chapter 113; and

11

(d) A person described in ORS 192.573.

12

(11)(a) “Protected health information” means individually identifiable

13

health information that is maintained or transmitted in any form of elec-

14

tronic or other medium by a covered entity.

15 16 17 18

(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);

19

(B) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); or

20

(C) Employment records held by a covered entity in its role as employer.

21

(12) “State health plan” means:

22

(a) Medical assistance as defined in ORS 414.025;

23

(b) The Health Care for All Oregon Children program;

24

[(c) The Family Health Insurance Assistance Program established in ORS

25 26 27 28 29

414.841 to 414.864; or] (c) The Affordable Health Care for All Oregon Plan established by section 1 of this 2013 Act; or (d) Any medical assistance or premium assistance program operated by the Oregon Health Authority or the Department of Human Services.

30

(13) “Treatment” includes but is not limited to:

31

(a) The provision, coordination or management of health care; and [43]


LC 1914 11/14/12 1

(b) Consultations and referrals between health care providers.

2

SECTION 49. ORS 243.886, as amended by sections 9 and 13, chapter 38,

3

Oregon Laws 2012, is amended to read:

4

243.886. (1) Except as provided in subsections (2), (3) and (4) of this sec-

5

tion, a district may not provide or contract for a benefit plan and eligible

6

employees of districts may not participate in a benefit plan unless the benefit

7

plan[:]

8 9 10 11

[(a)] is provided and administered by the Oregon Educators Benefit Board under ORS 243.860 to 243.886[; or] [(b) Is offered through the health insurance exchange under ORS 741.310 (1)(c)].

12

(2)(a) Except for community college districts, a district that was self-

13

insured before January 1, 2007, or a district that had an independent health

14

insurance trust established and functioning before January 1, 2007, may

15

provide or contract for benefit plans other than benefit plans provided and

16

administered by the board if the premiums for the benefit plans provided or

17

contracted for by the district are equal to or less than the premiums for

18

comparable benefit plans provided and administered by the board.

19 20

(b) A community college district may provide or contract for benefit plans other than benefit plans provided and administered by the board.

21

(c) In accordance with procedures adopted by the board to extend benefit

22

plan coverage under ORS 243.864 to 243.874 to eligible employees of a self-

23

insured district, a district with an independent health insurance trust or a

24

community college district, these districts may choose to offer benefit plans

25

that are provided and administered by the board. Once employees of a dis-

26

trict participate in benefit plans provided and administered by the board, the

27

district may not thereafter provide or contract for benefit plans other than

28

those provided and administered by the board.

29

(3)(a) A district that has not offered benefit plans provided and adminis-

30

tered by the board before June 23, 2009, may provide or contract for benefit

31

plans other than benefit plans provided and administered by the board if the [44]


LC 1914 11/14/12 1

premiums for the benefit plans provided or contracted for by the district are

2

equal to or less than the premiums for comparable benefit plans provided and

3

administered by the board. Once employees of a district or an employee

4

group within a district participates in benefit plans provided and adminis-

5

tered by the board, the district may not thereafter provide or contract for

6

benefit plans for those employees or employee groups other than those pro-

7

vided and administered by the board.

8

(b) To maintain the exception created in this subsection, the board must

9

perform an actuarial analysis of the district at least once every two years.

10

If requested by the district or a labor organization representing eligible em-

11

ployees of the district, the board shall perform the actuarial analysis annu-

12

ally.

13 14 15 16

(c) As used in this subsection, “district� does not include a community college district. (4) Nothing in ORS 243.860 to 243.886 may be construed to expand or contract collective bargaining rights or collective bargaining obligations.

17

SECTION 50. ORS 291.055 is amended to read:

18

291.055. (1) Notwithstanding any other law that grants to a state agency

19

the authority to establish fees, all new state agency fees or fee increases

20

adopted during the period beginning on the date of adjournment sine die of

21

a regular session of the Legislative Assembly and ending on the date of

22

adjournment sine die of the next regular session of the Legislative Assembly:

23

(a) Are not effective for agencies in the executive department of govern-

24

ment unless approved in writing by the Director of the Oregon Department

25

of Administrative Services;

26

(b) Are not effective for agencies in the judicial department of govern-

27

ment unless approved in writing by the Chief Justice of the Supreme Court;

28

(c) Are not effective for agencies in the legislative department of gov-

29

ernment unless approved in writing by the President of the Senate and the

30

Speaker of the House of Representatives;

31

(d) Shall be reported by the state agency to the Oregon Department of [45]


LC 1914 11/14/12 1

Administrative Services within 10 days of their adoption; and

2

(e) Are rescinded on adjournment sine die of the next regular session of

3

the Legislative Assembly as described in this subsection, unless otherwise

4

authorized by enabling legislation setting forth the approved fees.

5

(2) This section does not apply to:

6

(a) Any tuition or fees charged by the State Board of Higher Education

7

and the public universities listed in ORS 352.002.

8

(b) Taxes or other payments made or collected from employers for unem-

9

ployment insurance required by ORS chapter 657 or premium assessments

10

required by ORS 656.612 and 656.614 or contributions and assessments cal-

11

culated by cents per hour for workers’ compensation coverage required by

12

ORS 656.506.

13

(c) Fees or payments required for:

14

(A) Health care services provided by the Oregon Health and Science

15

University, by the Oregon Veterans’ Homes and by other state agencies and

16

institutions pursuant to ORS 179.610 to 179.770.

17 18 19 20 21 22

[(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.

23

(d) Fees created or authorized by statute that have no established rate

24

or amount but are calculated for each separate instance for each fee payer

25

and are based on actual cost of services provided.

26

(e) State agency charges on employees for benefits and services.

27

(f) Any intergovernmental charges.

28

(g) Forest protection district assessment rates established by ORS 477.210

29

to 477.265 and the Oregon Forest Land Protection Fund fees established by

30

ORS 477.760.

31

(h) State Department of Energy assessments required by ORS 469.421 (8) [46]


LC 1914 11/14/12 1 2 3

and 469.681. (i) Any charges established by the State Parks and Recreation Director in accordance with ORS 565.080 (3).

4

(j) Assessments on premiums charged by the Department of Consumer and

5

Business Services pursuant to ORS 731.804 or fees charged by the Division

6

of Finance and Corporate Securities of the Department of Consumer and

7

Business Services to banks, trusts and credit unions pursuant to ORS 706.530

8

and 723.114.

9

(k) Public Utility Commission operating assessments required by ORS

10

756.310 or charges paid to the Residential Service Protection Fund required

11

by chapter 290, Oregon Laws 1987.

12 13

(L) Fees charged by the Housing and Community Services Department for intellectual property pursuant to ORS 456.562.

14

(m) New or increased fees that are anticipated in the legislative budgeting

15

process for an agency, revenues from which are included, explicitly or im-

16

plicitly, in the legislatively adopted budget or the legislatively approved

17

budget for the agency.

18 19

(n) Tolls approved by the Oregon Transportation Commission pursuant to ORS 383.004.

20

(o) Convenience fees as defined in ORS 182.126 and established by the

21

Oregon Department of Administrative Services under ORS 182.132 (3) and

22

recommended by the Electronic Government Portal Advisory Board.

23

(3)(a) Fees temporarily decreased for competitive or promotional reasons

24

or because of unexpected and temporary revenue surpluses may be increased

25

to not more than their prior level without compliance with subsection (1)

26

of this section if, at the time the fee is decreased, the state agency specifies

27

the following:

28

(A) The reason for the fee decrease; and

29

(B) The conditions under which the fee will be increased to not more than

30 31

its prior level. (b) Fees that are decreased for reasons other than those described in [47]


LC 1914 11/14/12 1

paragraph (a) of this subsection may not be subsequently increased except

2

as allowed by ORS 291.050 to 291.060 and 294.160.

3

SECTION 51. ORS 411.402 is amended to read:

4

411.402. (1) The Department of Human Services and the Oregon Health

5

Authority shall adopt by rule the documentation required from each person

6

applying for medical assistance, including documentation of:

7

(a) The identity of the person;

8

(b) The category of aid that makes the person eligible for medical assist-

9

ance or the way in which the person qualifies as categorically needy;

10

(c) The status of the person as a resident of this state; and

11

(d) Information concerning the income and resources of the person, which

12

may include income tax return information and Social Security number, as

13

necessary to establish financial eligibility for medical assistance, premium

14

tax credits and cost-sharing reductions.

15

(2) Information obtained by the department or the authority under this

16

section may be exchanged with other state or federal agencies for the pur-

17

pose of:

18 19 20 21

(a) Verifying eligibility for medical assistance[, participation in the Oregon Health Insurance Exchange] or other health benefit programs; (b) Establishing the amount of any tax credit due to the person, costsharing reduction or premium assistance;

22

(c) Improving the provision of services; and

23

(d) Administering health benefit programs.

24

SECTION 52. ORS 413.011, as amended by section 15, chapter 38, Oregon

25

Laws 2012, is amended to read:

26

413.011. (1) The duties of the Oregon Health Policy Board are to:

27

(a) Be the policy-making and oversight body for the Oregon Health Au-

28

thority established in ORS 413.032 and all of the authority’s departmental

29

divisions.

30

[(b) Develop and submit a plan to the Legislative Assembly by December

31

31, 2010, to provide and fund access to affordable, quality health care for all [48]


LC 1914 11/14/12 1 2 3

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.]

4

[(d)] (b) Establish and continuously refine uniform, statewide health care

5

quality standards for use by all purchasers of health care, third-party payers

6

and health care providers as quality performance benchmarks.

7 8

[(e)] (c) Establish evidence-based clinical standards and practice guidelines that may be used by providers.

9

[(f)] (d) Approve and monitor community-centered health initiatives de-

10

scribed in ORS 413.032 (1)(i) that are consistent with public health goals,

11

strategies, programs and performance standards adopted by the Oregon

12

Health Policy Board to improve the health of all Oregonians, and shall reg-

13

ularly report to the Legislative Assembly on the accomplishments and needed

14

changes to the initiatives.

15 16

[(g)] (e) Establish cost containment mechanisms to reduce health care costs.

17

[(h)] (f) Ensure that Oregon’s health care workforce is sufficient in

18

numbers and training to meet the demand that will be created by the ex-

19

pansion in health coverage, health care system transformations, an increas-

20

ingly diverse population and an aging workforce.

21

[(i)] (g) Work with the Oregon congressional delegation to advance the

22

adoption of changes in federal law or policy to promote Oregon’s compre-

23

hensive health reform plan.

24

[(j) Establish a health benefit package in accordance with ORS 741.340 to

25

be used as the baseline for all health benefit plans offered through the Oregon

26

Health Insurance Exchange.]

27

[(k)] (h) By December 31 [, 2010] of each year, investigate and report to

28

the Legislative Assembly[, and annually thereafter,] on the feasibility and

29

advisability of future changes to the health insurance market in Oregon,

30

including but not limited to the following:

31

(A) A requirement for every resident to have health insurance coverage. [49]


LC 1914 11/14/12 1 2 3 4

[(B) A payroll tax as a means to encourage employers to continue providing health insurance to their employees.] [(C)] (B) The implementation of a system of interoperable electronic health records utilized by all health care providers in this state.

5

[(L)] (i) Meet cost-containment goals by structuring reimbursement rates

6

to reward comprehensive management of diseases, quality outcomes and the

7

efficient use of resources by promoting cost-effective procedures, services and

8

programs including, without limitation, preventive health, dental and pri-

9

mary care services, web-based office visits, telephone consultations and tele-

10

medicine consultations.

11

[(m)] (j) Oversee the expenditure of moneys from the Health Care

12

Workforce Strategic Fund to support grants to primary care providers and

13

rural health practitioners, to increase the number of primary care educators

14

and to support efforts to create and develop career ladder opportunities.

15

[(n)] (k) Work with the Public Health Benefit Purchasers Committee,

16

administrators of the medical assistance program and the Department of

17

Corrections to identify uniform contracting standards for health benefit

18

plans that achieve maximum quality and cost outcomes and align the con-

19

tracting standards for all state programs to the greatest extent practicable.

20

(2) The Oregon Health Policy Board is authorized to:

21

(a) Subject to the approval of the Governor and the Affordable Health

22

Care for All Oregon Board established in section 5 of this 2013 Act,

23

organize and reorganize the authority as the Oregon Health Policy Board

24

considers necessary to properly conduct the work of the authority.

25

(b) Submit directly to the Legislative Counsel, no later than October 1

26

of each even-numbered year, requests for measures necessary to provide

27

statutory authorization to carry out any of the board’s duties or to imple-

28

ment any of the board’s recommendations. The measures may be filed prior

29

to the beginning of the legislative session in accordance with the rules of

30

the House of Representatives and the Senate.

31

(3) If the board or the authority is unable to perform, in whole or in part, [50]


LC 1914 11/14/12 1

any of the duties described in ORS 413.006 to 413.042[,] and 413.101 [and

2

741.340] without federal approval, the authority is authorized to request, in

3

accordance with ORS 413.072, waivers or other approval necessary to perform

4

those duties. The authority shall implement any portions of those duties not

5

requiring legislative authority or federal approval, to the extent practicable.

6

(4) The enumeration of duties, functions and powers in this section is not

7

intended to be exclusive nor to limit the duties, functions and powers im-

8

posed on the board by ORS 413.006 to 413.042[,] and 413.101 [and 741.340] and

9

by other statutes.

10

(5) The board shall consult with the Department of Consumer and Busi-

11

ness Services in completing the [tasks] task set forth in subsection [(1)(j) and

12

(k)(A)] (1)(h)(A) of this section.

13

SECTION 53. ORS 413.017 is amended to read:

14

413.017. (1) The Oregon Health Policy Board shall establish the commit-

15 16 17

tees 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:

18

(A) The Public Employees’ Benefit Board.

19

(B) The Oregon Educators Benefit Board.

20

(C) Trustees of the Public Employees Retirement System.

21

(D) A city government.

22

(E) A county government.

23

(F) A special district.

24

(G) Any private nonprofit organization that receives the majority of its

25

funding from the state and requests to participate on the committee.

26

(b) The Public Health Benefit Purchasers Committee shall:

27

(A) Identify and make specific recommendations to achieve uniformity

28

across all public health benefit plan designs based on the best available

29

clinical evidence, recognized best practices for health promotion and disease

30

management, demonstrated

31

among the enrollees within the pools covered by the benefit plans.

cost-effectiveness

[51]

and

shared

demographics


LC 1914 11/14/12 1

(B) Develop an action plan for ongoing collaboration to implement the

2

benefit design alignment described in subparagraph (A) of this paragraph and

3

shall leverage purchasing to achieve benefit uniformity if practicable.

4

(C) Continuously review and report to the Oregon Health Policy Board

5

on the committee’s progress in aligning benefits while minimizing the cost

6

shift to individual purchasers of insurance without shifting costs to the pri-

7

vate sector [or the Oregon Health Insurance Exchange].

8

(c) The Oregon Health Policy Board shall work with the Public Health

9

Benefit Purchasers Committee to identify uniform provisions for state and

10

local public contracts for health benefit plans that achieve maximum quality

11

and cost outcomes. The board shall collaborate with the committee to de-

12

velop steps to implement joint contract provisions. The committee shall

13

identify a schedule for the implementation of contract changes. The process

14

for implementation of joint contract provisions must include a review process

15

to protect against unintended cost shifts to enrollees or agencies.

16

[(d) Proposals and plans developed in accordance with this subsection shall

17

be completed by October 1, 2010, and shall be submitted to the Oregon Health

18

Policy Board for its approval and possible referral to the Legislative Assembly

19

no later than December 31, 2010.]

20

(3)(a) The Health Care Workforce Committee shall include individuals

21

who have the collective expertise, knowledge and experience in a broad

22

range of health professions, health care education and health care workforce

23

development initiatives.

24

(b) The Health Care Workforce Committee shall coordinate efforts to re-

25

cruit and educate health care professionals and retain a quality workforce

26

to meet the demand that will be created by the expansion in health care

27

coverage, system transformations and an increasingly diverse population.

28

(c) The Health Care Workforce Committee shall conduct an inventory of

29

all grants and other state resources available for addressing the need to ex-

30

pand the health care workforce to meet the needs of Oregonians for health

31

care. [52]


LC 1914 11/14/12 1

(4) Members of the committees described in subsections (2) and (3) of this

2

section who are not members of the Oregon Health Policy Board are not

3

entitled to compensation but shall be reimbursed from funds available to the

4

board for actual and necessary travel and other expenses incurred by them

5

by their attendance at committee meetings, in the manner and amount pro-

6

vided in ORS 292.495.

7

SECTION 54. ORS 413.032 is amended to read:

8

413.032. (1) The Oregon Health Authority is established. The authority

9 10 11 12 13

shall: (a) Carry out policies adopted by the Oregon Health Policy Board and the Affordable Health Care for All Oregon Board; (b) Administer the Oregon Integrated and Coordinated Health Care Delivery System established in ORS 414.620;

14

(c) Administer the Oregon Prescription Drug Program;

15

(d) Administer the Family Health Insurance Assistance Program;

16

(e) Develop the policies for and the provision of publicly funded medical

17 18 19 20 21

care and medical assistance in this state; (f) Develop the policies for and the provision of mental health treatment and treatment of addictions; (g) Assess, promote and protect the health of the public as specified by state and federal law;

22

(h) Provide regular reports to the Oregon Health Policy Board with re-

23

spect to the performance of health services contractors serving recipients of

24

medical assistance, including reports of trends in health services and

25

enrollee satisfaction;

26

(i) Guide and support, with the authorization of the Oregon Health

27

Policy Board, community-centered health initiatives designed to address

28

critical risk factors, especially those that contribute to chronic disease;

29

(j) Be the state Medicaid agency for the administration of funds from

30

Titles XIX and XXI of the Social Security Act and administer medical as-

31

sistance under ORS chapter 414; [53]


LC 1914 11/14/12 1

(k) In consultation with the Director of the Department of Consumer and

2

Business Services, periodically review and recommend standards and meth-

3

odologies to the Legislative Assembly for:

4

(A) Review of administrative expenses of health insurers;

5

(B) Approval of rates; and

6

(C) Enforcement of rating rules adopted by the Department of Consumer

7

and Business Services;

8

(L) Structure reimbursement rates for providers that serve recipients of

9

medical assistance to reward comprehensive management of diseases, quality

10

outcomes and the efficient use of resources and to promote cost-effective

11

procedures, services and programs including, without limitation, preventive

12

health, dental and primary care services, web-based office visits, telephone

13

consultations and telemedicine consultations;

14

(m) Guide and support community three-share agreements in which an

15

employer, state or local government and an individual all contribute a por-

16

tion of a premium for a community-centered health initiative or for insur-

17

ance coverage;

18

(n) Develop, in consultation with the Department of Consumer and Busi-

19

ness Services, one or more products designed to provide more affordable

20

options for the small group market; and

21 22

(o) Implement policies and programs to expand the skilled, diverse workforce as described in ORS 414.018 (4).

23

(2) The Oregon Health Authority is authorized to:

24

(a) Create an all-claims, all-payer database to collect health care data and

25

monitor and evaluate health care reform in Oregon and to provide compar-

26

ative cost and quality information to consumers, providers and purchasers

27

of health care about Oregon’s health care systems and health plan networks

28

in order to provide comparative information to consumers.

29 30 31

(b) Develop uniform contracting standards for the purchase of health care, including the following: (A) Uniform quality standards and performance measures; [54]


LC 1914 11/14/12 1 2 3 4 5 6

(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.

7

(3) The enumeration of duties, functions and powers in this section is not

8

intended to be exclusive nor to limit the duties, functions and powers im-

9

posed on or vested in the Oregon Health Authority by ORS 413.006 to 413.042,

10 11 12 13 14 15 16 17 18

413.101 and 741.340 and section 10 of this 2013 Act or by other statutes. SECTION 55. ORS 413.032, as amended by section 54 of this 2013 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) Administer the Oregon Integrated and Coordinated Health Care Delivery System established in ORS 414.620;

19

(c) Administer the Oregon Prescription Drug Program;

20

[(d) Administer the Family Health Insurance Assistance Program;]

21

(d) Implement and administer the Affordable Health Care for All

22 23 24 25 26 27 28

Oregon Plan established in section 1 of this 2013 Act; (e) Develop the policies for and the provision of publicly funded medical care and medical assistance in this state; (f) Develop the policies for and the provision of mental health treatment and treatment of addictions; (g) Assess, promote and protect the health of the public as specified by state and federal law;

29

(h) Provide regular reports to the Oregon Health Policy Board with re-

30

spect to the performance of health services contractors serving recipients of

31

medical assistance, including reports of trends in health services and [55]


LC 1914 11/14/12 1

enrollee satisfaction;

2

(i) Guide and support, with the authorization of the Oregon Health Policy

3

Board, community-centered health initiatives designed to address critical

4

risk factors, especially those that contribute to chronic disease;

5

(j) Be the state Medicaid agency for the administration of funds from

6

Titles XIX and XXI of the Social Security Act and administer medical as-

7

sistance under ORS chapter 414;

8

(k) In consultation with the Director of the Department of Consumer and

9

Business Services, periodically review and recommend standards and meth-

10

odologies to the Legislative Assembly for:

11

(A) Review of administrative expenses of health insurers;

12

(B) Approval of rates; and

13

(C) Enforcement of rating rules adopted by the Department of Consumer

14

and Business Services;

15

(L) Structure reimbursement rates for providers that serve recipients of

16

medical assistance to reward comprehensive management of diseases, quality

17

outcomes and the efficient use of resources and to promote cost-effective

18

procedures, services and programs including, without limitation, preventive

19

health, dental and primary care services, web-based office visits, telephone

20

consultations and telemedicine consultations;

21

(m) Guide and support community three-share agreements in which an

22

employer, state or local government and an individual all contribute a por-

23

tion of a premium for a community-centered health initiative or for insur-

24

ance coverage;

25

(n) Develop, in consultation with the Department of Consumer and Busi-

26

ness Services, one or more products designed to provide more affordable

27

options for the small group market; and

28 29

(o) Implement policies and programs to expand the skilled, diverse workforce as described in ORS 414.018 (4).

30

(2) The Oregon Health Authority is authorized to:

31

(a) Create an all-claims, all-payer database to collect health care data and [56]


LC 1914 11/14/12 1

monitor and evaluate health care reform in Oregon and to provide compar-

2

ative cost and quality information to consumers, providers and purchasers

3

of health care about Oregon’s health care systems and health plan networks

4

in order to provide comparative information to consumers.

5 6

(b) Develop uniform contracting standards for the purchase of health care, including the following:

7

(A) Uniform quality standards and performance measures;

8

(B) Evidence-based guidelines for major chronic disease management and

9 10 11 12 13

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.

14

(3) The enumeration of duties, functions and powers in this section is not

15

intended to be exclusive nor to limit the duties, functions and powers im-

16

posed on or vested in the Oregon Health Authority by ORS 413.006 to

17

413.042[,] and 413.101 [and 741.340] and section 10 of this 2013 Act or by

18

other statutes.

19

SECTION 56. ORS 413.037 is amended to read:

20

413.037. The Director of the Oregon Health Authority, each deputy direc-

21

tor and authorized representatives of the director may administer oaths, take

22

depositions and issue subpoenas to compel the attendance of witnesses and

23

the production of documents or other written information necessary to carry

24

out the provisions of ORS 413.006 to 413.042[,] and 413.101 [and 741.340]. If

25

any person fails to comply with a subpoena issued under this section or re-

26

fuses to testify on matters on which the person lawfully may be interrogated,

27

the director, deputy director or authorized representative may follow the

28

procedure set out in ORS 183.440 to compel obedience.

29

SECTION 57. ORS 413.201 is amended to read:

30

413.201. (1) The Oregon Health Authority is responsible for statewide

31

outreach and marketing of the Health Care for All Oregon Children program [57]


LC 1914 11/14/12 1

established in ORS 414.231 [and administered by the authority and the Office

2

of Private Health Partnerships] with the goal of enrolling [in those

3

programs] all eligible children residing in this state.

4

(2) To maximize the enrollment and retention of eligible children in the

5

Health Care for All Oregon Children program, the authority shall develop

6

and administer a grant program to provide funding to organizations and

7

community based groups to deliver culturally specific and targeted outreach

8

and direct application assistance to:

9

(a) Members of racial, ethnic and language minority communities;

10

(b) Children living in geographic isolation; and

11

(c) Children and family members with additional barriers to accessing

12

health care, such as cognitive, mental health or sensory disorders, physical

13

disabilities or chemical dependency, and children experiencing homelessness.

14

SECTION 58. ORS 414.041 is amended to read:

15

414.041. (1) The Oregon Health Authority, under the direction of the

16

Oregon Health Policy Board and in collaboration with the Department of

17

Human Services, shall implement a streamlined and simple application pro-

18

cess for the medical assistance [and premium assistance programs] program

19

administered by the Oregon Health Authority [and the Office of Private

20

Health Partnerships]. The process shall include, but not be limited to:

21

(a) An online application that may be submitted via the Internet;

22

(b) Application forms that are readable at a sixth grade level and that

23

request the minimum amount of information necessary to begin processing

24

the application; and

25

(c) Application assistance from qualified staff to aid individuals who have

26

language, cognitive, physical or geographic barriers to applying for medical

27

assistance [or premium assistance].

28

(2) In developing the simplified application forms, the department shall

29

consult with persons not employed by the department who have experience

30

in serving vulnerable and hard-to-reach populations.

31

(3) The Oregon Health Authority shall facilitate outreach and enrollment [58]


LC 1914 11/14/12 1

efforts to connect eligible individuals with all available publicly funded

2

health programs[, including but not limited to the Family Health Insurance

3

Assistance Program].

4

SECTION 59. ORS 414.231 is amended to read:

5

414.231. (1) As used in this section, “child” means a person under 19 years

6

of age.

7

(2) The Health Care for All Oregon Children program is established to

8

make affordable, accessible health care available to all of Oregon’s children.

9

The program is composed of[:]

10

[(a)] medical assistance funded in whole or in part by Title XIX of the

11

Social Security Act, by the State Children’s Health Insurance Program under

12

Title XXI of the Social Security Act and by moneys appropriated or allocated

13

for that purpose by the Legislative Assembly.[; and]

14 15

[(b) A private health option administered by the Office of Private Health Partnerships under ORS 414.826.]

16

(3) A child is eligible for the program if the child is lawfully present in

17

this state and the income of the child’s family is at or below 300 percent of

18

the federal poverty guidelines. There is no asset limit to qualify for the

19

program.

20 21

(4)(a) A child receiving medical assistance under the program is continuously eligible for a minimum period of 12 months.

22

(b) The Department of Human Services shall reenroll a child for succes-

23

sive 12-month periods of enrollment as long as the child is eligible for med-

24

ical assistance on the date of reenrollment.

25

(c) The department may not require a new application as a condition of

26

reenrollment under paragraph (b) of this subsection and must determine the

27

child’s eligibility for medical assistance using information and sources

28

available to the department or documentation readily available.

29

(5) Except for medical assistance funded by Title XIX of the Social Secu-

30

rity Act, the department or the Oregon Health Authority may prescribe by

31

rule a period of uninsurance prior to enrollment in the program. [59]


LC 1914 11/14/12 1

SECTION 60. Section 1, chapter 867, Oregon Laws 2009, as amended by

2

section 46, chapter 828, Oregon Laws 2009, section 2, chapter 73, Oregon

3

Laws 2010, and section 31, chapter 602, Oregon Laws 2011, is amended to

4

read:

5

Sec. 1. (1) The Health System Fund is established in the State Treasury,

6

separate and distinct from the General Fund. Interest earned by the Health

7

System Fund shall be credited to the fund.

8

(2) Amounts in the Health System Fund are continuously appropriated to

9

the Oregon Health Authority for the purpose of funding the Health Care for

10

All Oregon Children program established in ORS 414.231, health services

11

described in ORS 414.025 (8)(a) to (j) and other health services. Moneys in

12

the fund may also be used by the authority to:

13 14 15 16 17 18 19 20

(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 414.025 (8) to individuals described in ORS 414.025 (3)(f)(B).

21

[(3) The authority shall develop a system for reimbursement by the authority

22

to the Office of Private Health Partnerships out of the Health System Fund

23

for costs associated with administering the private health option pursuant to

24

ORS 414.826.]

25

SECTION 61. ORS 430.315 is amended to read:

26

430.315. The Legislative Assembly finds alcoholism or drug dependence is

27

an illness. The alcoholic or drug-dependent person is ill and should be af-

28

forded treatment for that illness. To the greatest extent possible, the least

29

costly settings for treatment, outpatient services and residential facilities

30

shall be widely available and utilized except when contraindicated because

31

of individual health care needs. State agencies that purchase treatment for [60]


LC 1914 11/14/12 1

alcoholism or drug dependence shall develop criteria consistent with this

2

policy in consultation with the Oregon Health Authority. In [reviewing ap-

3

plications for] developing policies and approving the adoption of rules

4

for approving a certificate of need, the [Director of the Oregon Health Au-

5

thority] Affordable Health Care for All Oregon Board shall take this

6

policy into account.

7

SECTION 62. ORS 433.443 is amended to read:

8

433.443. (1) As used in this section:

9

(a) “Covered entity” means:

10 11 12 13 14 15

(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

16

[(D) The state medical assistance program; and]

17

[(E)] (D) A health care provider.

18

(b) “Health care provider” includes but is not limited to:

19

(A) A psychologist, occupational therapist, regulated social worker, pro-

20

fessional counselor or marriage and family therapist licensed or otherwise

21

authorized to practice under ORS chapter 675 or an employee of the psy-

22

chologist, occupational therapist, regulated social worker, professional

23

counselor or marriage and family therapist;

24

(B) A physician, podiatric physician and surgeon, physician assistant or

25

acupuncturist licensed under ORS chapter 677 or an employee of the physi-

26

cian, podiatric physician and surgeon, physician assistant or acupuncturist;

27 28 29 30 31

(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 [61]


LC 1914 11/14/12 1

employee of the dental hygienist or denturist;

2

(F) A speech-language pathologist or audiologist licensed under ORS

3

chapter 681 or an employee of the speech-language pathologist or audiologist;

4

(G) An emergency medical services provider licensed under ORS chapter

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

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 688.815 or an employee of the respiratory care practitioner; (P) A polysomnographic technologist licensed under ORS 688.819 or an employee of the polysomnographic technologist; (Q) A pharmacist licensed under ORS chapter 689 or an employee of the pharmacist; (R) A dietitian licensed under ORS 691.405 to 691.485 or an employee of the dietitian; (S) A funeral service practitioner licensed under ORS chapter 692 or an employee of the funeral service practitioner;

30

(T) A health care facility as defined in ORS 442.015;

31

(U) A home health agency as defined in ORS 443.005; [62]


LC 1914 11/14/12 1

(V) A hospice program as defined in ORS 443.850;

2

(W) A clinical laboratory as defined in ORS 438.010;

3

(X) A pharmacy as defined in ORS 689.005;

4

(Y) A diabetes self-management program as defined in ORS 743A.184; and

5

(Z) Any other person or entity that furnishes, bills for or is paid for

6

health care in the normal course of business.

7

(c) “Individual” means a natural person.

8

(d) “Individually identifiable health information” means any oral or

9 10 11

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

12

(B) Identifiable to an individual, including demographic information that

13

identifies the individual, or for which there is a reasonable basis to believe

14

the information can be used to identify an individual, and that relates to:

15 16

(i) The past, present or future physical or mental health or condition of an individual;

17

(ii) The provision of health care to an individual; or

18

(iii) The past, present or future payment for the provision of health care

19

to an individual.

20

(e) “Legal representative” means attorney at law, person holding a gen-

21

eral power of attorney, guardian, conservator or any person appointed by a

22

court to manage the personal or financial affairs of a person, or agency le-

23

gally responsible for the welfare or support of a person.

24

(2)(a) During a public health emergency declared under ORS 433.441, the

25

Public Health Director may, as necessary to appropriately respond to the

26

public health emergency:

27

(A) Adopt reporting requirements for and provide notice of those re-

28

quirements to health care providers, institutions and facilities for the pur-

29

pose of obtaining information directly related to the public health

30

emergency;

31

(B) After consultation with appropriate medical experts, create and re[63]


LC 1914 11/14/12 1

quire the use of diagnostic and treatment protocols to respond to the public

2

health emergency and provide notice of those protocols to health care pro-

3

viders, institutions and facilities;

4 5

(C) Order, or authorize local public health administrators to order, public health measures appropriate to the public health threat presented;

6

(D) Upon approval of the Governor, take other actions necessary to ad-

7

dress the public health emergency and provide notice of those actions to

8

health care providers, institutions and facilities, including public health

9

actions authorized by ORS 431.264;

10

(E) Take any enforcement action authorized by ORS 431.262, including the

11

imposition of civil penalties of up to $500 per day against individuals, insti-

12

tutions or facilities that knowingly fail to comply with requirements result-

13

ing from actions taken in accordance with the powers granted to the Public

14

Health Director under subparagraphs (A), (B) and (D) of this paragraph; and

15

(F) The authority granted to the Public Health Director under this sec-

16

tion:

17

(i) Supersedes any authority granted to a local public health authority if

18

the local public health authority acts in a manner inconsistent with guide-

19

lines established or rules adopted by the director under this section; and

20

(ii) Does not supersede the general authority granted to a local public

21

health authority or a local public health administrator except as authorized

22

by law or necessary to respond to a public health emergency.

23

(b) The authority of the Public Health Director to take administrative

24

action, and the effectiveness of any action taken, under paragraph (a)(A), (B),

25

(D), (E) and (F) of this subsection terminates upon the expiration of the

26

proclaimed state of public health emergency, unless the actions are contin-

27

ued under other applicable law.

28

(3) Civil penalties under subsection (2) of this section shall be imposed

29

in the manner provided in ORS 183.745. The Public Health Director must

30

establish that the individual, institution or facility subject to the civil pen-

31

alty had actual notice of the action taken that is the basis for the penalty. [64]


LC 1914 11/14/12 1

The maximum aggregate total for penalties that may be imposed against an

2

individual, institution or facility under subsection (2) of this section is $500

3

for each day of violation, regardless of the number of violations of subsection

4

(2) of this section that occurred on each day of violation.

5

(4)(a) During a proclaimed state of public health emergency, the Public

6

Health Director and local public health administrators shall be given imme-

7

diate access to individually identifiable health information necessary to:

8 9

(A) Determine the causes of an illness related to the public health emergency;

10

(B) Identify persons at risk;

11

(C) Identify patterns of transmission;

12

(D) Provide treatment; and

13

(E) Take steps to control the disease.

14

(b) Individually identifiable health information accessed as provided by

15

paragraph (a) of this subsection may not be used for conducting non-

16

emergency epidemiologic research or to identify persons at risk for post-

17

traumatic mental health problems, or for any other purpose except the

18

purposes listed in paragraph (a) of this subsection.

19

(c) Individually identifiable health information obtained by the Public

20

Health Director or local public health administrators under this subsection

21

may not be disclosed without written authorization of the identified indi-

22

vidual except:

23 24 25 26 27 28

(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

29

(D) Directly to a health care provider for the evaluation or treatment of

30

a condition that is the subject of a proclamation of a state of public health

31

emergency issued under ORS 433.441. [65]


LC 1914 11/14/12 1

(d) Upon expiration of the state of public health emergency, the Public

2

Health Director or local public health administrators may not use or disclose

3

any individually identifiable health information that has been obtained under

4

this section. If a state of emergency that is related to the state of public

5

health emergency has been declared under ORS 401.165, the Public Health

6

Director and local public health administrators may continue to use any in-

7

dividually identifiable information obtained as provided under this section

8

until termination of the state of emergency.

9

(5) All civil penalties recovered under this section shall be paid into the

10

State Treasury and credited to the General Fund and are available for gen-

11

eral governmental expenses.

12

(6) The Public Health Director may request assistance in enforcing orders

13

issued pursuant to this section from state or local law enforcement authori-

14

ties. If so requested by the Public Health Director, state and local law

15

enforcement authorities, to the extent resources are available, shall assist in

16

enforcing orders issued pursuant to this section.

17

(7) If the Oregon Health Authority adopts temporary rules to implement

18

the provisions of this section, the rules adopted are not subject to the pro-

19

visions of ORS 183.335 (6)(a). The authority may amend temporary rules

20

adopted pursuant to this subsection as often as necessary to respond to the

21

public health emergency.

22

SECTION 63. ORS 705.145 is amended to read:

23

705.145. (1) There is created in the State Treasury a fund to be known as

24

the Consumer and Business Services Fund, separate and distinct from the

25

General Fund. All moneys collected or received by the Department of Con-

26

sumer and Business Services, except moneys [collected pursuant to ORS

27

735.612 and those moneys required] to be paid into the Workers’ Benefit Fund,

28

shall be paid into the State Treasury and credited to the Consumer and

29

Business Services Fund. Moneys in the fund may be invested in the same

30

manner as other state moneys and any interest earned shall be credited to

31

the fund. [66]


LC 1914 11/14/12 1

(2) The department shall keep a record of all moneys deposited in the

2

Consumer and Business Services Fund that shall indicate, by separate ac-

3

count, the source from which the moneys are derived, the interest earned and

4

the activity or program against which any withdrawal is charged.

5

(3) If moneys credited to any one account are withdrawn, transferred or

6

otherwise used for purposes other than the program or activity for which the

7

account is established, interest shall accrue on the amount withdrawn from

8

the date of withdrawal and until such funds are restored.

9

(4) Moneys in the fund are continuously appropriated to the department

10

for its administrative expenses and for its expenses in carrying out its func-

11

tions and duties under any provision of law.

12

(5) Except as provided in ORS 705.165, it is the intention of the Legisla-

13

tive Assembly that the performance of the various duties and functions of

14

the department in connection with each of its programs shall be financed by

15

the fees, assessments and charges established and collected in connection

16

with those programs.

17

(6) There is created by transfer from the Consumer and Business Services

18

Fund a revolving administrative account in the amount of $100,000. The re-

19

volving account shall be disbursed by checks or orders issued by the director

20

or the Workers’ Compensation Board and drawn upon the State Treasury, to

21

carry on the duties and functions of the department and the board. All

22

checks or orders paid from the revolving account shall be reimbursed by a

23

warrant drawn in favor of the department charged against the Consumer and

24

Business Services Fund and recorded in the appropriate subsidiary record.

25 26

(7) For the purposes of ORS chapter 656, the revolving account created pursuant to subsection (6) of this section may also be used to:

27

(a) Pay compensation benefits; and

28

(b) Refund to employers amounts paid to the Consumer and Business

29

Services Fund in excess of the amounts required by ORS chapter 656.

30

(8) Notwithstanding subsections (2), (3) and (5) of this section and except

31

as provided in ORS 455.220 (1), the moneys derived pursuant to ORS 446.003 [67]


LC 1914 11/14/12 1

to 446.200, 446.210, 446.225 to 446.285, 446.395 to 446.420, 446.566 to 446.646,

2

446.661 to 446.756 and 455.220 (1) and deposited to the fund, interest earned

3

on those moneys and withdrawals of moneys for activities or programs under

4

ORS 446.003 to 446.200, 446.210, 446.225 to 446.285, 446.395 to 446.420, 446.566

5

to 446.646 and 446.661 to 446.756, or education and training programs per-

6

taining thereto, must be assigned to a single account within the fund.

7

(9) Notwithstanding subsections (2), (3) and (5) of this section, the moneys

8

derived pursuant to ORS 455.240 or 460.370 or from state building code or

9

specialty code program fees for which the amount is established by depart-

10

ment rule pursuant to ORS 455.020 (2) and deposited to the fund, interest

11

earned on those moneys and withdrawals of moneys for activities or pro-

12

grams described under ORS 455.240 or 446.566 to 446.646, 446.661 to 446.756

13

and 460.310 to 460.370, structural or mechanical specialty code programs or

14

activities for which a fee is collected under ORS 455.020 (2), or programs

15

described under subsection (10) of this section that provide training and ed-

16

ucation for persons employed in producing, selling, installing, delivering or

17

inspecting manufactured structures or manufactured dwelling parks or re-

18

creation parks, must be assigned to a single account within the fund.

19

(10) Notwithstanding ORS 279.835 to 279.855 and ORS chapters 279A and

20

279B, the department may, after consultation with the appropriate specialty

21

code advisory boards established under ORS 455.132, 455.135, 455.138, 480.535

22

and 693.115, contract for public or private parties to develop or provide

23

training and education programs relating to the state building code and as-

24

sociated licensing or certification programs.

25

SECTION 64. ORS 731.036 is amended to read:

26

731.036. Except as provided in ORS 743.061 or as specifically provided by

27

law, the Insurance Code does not apply to any of the following to the extent

28

of the subject matter of the exemption:

29

(1) A bail bondsman, other than a corporate surety and its agents.

30

(2) A fraternal benefit society that has maintained lodges in this state and

31

other states for 50 years prior to January 1, 1961, and for which a certificate [68]


LC 1914 11/14/12 1

of authority was not required on that date.

2

(3) A religious organization providing insurance benefits only to its em-

3

ployees, if the organization is in existence and exempt from taxation under

4

section 501(c)(3) of the federal Internal Revenue Code on September 13, 1975.

5

(4) Public bodies, as defined in ORS 30.260, that either individually or

6

jointly establish a self-insurance program for tort liability in accordance

7

with ORS 30.282.

8

(5) Public bodies, as defined in ORS 30.260, that either individually or

9

jointly establish a self-insurance program for property damage in accordance

10

with ORS 30.282.

11

(6) Cities, counties, school districts, community college districts, commu-

12

nity college service districts or districts, as defined in ORS 198.010 and

13

198.180, that either individually or jointly insure for supplemental health

14

insurance coverage, excluding disability insurance, their employees or retired

15

employees, or their dependents, or students engaged in school activities, or

16

combination of employees and dependents, with or without employee or stu-

17

dent contributions, if all of the following conditions are met:

18 19

(a) The individual or jointly self-insured program meets the following minimum requirements:

20

(A) In the case of a school district, community college district or com-

21

munity college service district, the number of covered employees and depen-

22

dents and retired employees and dependents aggregates at least 500

23

individuals;

24

(B) In the case of an individual public body program other than a school

25

district, community college district or community college service district, the

26

number of covered employees and dependents and retired employees and de-

27

pendents aggregates at least 500 individuals; and

28

(C) In the case of a joint program of two or more public bodies, the

29

number of covered employees and dependents and retired employees and de-

30

pendents aggregates at least 1,000 individuals;

31

(b) The individual or jointly self-insured supplemental health insurance [69]


LC 1914 11/14/12 1

program includes all coverages and benefits required of group health insur-

2

ance policies under ORS chapters 743 and 743A;

3 4 5 6 7 8 9 10 11 12 13 14 15

(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;

16

(B) The program must maintain adequate reserves. Reserves may be in-

17

vested in accordance with the provisions of ORS chapter 293. Reserve ade-

18

quacy must be calculated annually with proper actuarial calculations

19

including the following:

20

(i) Known claims, paid and outstanding;

21

(ii) A history of incurred but not reported claims;

22

(iii) Claims handling expenses;

23

(iv) Unearned contributions; and

24

(v) A claims trend factor; and

25

(C) The program must maintain adequate reinsurance against the risk of

26

economic loss in accordance with the provisions of ORS 742.065 unless the

27

program has received written approval for an alternative arrangement for

28

protection against economic loss from the Director of the Department of

29

Consumer and Business Services;

30

(f) The individual or jointly self-insured program must have sufficient

31

personnel to service the employee benefit program or must contract with a [70]


LC 1914 11/14/12 1

third party administrator licensed under ORS chapter 744 as a third party

2

administrator to provide such services;

3

[(g) The individual or jointly self-insured program shall be subject to as-

4

sessment in accordance with ORS 735.614 and former enrollees shall be eligible

5

for portability coverage in accordance with ORS 735.616;]

6

[(h)] (g) The public body, or the program administrator in the case of a

7

joint insurance program of two or more public bodies, files with the Director

8

of the Department of Consumer and Business Services copies of all docu-

9

ments creating and governing the program, all forms used to communicate

10

the coverage to beneficiaries, the schedule of payments established to support

11

the program and, annually, a financial report showing the total incurred cost

12

of the program for the preceding year. A copy of the annual audit required

13

by ORS 297.425 may be used to satisfy the financial report filing requirement;

14

and

15

[(i)] (h) Each public body in a joint insurance program is liable only to

16

its own employees and no others for benefits under the program in the event,

17

and to the extent, that no further funds, including funds from insurance

18

policies obtained by the pool, are available in the joint insurance pool.

19

(7) All ambulance services.

20

(8) A person providing any of the services described in this subsection.

21

The exemption under this subsection does not apply to an authorized insurer

22

providing such services under an insurance policy. This subsection applies

23

to the following services:

24

(a) Towing service.

25

(b) Emergency road service, which means adjustment, repair or replace-

26

ment of the equipment, tires or mechanical parts of a motor vehicle in order

27

to permit the motor vehicle to be operated under its own power.

28

(c) Transportation and arrangements for the transportation of human re-

29

mains, including all necessary and appropriate preparations for and actual

30

transportation provided to return a decedent’s remains from the decedent’s

31

place of death to a location designated by a person with valid legal authority [71]


LC 1914 11/14/12 1

under ORS 97.130.

2

(9)(a) A person described in this subsection who, in an agreement to lease

3

or to finance the purchase of a motor vehicle, agrees to waive for no addi-

4

tional charge the amount specified in paragraph (b) of this subsection upon

5

total loss of the motor vehicle because of physical damage, theft or other

6

occurrence, as specified in the agreement. The exemption established in this

7

subsection applies to the following persons:

8

(A) The seller of the motor vehicle, if the sale is made pursuant to a

9

motor vehicle retail installment contract.

10

(B) The lessor of the motor vehicle.

11

(C) The lender who finances the purchase of the motor vehicle.

12

(D) The assignee of a person described in this paragraph.

13

(b) The amount waived pursuant to the agreement shall be the difference,

14

or portion thereof, between the amount received by the seller, lessor, lender

15

or assignee, as applicable, that represents the actual cash value of the motor

16

vehicle at the date of loss, and the amount owed under the agreement.

17

(10) A self-insurance program for tort liability or property damage that

18

is established by two or more affordable housing entities and that complies

19

with the same requirements that public bodies must meet under ORS 30.282

20

(6). As used in this subsection:

21

(a) “Affordable housing” means housing projects in which some of the

22

dwelling units may be purchased or rented, with or without government as-

23

sistance, on a basis that is affordable to individuals of low income.

24

(b) “Affordable housing entity” means any of the following:

25

(A) A housing authority created under the laws of this state or another

26

jurisdiction and any agency or instrumentality of a housing authority, in-

27

cluding but not limited to a legal entity created to conduct a self-insurance

28

program for housing authorities that complies with ORS 30.282 (6).

29 30 31

(B) A nonprofit corporation that is engaged in providing affordable housing. (C) A partnership or limited liability company that is engaged in provid[72]


LC 1914 11/14/12 1

ing affordable housing and that is affiliated with a housing authority de-

2

scribed in subparagraph (A) of this paragraph or a nonprofit corporation

3

described in subparagraph (B) of this paragraph if the housing authority or

4

nonprofit corporation:

5 6 7 8 9 10 11 12

(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.

13

(11) A community-based health care initiative approved by the Adminis-

14

trator of the Office for Oregon Health Policy and Research under ORS

15

735.723 operating a community-based health care improvement program ap-

16

proved by the administrator.

17

(12) Except as provided in ORS 735.500 and 735.510, a person certified by

18

the Department of Consumer and Business Services to operate a retainer

19

medical practice.

20

SECTION 65. ORS 734.790 is amended to read:

21

734.790. (1) ORS 734.750 to 734.890 provide coverage for policies and con-

22

tracts specified in subsection (2) of this section to the following persons who

23

are not provided coverage under the laws of another state:

24

(a) To a person who is a resident, if the person is an owner of or a cer-

25

tificate holder under the policy or contract other than a structured settle-

26

ment annuity or, in the case of an unallocated annuity contract, an employee

27

participating in a governmental retirement plan established under section

28

401, 403(b) or 457 of the United States Internal Revenue Code or the benefi-

29

ciaries of each such individual if deceased.

30

(b) To a person who is not a resident, if the person is an owner of or a

31

certificate holder under the policy or contract other than a structured [73]


LC 1914 11/14/12 1

settlement annuity or, in the case of an unallocated annuity contract, an

2

employee participating in a governmental retirement plan established under

3

section 401, 403(b) or 457 of the United States Internal Revenue Code or the

4

beneficiaries of each such individual if deceased. This paragraph applies to

5

a person who is not a resident only if all of the following conditions are met:

6

(A) The insurer that issued the policy or contract must be a member

7 8 9

insurer. (B) The state in which the person resides must have an association similar to the Oregon Life and Health Insurance Guaranty Association.

10

(C) The person must not be eligible for coverage by an association in the

11

state in which the person resides, as described in subparagraph (B) of this

12

paragraph, due to the fact that the insurer was not authorized to transact

13

insurance or licensed in that state at the time specified in the state’s guar-

14

anty association law.

15

(c) To a person who, regardless of where the person resides, is a benefi-

16

ciary, assignee or payee of the persons covered under paragraph (a) or (b)

17

of this subsection. This paragraph does not include a nonresident certificate

18

holder under a group policy or contract.

19 20

(d) To a person who is a payee under a structured settlement annuity, or to the beneficiary of a payee if the payee is deceased, if the payee:

21

(A) Is a resident, regardless of where the contract owner resides; or

22

(B) Is not a resident, but only under both of the following conditions:

23

(i) The contract owner of the structured settlement annuity is a resident

24

and is not afforded any coverage by an association in another state that is

25

similar to the association created under ORS 734.800, or the contract owner

26

of the structured settlement annuity is not a resident but the insurer that

27

issued the structured settlement annuity is domiciled in this state and the

28

state in which the contract owner resides has an association similar to the

29

association created under ORS 734.800; and

30

(ii) Neither the payee or beneficiary nor the contract owner of the

31

structured settlement annuity is eligible for coverage by the association of [74]


LC 1914 11/14/12 1

the state in which the payee or contract owner resides.

2

(2) Except as limited by ORS 734.750 to 734.890, the association shall

3

provide coverage to the persons specified in subsection (1) of this section for

4

direct nongroup life or health insurance policies or annuity contracts, for

5

certificates under direct group policies or contracts, and for supplemental

6

contracts to any of these, in each case issued by member insurers.

7

(3) ORS 734.750 to 734.890 do not provide coverage for:

8

(a) That portion of any policy or contract not guaranteed by the member

9

insurer or under which the risk is borne by the policyholder or contract

10

owner.

11

(b) Any policy or contract or part thereof assumed by the impaired or

12

insolvent insurer under a contract of reinsurance, other than reinsurance for

13

which assumption certificates have been issued.

14 15

(c) Any policy or contract issued by a health care service contractor complying with ORS 750.005 to 750.095.

16

(d) Any policy or contract issued by a fraternal benefit society.

17

(e) Any portion of a policy or contract to the extent that the interest rate

18

on which the policy or contract is based, or to the extent that the interest

19

rate, crediting rate or similar factor determined by use of an index or other

20

external reference stated in the policy or contract for the purpose of calcu-

21

lating returns or changes in value:

22

(A) Exceeds, when averaged over the period of four years prior to the date

23

on which the member insurer becomes either an impaired or insolvent

24

insurer under ORS 734.750 to 734.890, whichever occurs first, a rate of in-

25

terest determined by subtracting four percentage points from Moody’s Cor-

26

porate Bond Yield Average averaged for that same four-year period or for a

27

lesser period if the policy or contract was issued less than four years before

28

the member insurer becomes either an impaired or insolvent insurer under

29

ORS 734.750 to 734.890, whichever occurred first; and

30

(B) Exceeds, on and after the date on which the member insurer becomes

31

either an impaired or insolvent insurer under ORS 734.750 to 734.890, [75]


LC 1914 11/14/12 1

whichever occurs first, the rate of interest determined by subtracting three

2

percentage points from Moody’s Corporate Bond Yield Average as most re-

3

cently available.

4

(f) Any portion of a policy or contract issued to a plan or program of an

5

employer, association or similar entity to provide life insurance, health in-

6

surance or annuity benefits to its employees or members to the extent that

7

the plan or program is self-funded or uninsured, including benefits payable

8

by an employer, association or similar entity under any of the following:

9

(A) A multiple employer welfare arrangement as defined in section 3(40)

10

(29 U.S.C. 1002(40)) of the Employee Retirement Income Security Act of 1974,

11

as amended.

12

(B) A minimum premium group insurance plan.

13

(C) A stop-loss group insurance plan.

14

(D) An administrative services only contract.

15

(g) Any portion of a policy or contract to the extent that it provides

16

dividends or experience rating credits or voting rights, or provides that any

17

fees or allowances be paid to any person, including the policyholder or con-

18

tract owner, in connection with the service to or administration of the policy

19

or contract.

20

(h) Any policy or contract issued in this state by a member insurer at a

21

time that the insurer did not have a certificate of authority to issue the

22

policy or contract in this state.

23

(i) Any unallocated annuity contract issued to or in connection with an

24

employee benefit plan protected under the federal Pension Benefit Guaranty

25

Corporation, regardless of whether the federal Pension Benefit Guaranty

26

Corporation has yet become liable to make any payments with respect to the

27

benefit plan.

28

(j) Any portion of any unallocated annuity contract that is not issued to

29

or in connection with a government retirement plan referred to in subsection

30

(1) of this section, or a government lottery.

31

[(k) Any coverage issued by the Oregon Medical Insurance Pool.] [76]


LC 1914 11/14/12 1

[(L)] (k) Any portion of a policy or contract to the extent that the as-

2

sessments required by ORS 734.815 with respect to the policy or contract are

3

preempted by federal or state law.

4

[(m)] (L) An obligation that does not arise under the express written

5

terms of the policy or contract issued by the insurer to the policyholder or

6

contract owner, including but not limited to:

7

(A) Claims based on marketing materials;

8

(B) Claims based on side letters, riders or other documents that were is-

9

sued by the insurer without meeting applicable policy or contract form filing

10

or approval requirements;

11

(C) Misrepresentations of, or regarding, policy or contract benefits;

12

(D) Extracontractual claims, including but not limited to claims related

13

to bad faith in the payment of claims, punitive or exemplary damages or at-

14

torney fees or costs; or

15

(E) A claim for penalties or consequential or incidental damages.

16

[(n)] (m) A contractual agreement that establishes the member insurer’s

17

obligations to provide a book value accounting guaranty for defined contri-

18

bution benefit plan participants by reference to a portfolio of assets that is

19

owned by the benefit plan or its trustee that in either case is not an affiliate

20

of the member insurer.

21

[(o)] (n) Any portion of a policy or contract to the extent that portion

22

provides for interest or other changes in value to be determined by the use

23

of an index or other external reference stated in the policy or contract, but

24

the changes in value have not been credited to the policy or contract, or as

25

to which the policyholder’s or contract owner’s rights are subject to forfei-

26

ture, as of the date on which the member insurer becomes either an impaired

27

or insolvent insurer, whichever occurs first.

28

value in a policy or contract are credited less frequently than annually, for

29

purposes of determining the values that have been credited and are not sub-

30

ject to forfeiture under this paragraph, the interest or change in value that

31

is determined by using the procedures specified in the policy or contract [77]

If the interest or changes in


LC 1914 11/14/12 1

shall be credited as if the contractual date of crediting interest or changing

2

value was the date of the impairment or insolvency, whichever is earlier, and

3

may not be subject to forfeiture.

4

[(p)] (o) Any policy or contract providing any hospital, medical, pre-

5

scription drug or other health care benefits under Part C or Part D of sub-

6

chapter XVIII, chapter 7, Title 42 of the United States Code, or any

7

regulations issued under those provisions.

8

(4) As used in this section, “Moody’s Corporate Bond Yield Average”

9

means the Monthly Average Corporates as published by Moody’s Investors

10

Service, Inc., or any successor thereto.

11

SECTION 66. ORS 743.402 is amended to read:

12

743.402. Nothing in ORS 743.405 to 743.498, 743A.160 and 743A.164 shall

13 14 15

apply to or affect: (1) Any workers’ compensation insurance policy or any liability insurance policy with or without supplementary expense coverage therein;

16

(2) Any policy of reinsurance;

17

(3) Any blanket or group policy of insurance; or

18

(4) Any life insurance policy, or policy supplemental thereto which con-

19 20 21

tains 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

22

(b) Operate to safeguard such policy against lapse, or to give a special

23

surrender value or special benefit or an annuity in the event the insured

24

shall become totally and permanently disabled, as defined by the policy or

25

supplemental policy.

26

[(5) Coverage under ORS 735.600 to 735.650.]

27

SECTION 67. ORS 743.730, as amended by section 49, chapter 500, Oregon

28

Laws 2011, and section 20, chapter 38, Oregon Laws 2012, is amended to read:

29

743.730. For purposes of ORS 743.730 to 743.773:

30

(1) “Actuarial certification” means a written statement by a member of

31

the American Academy of Actuaries or other individual acceptable to the [78]


LC 1914 11/14/12 1

Director of the Department of Consumer and Business Services that a carrier

2

is in compliance with the provisions of ORS 743.736, 743.760 or 743.761, based

3

upon the person’s examination, including a review of the appropriate records

4

and of the actuarial assumptions and methods used by the carrier in estab-

5

lishing premium rates for small employer and portability health benefit

6

plans.

7

(2) “Affiliate” of, or person “affiliated” with, a specified person means any

8

carrier who, directly or indirectly through one or more intermediaries, con-

9

trols or is controlled by or is under common control with a specified person.

10

For purposes of this definition, “control” has the meaning given that term

11

in ORS 732.548.

12 13

(3) “Affiliation period” means, under the terms of a group health benefit plan issued by a health care service contractor, a period:

14

(a) That is applied uniformly and without regard to any health status

15

related factors to an enrollee or late enrollee in lieu of a preexisting condi-

16

tion exclusion;

17 18 19 20

(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

21

(d) That begins on the enrollee’s or late enrollee’s first date of eligibility

22

for coverage and runs concurrently with any eligibility waiting period under

23

the plan.

24

[(4) “Basic health benefit plan” means a health benefit plan that provides

25

bronze plan coverage and that is approved by the Department of Consumer and

26

Business Services under ORS 743.736.]

27

[(5)] (4) “Bona fide association” means an association that meets the re-

28

quirements of 42 U.S.C. 300gg-91 as amended and in effect on March 23, 2010.

29

[(6) “Bronze plan” means a health benefit plan that meets the criteria for

30

a bronze plan prescribed by the director by rule pursuant to ORS 743.822

31

(2).] [79]


LC 1914 11/14/12 1 2

[(7)] (5) “Carrier,” except as provided in ORS 743.760, means any person who provides health benefit plans in this state, including:

3

(a) A licensed insurance company;

4

(b) A health care service contractor;

5

(c) A health maintenance organization;

6

(d) An association or group of employers that provides benefits by means

7

of a multiple employer welfare arrangement and that:

8

(A) Is subject to ORS 750.301 to 750.341; or

9

(B) Is fully insured and otherwise exempt under ORS 750.303 (4) but elects

10 11 12

to be governed by ORS 743.733 to 743.737; or (e) Any other person or corporation responsible for the payment of benefits or provision of services.

13

[(8) “Catastrophic plan” means a health benefit plan that meets the re-

14

quirements for a catastrophic plan under 42 U.S.C. 18022(e) and that is of-

15

fered through the Oregon Health Insurance Exchange.]

16

[(9)] (6) “Creditable coverage” means prior health care coverage as de-

17

fined in 42 U.S.C. 300gg as amended and in effect on February 17, 2009, and

18

includes coverage remaining in force at the time the enrollee obtains new

19

coverage.

20

[(10)] (7) “Dependent” means the spouse or child of an eligible employee,

21

subject to applicable terms of the health benefit plan covering the employee.

22

[(11)] (8) “Eligible employee” means an employee who works on a regu-

23

larly scheduled basis, with a normal work week of 17.5 or more hours. The

24

employer may determine hours worked for eligibility between 17.5 and 40

25

hours per week subject to rules of the carrier. “Eligible employee” does not

26

include employees who work on a temporary, seasonal or substitute basis.

27

Employees who have been employed by the employer for fewer than 90 days

28

are not eligible employees unless the employer so allows.

29

[(12)] (9) “Employee” means any individual employed by an employer.

30

[(13)] (10) “Enrollee” means an employee, dependent of the employee or

31

an individual otherwise eligible for a group, individual or portability health [80]


LC 1914 11/14/12 1

benefit plan who has enrolled for coverage under the terms of the plan.

2

[(14) “Exchange” means the health insurance exchange administered by the

3

Oregon Health Insurance Exchange Corporation in accordance with ORS

4

741.310.]

5 6 7 8 9 10 11 12

[(15)] (11) “Exclusion period” means a period during which specified treatments or services are excluded from coverage. [(16)] (12) “Financial impairment” means that a carrier is not insolvent and is: (a) Considered by the director 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.

13

[(17)(a)] (13)(a) “Geographic average rate” means the arithmetical average

14

of the lowest premium and the corresponding highest premium to be charged

15

by a carrier in a geographic area established by the director for the carrier’s:

16

(A) Group health benefit plans offered to small employers;

17

(B) Individual health benefit plans; or

18

(C) Portability health benefit plans.

19

(b) “Geographic average rate” does not include premium differences that

20

are due to differences in benefit design or family composition.

21

[(18)] (14) “Grandfathered health plan” has the meaning prescribed by the

22

United States Secretaries of Labor, Health and Human Services and the

23

Treasury pursuant to 42 U.S.C. 18011(e).

24

[(19)] (15) “Group eligibility waiting period” means, with respect to a

25

group health benefit plan, the period of employment or membership with the

26

group that a prospective enrollee must complete before plan coverage begins.

27

[(20)(a)] (16)(a) “Health benefit plan” means any:

28

(A) Hospital expense, medical expense or hospital or medical expense

29 30 31

policy or certificate; (B) Health care service contractor or health maintenance organization subscriber contract; or [81]


LC 1914 11/14/12 1

(C) Plan provided by a multiple employer welfare arrangement or by an-

2

other benefit arrangement defined in the federal Employee Retirement In-

3

come Security Act of 1974, as amended, to the extent that the plan is subject

4

to state regulation.

5

(b) “Health benefit plan� does not include:

6

(A) Coverage for accident only, specific disease or condition only, credit

7 8 9

or disability income; (B) Coverage of Medicare services pursuant to contracts with the federal government;

10

(C) Medicare supplement insurance policies;

11

(D) Coverage of TRICARE services pursuant to contracts with the federal

12

government;

13

(E) Benefits delivered through a flexible spending arrangement estab-

14

lished pursuant to section 125 of the Internal Revenue Code of 1986, as

15

amended, when the benefits are provided in addition to a group health ben-

16

efit plan;

17

(F) Separately offered long term care insurance, including, but not limited

18

to, coverage of nursing home care, home health care and community-based

19

care;

20 21 22 23

(G) Independent, noncoordinated, hospital-only indemnity insurance or other fixed indemnity insurance; (H) Short term health insurance policies that are in effect for periods of 12 months or less, including the term of a renewal of the policy;

24

(I) Dental only coverage;

25

(J) Vision only coverage;

26

(K) Stop-loss coverage that meets the requirements of ORS 742.065;

27

(L) Coverage issued as a supplement to liability insurance;

28

(M) Insurance arising out of a workers’ compensation or similar law;

29

(N) Automobile medical payment insurance or insurance under which

30

benefits are payable with or without regard to fault and that is statutorily

31

required to be contained in any liability insurance policy or equivalent self[82]


LC 1914 11/14/12 1

insurance; [or]

2

(O) Any employee welfare benefit plan that is exempt from state regu-

3

lation because of the federal Employee Retirement Income Security Act of

4

1974, as amended; or

5 6

(P) Coverage provided by the Affordable Health Care for All Oregon Plan.

7

(c) For purposes of this subsection, renewal of a short term health in-

8

surance policy includes the issuance of a new short term health insurance

9

policy by an insurer to a policyholder within 60 days after the expiration of

10

a policy previously issued by the insurer to the policyholder.

11

[(21)] (17) “Health statement” means any information that is intended to

12

inform the carrier or insurance producer of the health status of an enrollee

13

or prospective enrollee in a health benefit plan. “Health statement” includes

14

the standard health statement approved by the director under ORS 743.745.

15

[(22)] (18) “Individual coverage waiting period” means a period in an in-

16

dividual health benefit plan during which no premiums may be collected and

17

health benefit plan coverage issued is not effective.

18 19

[(23)] (19) “Initial enrollment period” means a period of at least 30 days following commencement of the first eligibility period for an individual.

20

[(24)] (20) “Late enrollee” means an individual who enrolls in a group

21

health benefit plan subsequent to the initial enrollment period during which

22

the individual was eligible for coverage but declined to enroll. However, an

23

eligible individual shall not be considered a late enrollee if:

24 25

(a) The individual qualifies for a special enrollment period in accordance with 42 U.S.C. 300gg as amended and in effect on February 17, 2009;

26

(b) The individual applies for coverage during an open enrollment period;

27

(c) A court issues an order that coverage be provided for a spouse or

28

minor child under an employee’s employer sponsored health benefit plan and

29

request for enrollment is made within 30 days after issuance of the court

30

order;

31

(d) The individual is employed by an employer that offers multiple health [83]


LC 1914 11/14/12 1

benefit plans and the individual elects a different health benefit plan during

2

an open enrollment period; or

3

(e) The individual’s coverage under Medicaid, Medicare, TRICARE, In-

4

dian Health Service or a publicly sponsored or subsidized health plan, in-

5

cluding, but not limited to, the medical assistance program under ORS

6

chapter 414, has been involuntarily terminated within 63 days after applying

7

for coverage in a group health benefit plan.

8 9

[(25) “Minimal essential coverage” has the meaning given that term in section 5000A(f) of the Internal Revenue Code.]

10

[(26)] (21) “Multiple employer welfare arrangement” means a multiple

11

employer welfare arrangement as defined in section 3 of the federal Employee

12

Retirement Income Security Act of 1974, as amended, 29 U.S.C. 1002, that is

13

subject to ORS 750.301 to 750.341.

14 15

[(27) “Oregon Medical Insurance Pool” means the pool created under ORS 735.610.]

16

[(28)] (22) “Preexisting condition exclusion” means a health benefit plan

17

provision applicable to an enrollee or late enrollee that excludes coverage

18

for services, charges or expenses incurred during a specified period imme-

19

diately following enrollment for a condition for which medical advice, diag-

20

nosis, care or treatment was recommended or received during a specified

21

period immediately preceding enrollment. For purposes of ORS 743.730 to

22

743.773:

23 24 25 26

(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

27

(c) Except for coverage under an individual grandfathered health plan, a

28

preexisting condition exclusion may not exclude coverage for services,

29

charges or expenses incurred by an individual who is under 19 years of age.

30

[(29)] (23) “Premium” includes insurance premiums or other fees charged

31

for a health benefit plan, including the costs of benefits paid or reimburse[84]


LC 1914 11/14/12 1

ments made to or on behalf of enrollees covered by the plan.

2

[(30)] (24) “Rating period” means the 12-month calendar period for which

3

premium rates established by a carrier are in effect, as determined by the

4

carrier.

5 6

[(31)] (25) “Representative” does not include an insurance producer or an employee or authorized representative of an insurance producer or carrier.

7

[(32) “Silver plan” means an individual or small group health benefit plan

8

that meets the criteria for a silver plan prescribed by the director by rule

9

pursuant to ORS 743.822 (2).]

10

[(33)(a)] (26)(a) “Small employer” means an employer that employed an

11

average of at least two but not more than 50 employees on business days

12

during the preceding calendar year, the majority of whom are employed

13

within this state, and that employs at least two eligible employees on the

14

date on which coverage takes effect under a health benefit plan offered by

15

the employer.

16

(b) Any person that is treated as a single employer under subsection (b),

17

(c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall be

18

treated as one employer for purposes of this subsection.

19

(c) The determination of whether an employer that was not in existence

20

throughout the preceding calendar year is a small employer shall be based

21

on the average number of employees that it is reasonably expected the em-

22

ployer will employ on business days in the current calendar year.

23 24

SECTION 68. ORS 743.748, as amended by section 18, chapter 500, Oregon Laws 2011, is amended to read:

25

743.748. (1) Each carrier offering a health benefit plan shall submit to the

26

Director of the Department of Consumer and Business Services on or before

27

April 1 of each year a report that contains:

28

(a) The following information for the preceding year that is derived from

29

the exhibit of premiums, enrollment and utilization included in the carrier’s

30

annual report:

31

(A) The total number of members; [85]


LC 1914 11/14/12 1

(B) The total amount of premiums;

2

(C) The total amount of costs for claims;

3

(D) The medical loss ratio;

4

(E) The average amount of premiums per member per month; and

5

(F) The percentage change in the average premium per member per month,

6 7 8

measured from the previous year. (b) The following aggregate financial information for the preceding year that is derived from the carrier’s annual report:

9

(A) The total amount of general administrative expenses, including iden-

10

tification of the five largest nonmedical administrative expenses [and the

11

assessment against the carrier for the Oregon Medical Insurance Pool];

12

(B) The total amount of the surplus maintained;

13

(C) The total amount of the reserves maintained for unpaid claims;

14

(D) The total net underwriting gain or loss; and

15

(E) The carrier’s net income after taxes.

16

(2) A carrier shall electronically submit the information described in

17

subsection (1) of this section in a format and according to instructions pre-

18

scribed by the Department of Consumer and Business Services by rule.

19 20

(3) The department shall evaluate the reporting requirements under subsection (1)(a) of this section by the following market segments:

21

(a) Individual health benefit plans;

22

(b) Health benefit plans for small employers;

23

(c) Health benefit plans for employers described in ORS 743.733; and

24

(d) Health benefit plans for employers with more than 50 employees.

25

(4) The department shall make the information reported under this section

26

available to the public through a searchable public website on the Internet.

27

SECTION 69. ORS 743.766, as amended by section 4, chapter 24, Oregon

28

Laws 2012, is amended to read:

29

743.766. (1) All carriers that offer an individual health benefit plan and

30

evaluate the health status of individuals for purposes of eligibility shall use

31

the standard health statement established under ORS 743.745 and may not [86]


LC 1914 11/14/12 1

use any other method to determine the health status of an individual.

2

Nothing in this subsection shall prevent a carrier from using health infor-

3

mation after enrollment for the purpose of providing services or arranging

4

for the provision of services under a health benefit plan.

5

(2)(a) If an individual is accepted for coverage under an individual health

6

benefit plan, the carrier shall not impose exclusions or limitations other

7

than:

8 9

(A) A preexisting condition exclusion that complies with the following requirements:

10

(i) The exclusion applies only to a condition for which medical advice,

11

diagnosis, care or treatment was recommended or received during the six-

12

month period immediately preceding the individual’s effective date of cover-

13

age;

14 15 16 17

(ii) The exclusion expires no later than six months after the individual’s effective date of coverage; and (iii) Except for grandfathered health plans, the exclusion does not apply to individuals who are under 19 years of age;

18

(B) An individual coverage waiting period of 90 days; or

19

(C) An exclusion period for specified covered services applicable to all

20

individuals enrolling for the first time in the individual health benefit plan.

21

(b) Except for grandfathered health plans, pregnancy of individuals who

22

are under 19 years of age may not constitute a preexisting condition for

23

purposes of this section.

24

(3) If the carrier elects to restrict coverage through the application of a

25

preexisting condition exclusion or an individual coverage waiting period

26

provision, the carrier shall reduce the duration of the provision by an

27

amount equal to the individual’s aggregate periods of creditable coverage if

28

the most recent period of creditable coverage is ongoing or ended within 63

29

days after the effective date of coverage in the new individual health benefit

30

plan. The crediting of prior coverage in accordance with this subsection shall

31

be applied without regard to the specific benefits covered during the prior [87]


LC 1914 11/14/12 1

period.

2

[(4) If an eligible prospective enrollee is rejected for coverage under an in-

3

dividual health benefit plan, the prospective enrollee shall be eligible to apply

4

for coverage under the Oregon Medical Insurance Pool.]

5

[(5)] (4) If a carrier accepts an individual for coverage under an individual

6

health benefit plan, the carrier shall renew the policy unless:

7

(a) The policyholder fails to pay the required premiums.

8

(b) The policyholder or a representative of the policyholder engages in

9

fraud or makes an intentional misrepresentation of a material fact as pro-

10

hibited by the terms of the policy.

11

(c) The carrier discontinues offering or renewing, or offering and renew-

12

ing, all of its individual health benefit plans in this state or in a specified

13

service area within this state. In order to discontinue the plans under this

14

paragraph, the carrier:

15 16

(A) Must give notice of the decision to the Department of Consumer and Business Services and to all policyholders covered by the plans;

17

(B) May not cancel coverage under the plans for 180 days after the date

18

of the notice required under subparagraph (A) of this paragraph if coverage

19

is discontinued in the entire state or, except as provided in subparagraph (C)

20

of this paragraph, in a specified service area;

21

(C) May not cancel coverage under the plans for 90 days after the date

22

of the notice required under subparagraph (A) of this paragraph if coverage

23

is discontinued in a specified service area because of an inability to reach

24

an agreement with the health care providers or organization of health care

25

providers to provide services under the plans within the service area; and

26

(D) Must discontinue offering or renewing, or offering and renewing, all

27

health benefit plans issued by the carrier in the individual market in this

28

state or in the specified service area.

29

(d) The carrier discontinues offering and renewing an individual health

30

benefit plan in a specified service area within this state because of an ina-

31

bility to reach an agreement with the health care providers or organization [88]


LC 1914 11/14/12 1

of health care providers to provide services under the plan within the service

2

area. In order to discontinue a plan under this paragraph, the carrier:

3 4 5 6

(A) Must give notice of the decision to the department 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

7

(C) Must offer in writing to each policyholder covered by the plan, all

8

other individual health benefit plans that the carrier offers in the specified

9

service area. The carrier shall offer the plans at least 90 days prior to dis-

10

continuation.

11

(e) The carrier discontinues offering or renewing, or offering and renew-

12

ing, an individual health benefit plan, other than a grandfathered health

13

plan, for all individuals in this state or in a specified service area within this

14

state, other than a plan discontinued under paragraph (d) of this subsection.

15

(f) The carrier discontinues renewing or offering and renewing a grand-

16

fathered health plan for all individuals in this state or in a specified service

17

area within this state, other than a plan discontinued under paragraph (d)

18

of this subsection.

19 20

(g) With respect to plans that are being discontinued under paragraph (e) or (f) of this subsection, the carrier must:

21

(A) Offer in writing to each policyholder covered by the plan, all health

22

benefit plans that the carrier offers to individuals in the specified service

23

area.

24

(B) Offer the plans at least 90 days prior to discontinuation.

25

(C) Act uniformly without regard to the claims experience of the affected

26

policyholders or the health status of any current or prospective enrollee.

27

(h) The Director of the Department of Consumer and Business Services

28

orders the carrier to discontinue coverage in accordance with procedures

29

specified or approved by the director upon finding that the continuation of

30

the coverage would:

31

(A) Not be in the best interests of the enrollee; or [89]


LC 1914 11/14/12 1

(B) Impair the carrier’s ability to meet its contractual obligations.

2

(i) In the case of an individual health benefit plan that delivers covered

3

services through a specified network of health care providers, the enrollee

4

no longer lives, resides or works in the service area of the provider network

5

and the termination of coverage is not related to the health status of any

6

enrollee.

7

(j) In the case of a health benefit plan that is offered in the individual

8

market only through one or more bona fide associations, the membership of

9

an individual in the association ceases and the termination of coverage is

10

not related to the health status of any enrollee.

11

[(6)] (5) A carrier may modify an individual health benefit plan at the

12

time of coverage renewal. The modification is not a discontinuation of the

13

plan under subsection [(5)(c)] (4)(c), (e) and (f) of this section.

14

[(7)] (6) Notwithstanding any other provision of this section, and subject

15

to the provisions of ORS 743.894 (2) and (4), a carrier may rescind an indi-

16

vidual health benefit plan if the policyholder or a representative of the

17

policyholder:

18

(a) Performs an act, practice or omission that constitutes fraud; or

19

(b) Makes an intentional misrepresentation of a material fact as prohib-

20

ited by the terms of the policy.

21

[(8)] (7) A carrier that withdraws from the market for individual health

22

benefit plans must continue to renew its portability health benefit plans that

23

have been approved pursuant to ORS 743.761.

24

[(9)] (8) A carrier that continues to offer coverage in the individual mar-

25

ket in this state is not required to offer coverage in all of the carrier’s in-

26

dividual health benefit plans. However, if a carrier elects to continue a plan

27

that is closed to new individual policyholders instead of offering alternative

28

coverage in its other individual health benefit plans, the coverage for all

29

existing policyholders in the closed plan is renewable in accordance with

30

subsection [(5)] (4) of this section.

31

[(10)] (9) An individual health benefit plan may not impose annual or [90]


LC 1914 11/14/12 1

lifetime limits on the dollar amount of the essential health benefits pre-

2

scribed by the United States Secretary of Health and Human Services pur-

3

suant to 42 U.S.C. 300gg-11, except as permitted by federal law.

4

[(11)] (10) This section does not require a carrier to actively market, offer,

5

issue or accept applications for a grandfathered health plan or from an in-

6

dividual not eligible for coverage under such a plan as provided by the Pa-

7

tient Protection and Affordable Care Act (P.L. 111-148) as amended by the

8

Health Care and Education Reconciliation Act (P.L. 111-152).

9 10 11

SECTION 70. ORS 743.767 is amended to read: 743.767. Premium rates for individual health benefit plans shall be subject to the following provisions:

12

(1) Each carrier must file the carrier’s initial geographic average rate and

13

any changes to the geographic average rate for its individual health benefit

14

plans with the Director of the Department of Consumer and Business Ser-

15

vices.

16

(2) The premium rates charged during a rating period for individual

17

health benefit plans issued to individuals shall not vary from the individual

18

geographic average rate, except that the premium rate may be adjusted to

19

reflect differences in benefit design, family composition and age. For age

20

adjustments to the individual plans, a carrier shall apply uniformly its

21

schedule of age adjustments for individual health benefit plans as approved

22

by the director.

23

(3) A carrier may not increase the rates of an individual health benefit

24

plan more than once in a 12-month period except as approved by the director.

25

Annual rate increases shall be effective on the anniversary date of the indi-

26

vidual health benefit plan’s issuance. The percentage increase in the pre-

27

mium rate charged for an individual health benefit plan for a new rating

28

period may not exceed the sum of the following:

29

(a) The percentage change in the carrier’s geographic average rate for its

30

individual health benefit plan measured from the first day of the prior rating

31

period to the first day of the new period; and [91]


LC 1914 11/14/12 1 2

(b) Any adjustment attributable to changes in age and differences in benefit design and family composition.

3

(4) Notwithstanding any other provision of this section, a carrier that

4

imposes an individual coverage waiting period pursuant to ORS 743.766 may

5

impose a monthly premium rate surcharge for a period not to exceed six

6

months and in an amount not to exceed [the percentage by which the rates for

7

coverage under the Oregon Medical Insurance Pool exceed the rates established

8

by the Oregon Medical Insurance Pool Board as applicable for individual

9

risks under ORS 735.625] a percentage adopted by the director by rule.

10

The surcharge [shall] must be approved by the director [of the Department

11

of Consumer and Business Services] and, in combination with the waiting

12

period, [shall] may not exceed the actuarial value of a six-month preexisting

13

condition exclusion.

14

SECTION 71. ORS 743.769 is amended to read:

15

743.769. (1) Each carrier shall actively market all individual health bene-

16

fit plans sold by the carrier.

17

(2) Except as provided in subsection (3) of this section, no carrier or in-

18

surance producer shall, directly or indirectly, discourage an individual from

19

filing an application for coverage because of the health status, claims expe-

20

rience, occupation or geographic location of the individual.

21

(3) Subsection (2) of this section does not apply with respect to informa-

22

tion provided by a carrier to an individual regarding the established ge-

23

ographic service area or a restricted network provision of a carrier.

24 25

(4) Rejection by a carrier of an application for coverage shall be in writing and shall state the reason or reasons for the rejection.

26

(5) The Director of the Department of Consumer and Business Services

27

may establish by rule additional standards to provide for the fair marketing

28

and broad availability of individual health benefit plans.

29

(6) A carrier that elects to discontinue offering all of its individual health

30

benefit plans under ORS 743.766 [(5)(c)] (4)(c) or to discontinue offering and

31

renewing all such plans is prohibited from offering and renewing health [92]


LC 1914 11/14/12 1

benefit plans in the individual market in this state for a period of five years

2

from the date of notice to the director pursuant to ORS 743.766 [(5)(c)] (4)(c)

3

or, if such notice is not provided, from the date on which the director pro-

4

vides notice to the carrier that the director has determined that the carrier

5

has effectively discontinued offering individual health benefit plans in this

6

state. This subsection does not apply with respect to a health benefit plan

7

discontinued in a specified service area by a carrier that covers services

8

provided only by a particular organization of health care providers or only

9

by health care providers who are under contract with the carrier.

10

SECTION 72. ORS 743A.001 is amended to read:

11

743A.001. (1) [Except as provided in subsection (4) of this section,] Any

12

statute described in subsection (2) of this section:

13

(a) That becomes effective on or after July 13, 1985, except as provided

14

in subsection (4) of this section, is repealed on the sixth anniversary of

15

the effective date of the statute, unless the Legislative Assembly specifically

16

provides otherwise; and

17 18 19 20

(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:

21

(a) Requires the insurer to include coverage for specific physical or men-

22

tal conditions or specific hospital, medical, surgical or dental health services.

23

(b) Requires the insurer to include coverage for specified persons.

24

(c) Requires the insurer to provide payment or reimbursement to specified

25

providers of services if the services are within the lawful scope of practice

26

of the provider and the insurance policy provides payment or reimbursement

27

for those services.

28 29 30 31

(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. [93]


LC 1914 11/14/12 1 2

(f) Forbids the insurer to exclude coverage of a person because of that person’s medical history.

3

(3) A repeal of a statute under subsection (1) of this section does not ap-

4

ply to any insurance policy in effect on the effective date of the repeal.

5

However, the repeal of the statute applies to a renewal or extension of an

6

existing insurance policy on or after the effective date of the repealer as well

7

as to a new policy issued on or after the effective date of the repealer.

8 9

(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.

10

SECTION 73. ORS 743A.012 is amended to read:

11

743A.012. (1) As used in this section:

12

(a) “Emergency medical condition” means a medical condition:

13

(A) That manifests itself by acute symptoms of sufficient severity, in-

14

cluding severe pain, that a prudent layperson possessing an average knowl-

15

edge of health and medicine would reasonably expect that failure to receive

16

immediate medical attention would:

17 18

(i) Place the health of a person, or an unborn child in the case of a pregnant woman, in serious jeopardy;

19

(ii) Result in serious impairment to bodily functions; or

20

(iii) Result in serious dysfunction of any bodily organ or part; or

21

(B) With respect to a pregnant woman who is having contractions, for

22

which there is inadequate time to effect a safe transfer to another hospital

23

before delivery or for which a transfer may pose a threat to the health or

24

safety of the woman or the unborn child.

25

(b) “Emergency medical screening exam” means the medical history, ex-

26

amination, ancillary tests and medical determinations required to ascertain

27

the nature and extent of an emergency medical condition.

28 29

(c) “Emergency services” means, with respect to an emergency medical condition:

30

(A) An emergency medical screening exam that is within the capability

31

of the emergency department of a hospital, including ancillary services rou[94]


LC 1914 11/14/12 1

tinely available to the emergency department to evaluate such emergency

2

medical condition; and

3

(B) Such further medical examination and treatment as are required under

4

42 U.S.C. 1395dd to stabilize a patient, to the extent the examination and

5

treatment are within the capability of the staff and facilities available at a

6

hospital.

7 8

(d) “Grandfathered health plan” has the meaning given that term in ORS 743.730.

9

(e) “Health benefit plan” has the meaning given that term in ORS 743.730.

10

(f) “Prior authorization” has the meaning given that term in ORS 743.801.

11

(g) “Stabilize” means to provide medical treatment as necessary to:

12

(A) Ensure that, within reasonable medical probability, no material dete-

13

rioration of an emergency medical condition is likely to occur during or to

14

result from the transfer of the patient from a facility; and

15 16 17 18

(B) With respect to a pregnant woman who is in active labor, to perform the delivery, including the delivery of the placenta. (2) All insurers offering a health benefit plan shall provide coverage without prior authorization for emergency services.

19

(3) Except as provided in section 3 of this 2013 Act, a health benefit

20

plan, other than a grandfathered health plan, must provide coverage required

21

by subsection (2) of this section:

22

(a) For the services of participating providers, without regard to any term

23

or condition of coverage other than:

24

(A) The coordination of benefits;

25

(B) An affiliation period or waiting period permitted under part 7 of the

26

Employee Retirement Income Security Act, part A of Title XXVII of the

27

Public Health Service Act or chapter 100 of the Internal Revenue Code;

28

(C) An exclusion other than an exclusion of emergency services; or

29

(D) Applicable cost-sharing; and

30

(b) For the services of a nonparticipating provider:

31

(A) Without imposing any administrative requirement or limitation on [95]


LC 1914 11/14/12 1

coverage that is more restrictive than requirements or limitations that apply

2

to participating providers;

3 4 5 6 7 8 9 10

(B) Without imposing a copayment amount or coinsurance rate that exceeds the amount or rate for participating providers; (C) Without imposing a deductible, unless the deductible applies generally to nonparticipating providers; and (D) Subject only to an out-of-pocket maximum that applies to all services from nonparticipating providers. (4) All insurers offering a health benefit plan shall provide information to enrollees in plain language regarding:

11

(a) What constitutes an emergency medical condition;

12

(b) The coverage provided for emergency services;

13

(c) How and where to obtain emergency services; and

14

(d) The appropriate use of 9-1-1.

15

(5) An insurer offering a health benefit plan may not discourage appro-

16

priate use of 9-1-1 and may not deny coverage for emergency services solely

17

because 9-1-1 was used.

18

(6) This section is exempt from ORS 743A.001.

19

SECTION 74. ORS 743A.070 is amended to read:

20

743A.070. (1) Except as provided in section 3 of this 2013 Act, all pol-

21

icies providing health insurance, as defined in ORS 731.162, except those

22

policies whose coverage is limited to expenses from accidents or specific

23

diseases that are unrelated to the coverage required by this section, shall

24

include coverage for a nonprescription elemental enteral formula for home

25

use, if the formula is medically necessary for the treatment of severe

26

intestinal malabsorption and a physician has issued a written order for the

27

formula and the formula comprises the sole source, or an essential source,

28

of nutrition.

29

(2) The coverage required by subsection (1) of this section may be made

30

subject to provisions of the policy that apply to other benefits under the

31

policy including, but not limited to, provisions related to deductibles and [96]


LC 1914 11/14/12 1

coinsurance. Deductibles and coinsurance for elemental enteral formulas

2

shall be no greater than those for any other treatment for the condition

3

under the policy.

4

(3) This section is exempt from ORS 743A.001.

5

SECTION 75. ORS 743A.080 is amended to read:

6

743A.080. (1) As used in this section, “pregnancy care” means the care

7

necessary to support a healthy pregnancy and care related to labor and de-

8

livery.

9

(2) Except as provided in section 3 of this 2013 Act, all health benefit

10

plans as defined in ORS 743.730 must provide payment or reimbursement for

11

expenses associated with pregnancy care and childbirth. Benefits provided

12

under this section shall be extended to all enrollees, enrolled spouses and

13

enrolled dependents.

14

SECTION 76. ORS 743A.100 is amended to read:

15

743A.100. (1) Except as provided in section 3 of this 2013 Act, every

16

health insurance policy that covers hospital, medical or surgical expenses,

17

other than coverage limited to expenses from accidents or specific diseases,

18

shall provide coverage of mammograms as follows:

19 20

(a) Mammograms for the purpose of diagnosis in symptomatic or high-risk women at any time upon referral of the woman’s health care provider; and

21

(b) An annual mammogram for the purpose of early detection for a woman

22

40 years of age or older, with or without referral from the woman’s health

23

care provider.

24

(2) An insurance policy described in subsection (1) of this section must

25

not limit coverage of mammograms to the schedule provided in subsection

26

(1) of this section if the woman is determined by her health care provider to

27

be at high risk for breast cancer.

28

SECTION 77. ORS 743A.104 is amended to read:

29

743A.104. Except as provided in section 3 of this 2013 Act, all policies

30

providing health insurance, except those policies whose coverage is limited

31

to expenses from accidents or specific diseases that are unrelated to the [97]


LC 1914 11/14/12 1

coverage required by this section, shall include coverage for pelvic exam-

2

inations and Pap smear examinations as follows:

3

(1) Annually for women 18 to 64 years of age; and

4

(2) At any time upon referral of the woman’s health care provider.

5

SECTION 78. ORS 743A.105 is amended to read:

6

743A.105. (1) Except as provided in section 3 of this 2013 Act, all

7

health benefit plans, as defined in ORS 743.730, shall include coverage of the

8

human papillomavirus vaccine for female beneficiaries under the health

9

benefit plan who are at least 11 years of age but no older than 26 years of

10

age.

11

(2) ORS 743A.001 does not apply to this section.

12

SECTION 79. ORS 743A.108 is amended to read:

13

743A.108. (1) Except as provided in section 3 of this 2013 Act, a health

14

insurance policy that covers hospital, medical or surgical expenses, other

15

than coverage limited to expenses from accidents or specific diseases, shall

16

provide coverage for a complete and thorough physical examination of the

17

breast, including but not limited to a clinical breast examination, performed

18

by a health care provider to check for lumps and other changes for the pur-

19

pose of early detection and prevention of breast cancer as follows:

20

(a) Annually for women 18 years of age and older; and

21

(b) At any time at the recommendation of the woman’s health care pro-

22

vider.

23

(2) An insurance policy must provide coverage of physical examinations

24

of the breast as described in subsection (1) of this section regardless of

25

whether a health care provider performs other preventative women’s health

26

examinations or makes a referral for other preventative women’s health ex-

27

aminations at the same time the health care provider performs the breast

28

examination.

29

(3) This section applies to health care service contractors, as defined in

30

ORS 750.005, and trusts carrying out a multiple employer welfare arrange-

31

ment, as defined in ORS 750.301. [98]


LC 1914 11/14/12 1

SECTION 80. ORS 743A.110 is amended to read:

2

743A.110. (1) As used in this section, “mastectomy” means the surgical

3

removal of all or part of a breast or a breast tumor suspected to be malig-

4

nant.

5

(2) Except as provided in section 3 of this 2013 Act, all insurers of-

6

fering a health benefit plan as defined in ORS 743.730 shall provide payment,

7

coverage or reimbursement for mastectomy and for the following services

8

related to a mastectomy as determined by the attending physician and

9

enrollee to be part of the enrollee’s course or plan of treatment:

10

(a) All stages of reconstruction of the breast on which a mastectomy was

11

performed, including but not limited to nipple reconstruction, skin grafts and

12

stippling of the nipple and areola;

13

(b) Surgery and reconstruction of the other breast to produce a symmet-

14

rical appearance;

15

(c) Prostheses;

16

(d) Treatment of physical complications of the mastectomy, including

17

lymphedemas; and

18

(e) Inpatient care related to the mastectomy and post-mastectomy services.

19

(3) An insurer providing coverage under subsection (2) of this section

20

shall provide written notice describing the coverage to the enrollee at the

21

time of enrollment in the health benefit plan and annually thereafter.

22

(4) A health benefit plan must provide a single determination of prior

23

authorization for all services related to a mastectomy covered under sub-

24

section (2) of this section that are part of the enrollee’s course or plan of

25

treatment.

26

(5) When an enrollee requests an external review of an adverse benefit

27

determination as defined in ORS 743.801 by the insurer regarding services

28

described in subsection (2) of this section, the insurer or the Director of the

29

Department of Consumer and Business Services must expedite the enrollee’s

30

case pursuant to ORS 743.857 (5).

31

(6) The coverage required under subsection (2) of this section is subject [99]


LC 1914 11/14/12 1

to the same terms and conditions in the plan that apply to other benefits

2

under the plan.

3

(7) This section is exempt from ORS 743A.001.

4

SECTION 81. ORS 743A.120 is amended to read:

5

743A.120. (1) Except as provided in section 3 of this 2013 Act, an

6

insurer offering a health insurance policy that covers hospital, medical or

7

surgical expenses, other than coverage limited to expenses from accidents or

8

specific diseases, shall provide coverage for prostate cancer screening exam-

9

inations including a digital rectal examination and a prostate-specific

10 11 12

antigen test: (a) For men who are 50 years of age or older biennially or as determined by the treating physician; and

13

(b) For men younger than 50 years of age who are at high risk for pro-

14

state cancer as determined by the treating physician, including African-

15

American men and men with a family medical history of prostate cancer.

16

(2) Health care service contractors, as defined in ORS 750.005, and trusts

17

carrying out a multiple employer welfare arrangement, as defined in ORS

18

750.301, are subject to subsection (1) of this section.

19

SECTION 82. ORS 743A.124 is amended to read:

20

743A.124. (1) Except as provided in section 3 of this 2013 Act, an

21

insurer offering a health insurance policy that covers hospital, medical or

22

surgical expenses, other than coverage limited to expenses from accidents or

23

specific diseases, shall provide coverage for the following colorectal cancer

24

screening examinations and laboratory tests:

25

(a) For an insured 50 years of age or older:

26

(A) One fecal occult blood test per year plus one flexible sigmoidoscopy

27

every five years;

28

(B) One colonoscopy every 10 years; or

29

(C) One double contrast barium enema every five years.

30

(b) For an insured who is at high risk for colorectal cancer, colorectal

31

cancer screening examinations and laboratory tests as recommended by the [100]


LC 1914 11/14/12 1 2

treating physician. (2) For the purposes of subsection (1)(b) of this section, an individual is

3

at high risk for colorectal cancer if the individual has:

4

(a) A family medical history of colorectal cancer;

5

(b) A prior occurrence of cancer or precursor neoplastic polyps;

6

(c) A prior occurrence of a chronic digestive disease condition such as

7

inflammatory bowel disease, Crohn’s disease or ulcerative colitis; or

8

(d) Other predisposing factors.

9

(3) Health care service contractors, as defined in ORS 750.005, and trusts

10

carrying out a multiple employer welfare arrangement, as defined in ORS

11

750.301, are also subject to this section.

12

SECTION 83. ORS 743A.141 is amended to read:

13

743A.141. (1) As used in this section, “hearing aid” means any nondispos-

14

able, wearable instrument or device designed to aid or compensate for im-

15

paired human hearing and any necessary ear mold, part, attachments or

16

accessory for the instrument or device, except batteries and cords.

17

(2) Except as provided in section 3 of this 2013 Act, a health benefit

18

plan, as defined in ORS 743.730, shall provide payment, coverage or re-

19

imbursement for one hearing aid per hearing impaired ear if:

20 21 22 23

(a) Prescribed, fitted and dispensed by a licensed audiologist with the approval of a licensed physician; and (b) Necessary for the treatment of hearing loss in an enrollee in the plan who is:

24

(A) 18 years of age or younger; or

25

(B) 19 to 25 years of age and enrolled in a secondary school or an ac-

26

credited educational institution.

27

(3)(a) The maximum benefit amount required by this section is $4,000 ev-

28

ery 48 months, but a health benefit plan may offer a benefit that is more

29

favorable to the enrollee. The benefit amount shall be adjusted on January

30

1 of each year to reflect the increase since January 1, 2010, in the U.S. City

31

Average Consumer Price Index for All Urban Consumers for medical care [101]


LC 1914 11/14/12 1

as published by the Bureau of Labor Statistics of the United States Depart-

2

ment of Labor.

3

(b) A health benefit plan may not impose any financial or contractual

4

penalty upon an audiologist if an enrollee elects to purchase a hearing aid

5

priced higher than the benefit amount by paying the difference between the

6

benefit amount and the price of the hearing aid.

7

(4) A health benefit plan may subject the payment, coverage or re-

8

imbursement required under this section to provisions of the plan that apply

9

to other durable medical equipment benefits covered by the plan, including

10

but not limited to provisions relating to deductibles, coinsurance and prior

11

authorization.

12

(5) This section is exempt from ORS 743A.001.

13

SECTION 84. ORS 743A.144 is amended to read:

14

743A.144. (1) Except as provided in section 3 of this 2013 Act, all in-

15

dividual and group health insurance policies providing coverage for hospital,

16

medical or surgical expenses shall include coverage for prosthetic and

17

orthotic devices that are medically necessary to restore or maintain the

18

ability to complete activities of daily living or essential job-related activities

19

and that are not solely for comfort or convenience. The coverage required

20

by this subsection includes all services and supplies medically necessary for

21

the effective use of a prosthetic or orthotic device, including formulating its

22

design, fabrication, material and component selection, measurements, fit-

23

tings, static and dynamic alignments, and instructing the patient in the use

24

of the device.

25

(2) As used in this section:

26

(a) “Orthotic device” means a rigid or semirigid device supporting a weak

27

or deformed leg, foot, arm, hand, back or neck, or restricting or eliminating

28

motion in a diseased or injured leg, foot, arm, hand, back or neck.

29 30 31

(b) “Prosthetic device” means an artificial limb device or appliance designed to replace in whole or in part an arm or a leg. (3) The Director of the Department of Consumer and Business Services [102]


LC 1914 11/14/12 1

shall adopt and annually update rules listing the prosthetic and orthotic

2

devices covered under this section. The list shall be no more restrictive than

3

the list of prosthetic and orthotic devices and supplies in the Medicare fee

4

schedule for Durable Medical Equipment, Prosthetics, Orthotics and Sup-

5

plies, but only to the extent consistent with this section.

6

(4) The coverage required by subsection (1) of this section may be made

7

subject to, and no more restrictive than, the provisions of a health insurance

8

policy that apply to other benefits under the policy.

9

(5) The coverage required by subsection (1) of this section shall include

10

any repair or replacement of a prosthetic or orthotic device that is deter-

11

mined medically necessary to restore or maintain the ability to complete

12

activities of daily living or essential job-related activities and that is not

13

solely for comfort or convenience.

14

(6) If coverage under subsection (1) of this section is provided through a

15

managed care plan, the insured shall have access to medically necessary

16

clinical care and to prosthetic and orthotic devices and technology from not

17

less than two distinct Oregon prosthetic and orthotic providers in the man-

18

aged care plan’s provider network.

19

SECTION 85. ORS 743A.148 is amended to read:

20

743A.148. (1) The Legislative Assembly declares that all group health in-

21

surance policies providing hospital, medical or surgical expense benefits in-

22

clude coverage for maxillofacial prosthetic services considered necessary for

23

adjunctive treatment unless the coverage is available through the Af-

24

fordable Health Care for All Oregon Plan.

25

(2) As used in this section, “maxillofacial prosthetic services considered

26

necessary for adjunctive treatment� means restoration and management of

27

head and facial structures that cannot be replaced with living tissue and that

28

are defective because of disease, trauma or birth and developmental

29

deformities when such restoration and management are performed for the

30

purpose of:

31

(a) Controlling or eliminating infection; [103]


LC 1914 11/14/12 1

(b) Controlling or eliminating pain; or

2

(c) Restoring facial configuration or functions such as speech, swallowing

3

or chewing but not including cosmetic procedures rendered to improve on the

4

normal range of conditions.

5

(3) The coverage required by subsection (1) of this section may be made

6

subject to provisions of the policy that apply to other benefits under the

7

policy including, but not limited to, provisions relating to deductibles and

8

coinsurance.

9 10

(4) The services described in this section shall apply to individual health policies entered into or renewed on or after January 1, 1982.

11

SECTION 86. ORS 743A.160 is amended to read:

12

743A.160. Except as provided in section 3 of this 2013 Act, a health

13

insurance policy providing coverage for hospital or medical expenses not

14

limited to expenses from accidents or specified sicknesses shall provide, at

15

the request of the applicant, coverage for expenses arising from treatment

16

for alcoholism. The following conditions apply to the requirement for such

17

coverage:

18 19 20 21

(1) The applicant shall be informed of the applicant’s option to request this coverage. (2) The inclusion of the coverage may be made subject to the insurer’s usual underwriting requirements.

22

(3) The coverage may be made subject to provisions of the policy that

23

apply to other benefits under the policy, including but not limited to pro-

24

visions relating to deductibles and coinsurance.

25 26

(4) The policy may limit hospital expense coverage to treatment provided by the following facilities:

27

(a) A health care facility licensed as required by ORS 441.015.

28

(b) A health care facility accredited by the Joint Commission on Accred-

29

itation of Hospitals.

30

(5) Except as permitted by subsection (3) of this section, the policy shall

31

not limit payments thereunder for alcoholism to an amount less than $4,500 [104]


LC 1914 11/14/12 1

in any 24-consecutive month period and the policy shall provide coverage,

2

within the limits of this subsection, of not less than 80 percent of the hos-

3

pital and medical expenses for treatment for alcoholism.

4

SECTION 87. ORS 743A.168 is amended to read:

5

743A.168. Except as provided in section 3 of this 2013 Act, a group

6

health insurance policy providing coverage for hospital or medical expenses

7

shall provide coverage for expenses arising from treatment for chemical de-

8

pendency, including alcoholism, and for mental or nervous conditions at the

9

same level as, and subject to limitations no more restrictive than, those im-

10

posed on coverage or reimbursement of expenses arising from treatment for

11

other medical conditions. The following apply to coverage for chemical de-

12

pendency and for mental or nervous conditions:

13

(1) As used in this section:

14

(a) “Chemical dependency” means the addictive relationship with any

15

drug or alcohol characterized by a physical or psychological relationship, or

16

both, that interferes on a recurring basis with the individual’s social, psy-

17

chological or physical adjustment to common problems. For purposes of this

18

section, “chemical dependency” does not include addiction to, or dependency

19

on, tobacco, tobacco products or foods.

20

(b) “Facility” means a corporate or governmental entity or other provider

21

of services for the treatment of chemical dependency or for the treatment of

22

mental or nervous conditions.

23 24 25 26

(c) “Group health insurer” means an insurer, a health maintenance organization or a health care service contractor. (d) “Program” means a particular type or level of service that is organizationally distinct within a facility.

27

(e) “Provider” means a person that has met the credentialing requirement

28

of a group health insurer, is otherwise eligible to receive reimbursement for

29

coverage under the policy and is:

30

(A) A health care facility;

31

(B) A residential program or facility; [105]


LC 1914 11/14/12 1

(C) A day or partial hospitalization program;

2

(D) An outpatient service; or

3

(E) An individual behavioral health or medical professional authorized for

4

reimbursement under Oregon law.

5

(2) The coverage may be made subject to provisions of the policy that

6

apply to other benefits under the policy, including but not limited to pro-

7

visions relating to deductibles and coinsurance. Deductibles and coinsurance

8

for treatment in health care facilities or residential programs or facilities

9

may

not

be

greater

than

those

under

the

policy

for

expenses

of

10

hospitalization in the treatment of other medical conditions.

Deductibles

11

and coinsurance for outpatient treatment may not be greater than those un-

12

der the policy for expenses of outpatient treatment of other medical condi-

13

tions.

14

(3) The coverage may not be made subject to treatment limitations, limits

15

on total payments for treatment, limits on duration of treatment or financial

16

requirements unless similar limitations or requirements are imposed on cov-

17

erage of other medical conditions. The coverage of eligible expenses may be

18

limited to treatment that is medically necessary as determined under the

19

policy for other medical conditions.

20

(4)(a) Nothing in this section requires coverage for:

21

(A) Educational or correctional services or sheltered living provided by

22 23 24

a school or halfway house; (B) A long-term residential mental health program that lasts longer than 45 days;

25

(C) Psychoanalysis or psychotherapy received as part of an educational

26

or training program, regardless of diagnosis or symptoms that may be pres-

27

ent;

28

(D) A court-ordered sex offender treatment program; or

29

(E) A screening interview or treatment program under ORS 813.021.

30

(b) Notwithstanding paragraph (a)(A) of this subsection, an insured may

31

receive covered outpatient services under the terms of the insured’s policy [106]


LC 1914 11/14/12 1

while the insured is living temporarily in a sheltered living situation.

2

(5) A provider is eligible for reimbursement under this section if:

3

(a) The provider is approved by the Department of Human Services;

4

(b) The provider is accredited for the particular level of care for which

5

reimbursement is being requested by the Joint Commission on Accreditation

6

of Hospitals or the Commission on Accreditation of Rehabilitation Facilities;

7

(c) The patient is staying overnight at the facility and is involved in a

8

structured program at least eight hours per day, five days per week; or

9

(d) The provider is providing a covered benefit under the policy.

10

(6) Payments may not be made under this section for support groups.

11

(7) If specified in the policy, outpatient coverage may include follow-up

12

in-home service or outpatient services. The policy may limit coverage for

13

in-home service to persons who are homebound under the care of a physician.

14

(8) Nothing in this section prohibits a group health insurer from manag-

15

ing the provision of benefits through common methods, including but not

16

limited to selectively contracted panels, health plan benefit differential de-

17

signs, preadmission screening, prior authorization of services, utilization re-

18

view or other mechanisms designed to limit eligible expenses to those

19

described in subsection (3) of this section.

20

(9) The Legislative Assembly has found that health care cost containment

21

is necessary and intends to encourage insurance policies designed to achieve

22

cost containment by ensuring that reimbursement is limited to appropriate

23

utilization under criteria incorporated into such policies, either directly or

24

by reference.

25

(10)(a) Subject to the patient or client confidentiality provisions of ORS

26

40.235 relating to physicians, ORS 40.240 relating to nurse practitioners, ORS

27

40.230 relating to psychologists, ORS 40.250 and 675.580 relating to licensed

28

clinical social workers and ORS 40.262 relating to licensed professional

29

counselors and licensed marriage and family therapists, a group health

30

insurer may provide for review for level of treatment of admissions and

31

continued stays for treatment in health care facilities, residential programs [107]


LC 1914 11/14/12 1

or facilities, day or partial hospitalization programs and outpatient services

2

by either group health insurer staff or personnel under contract to the group

3

health insurer, or by a utilization review contractor, who shall have the

4

authority to certify for or deny level of payment.

5 6

(b) Review shall be made according to criteria made available to providers in advance upon request.

7

(c) Review shall be performed by or under the direction of a medical or

8

osteopathic physician licensed by the Oregon Medical Board, a psychologist

9

licensed by the State Board of Psychologist Examiners, a clinical social

10

worker licensed by the State Board of Licensed Social Workers or a profes-

11

sional counselor or marriage and family therapist licensed by the Oregon

12

Board of Licensed Professional Counselors and Therapists, in accordance

13

with standards of the National Committee for Quality Assurance or Medi-

14

care review standards of the Centers for Medicare and Medicaid Services.

15

(d) Review may involve prior approval, concurrent review of the contin-

16

uation of treatment, post-treatment review or any combination of these.

17

However, if prior approval is required, provision shall be made to allow for

18

payment of urgent or emergency admissions, subject to subsequent review.

19

If prior approval is not required, group health insurers shall permit provid-

20

ers, policyholders or persons acting on their behalf to make advance in-

21

quiries regarding the appropriateness of a particular admission to a

22

treatment program. Group health insurers shall provide a timely response to

23

such inquiries. Noncontracting providers must cooperate with these proce-

24

dures to the same extent as contracting providers to be eligible for re-

25

imbursement.

26

(11) Health maintenance organizations may limit the receipt of covered

27

services by enrollees to services provided by or upon referral by providers

28

contracting with the health maintenance organization. Health maintenance

29

organizations and health care service contractors may create substantive

30

plan benefit and reimbursement differentials at the same level as, and subject

31

to limitations no more restrictive than, those imposed on coverage or re[108]


LC 1914 11/14/12 1

imbursement of expenses arising out of other medical conditions and apply

2

them to contracting and noncontracting providers.

3

(12) Nothing in this section prevents a group health insurer from con-

4

tracting with providers of health care services to furnish services to

5

policyholders or certificate holders according to ORS 743.531 or 750.005,

6

subject to the following conditions:

7 8

(a) A group health insurer is not required to contract with all eligible providers.

9

(b) An insurer or health care service contractor shall, subject to sub-

10

sections (2) and (3) of this section, pay benefits toward the covered charges

11

of noncontracting providers of services for the treatment of chemical de-

12

pendency or mental or nervous conditions. The insured shall, subject to

13

subsections (2) and (3) of this section, have the right to use the services of

14

a noncontracting provider of services for the treatment of chemical depend-

15

ency or mental or nervous conditions, whether or not the services for

16

chemical dependency or mental or nervous conditions are provided by con-

17

tracting or noncontracting providers.

18

(13) The intent of the Legislative Assembly in adopting this section is to

19

reserve benefits for different types of care to encourage cost effective care

20

and to ensure continuing access to levels of care most appropriate for the

21

insured’s condition and progress.

22

(14) The Director of the Department of Consumer and Business Services,

23

after notice and hearing, may adopt reasonable rules not inconsistent with

24

this section that are considered necessary for the proper administration of

25

these provisions.

26

SECTION 88. ORS 743A.170 is amended to read:

27

743A.170. (1) Except as provided in section 3 of this 2013 Act, a health

28

benefit plan as defined in ORS 743.730 must provide payment, coverage or

29

reimbursement of at least $500 for a tobacco use cessation program for a

30

person enrolled in the plan who is 15 years of age or older.

31

(2) As used in this section, “tobacco use cessation program� means a [109]


LC 1914 11/14/12 1

program recommended by a physician that follows the United States Public

2

Health Service guidelines for tobacco use cessation. “Tobacco use cessation

3

program” includes education and medical treatment components designed to

4

assist a person in ceasing the use of tobacco products.

5

(3) This section is exempt from ORS 743A.001.

6

SECTION 89. ORS 743A.175 is amended to read:

7

743A.175. (1) Except as provided in section 3 of this 2013 Act, a health

8

benefit plan, as defined in ORS 743.730, shall provide coverage of medically

9

necessary therapy and services for the treatment of traumatic brain injury.

10

(2) This section is exempt from ORS 743A.001.

11

SECTION 90. ORS 743A.184 is amended to read:

12

743A.184. (1) Except as provided in section 3 of this 2013 Act, and

13

subject to other terms, conditions and benefits in the plan, group health

14

benefit plans as described in ORS 743.730 shall provide payment, coverage

15

or reimbursement for supplies, equipment and diabetes self-management pro-

16

grams associated with the treatment of insulin-dependent diabetes, insulin-

17

using diabetes, gestational diabetes and noninsulin-using diabetes prescribed

18

by a health care professional legally authorized to prescribe such items.

19

(2) As used in this section, “diabetes self-management program” means

20

one program of assessment and training after diagnosis and no more than

21

three hours per year of assessment and training upon a material change of

22

condition, medication or treatment that is provided by:

23 24

(a) An education program credentialed or accredited by a state or national entity accrediting such programs; or

25

(b) A program provided by a physician licensed under ORS chapter 677,

26

a registered nurse, a nurse practitioner, a certified diabetes educator or a

27

licensed dietitian with demonstrated expertise in diabetes.

28

SECTION 91. ORS 743A.188 is amended to read:

29

743A.188. (1) Except as provided in section 3 of this 2013 Act, all in-

30

dividual and group health insurance policies providing coverage for hospital,

31

medical or surgical expenses, other than coverage limited to expenses from [110]


LC 1914 11/14/12 1

accidents or specific diseases, shall include coverage for treatment of inborn

2

errors of metabolism that involve amino acid, carbohydrate and fat

3

metabolism and for which medically standard methods of diagnosis, treat-

4

ment and monitoring exist, including quantification of metabolites in blood,

5

urine or spinal fluid or enzyme or DNA confirmation in tissues. Coverage

6

shall include expenses of diagnosing, monitoring and controlling the disor-

7

ders by nutritional and medical assessment, including but not limited to

8

clinical visits, biochemical analysis and medical foods used in the treatment

9

of such disorders.

10

(2) As used in this section, “medical foods� means foods that are formu-

11

lated to be consumed or administered enterally under the supervision of a

12

physician, as defined in ORS 677.010, that are specifically processed or for-

13

mulated to be deficient in one or more of the nutrients present in typical

14

nutritional counterparts, that are for the medical and nutritional manage-

15

ment of patients with limited capacity to metabolize ordinary foodstuffs or

16

certain nutrients contained therein or have other specific nutrient require-

17

ments as established by medical evaluation and that are essential to optimize

18

growth, health and metabolic homeostasis.

19

(3) This section is exempt from ORS 743A.001.

20

SECTION 92. ORS 743A.190 is amended to read:

21

743A.190. (1) Except as provided in section 3 of this 2013 Act, a health

22

benefit plan, as defined in ORS 743.730, must cover for a child enrolled in

23

the plan who is under 18 years of age and who has been diagnosed with a

24

pervasive developmental disorder all medical services, including rehabili-

25

tation services, that are medically necessary and are otherwise covered under

26

the plan.

27

(2) The coverage required under subsection (1) of this section, including

28

rehabilitation services, may be made subject to other provisions of the health

29

benefit plan that apply to covered services, including but not limited to:

30

(a) Deductibles, copayments or coinsurance;

31

(b) Prior authorization or utilization review requirements; or [111]


LC 1914 11/14/12 1 2

(c) Treatment limitations regarding the number of visits or the duration of treatment.

3

(3) As used in this section:

4

(a) “Medically necessary” means in accordance with the definition of

5

medical necessity that is specified in the policy, certificate or contract for

6

the health benefit plan and that applies uniformly to all covered services

7

under the health benefit plan.

8

(b) “Pervasive developmental disorder” means a neurological condition

9

that includes Asperger’s syndrome, autism, developmental delay, develop-

10 11 12

mental disability or mental retardation. (c) “Rehabilitation services” means physical therapy, occupational therapy or speech therapy services to restore or improve function.

13

(4) The provisions of ORS 743A.001 do not apply to this section.

14

(5) The definition of “pervasive developmental disorder” is not intended

15

to apply to coverage required under ORS 743A.168.

16

SECTION 93. ORS 743A.192 is amended to read:

17

743A.192. (1) Except as provided in section 3 of this 2013 Act, a health

18

benefit plan, as defined in ORS 743.730, shall provide coverage for the rou-

19

tine costs of the care of patients enrolled in and participating in qualifying

20

clinical trials.

21

(2) As used in subsection (1) of this section, “routine costs”:

22

(a) Means medically necessary conventional care, items or services cov-

23

ered by the health benefit plan if typically provided absent a clinical trial.

24

(b) Does not include:

25

(A) The drug, device or service being tested in the clinical trial unless

26

the drug, device or service would be covered for that indication by the health

27

benefit plan if provided outside of a clinical trial;

28 29 30 31

(B) Items or services required solely for the provision of the drug device or service being tested in the clinical trial; (C) Items or services required solely for the clinically appropriate monitoring of the drug, device or service being tested in the clinical trial; [112]


LC 1914 11/14/12 1

(D) Items or services required solely for the prevention, diagnosis or

2

treatment of complications arising from the provision of the drug, device or

3

service being tested in the clinical trial;

4

(E) Items or services that are provided solely to satisfy data collection

5

and analysis needs and that are not used in the direct clinical management

6

of the patient;

7 8 9 10 11 12

(F) Items or services customarily provided by a clinical trial sponsor free of charge to any participant in the clinical trial; or (G) Items or services that are not covered by the health plan if provided outside of the clinical trial. (3) As used in subsection (1) of this section, “qualifying clinical trial� means a clinical trial that is:

13

(a) Funded by the National Institutes of Health, the Centers for Disease

14

Control and Prevention, the Agency for Healthcare Research and Quality,

15

the Centers for Medicare and Medicaid Services, the United States Depart-

16

ment of Defense or the United States Department of Veterans Affairs;

17

(b) Supported by a center or cooperative group that is funded by the Na-

18

tional Institutes of Health, the Centers for Disease Control and Prevention,

19

the Agency for Healthcare Research and Quality, the Centers for Medicare

20

and Medicaid Services, the United States Department of Defense or the

21

United States Department of Veterans Affairs;

22

(c)

Conducted

as

an

investigational

new

drug

application,

an

23

investigational device exemption or a biologics license application subject

24

to approval by the United States Food and Drug Administration; or

25

(d) Exempt by federal law from the requirement to submit an

26

investigational new drug application to the United States Food and Drug

27

Administration.

28

(4) The coverage required by this section may be subject to provisions of

29

the health benefit plan that apply to other benefits within the same category,

30

including but not limited to copayments, deductibles and coinsurance.

31

(5) An insurer that provides coverage required by this section is not, [113]


LC 1914 11/14/12 1

based upon that coverage, liable for any adverse effects of the clinical trial.

2

SECTION 94. ORS 744.704 is amended to read:

3

744.704. (1) The following persons are exempt from the licensing require-

4

ment for third party administrators in ORS 744.702 and from all other pro-

5

visions of ORS 744.700 to 744.740 applicable to third party administrators:

6

(a) A person licensed under ORS 744.002 as an adjuster, whose activities

7

are limited to adjustment of claims and whose activities do not include the

8

activities of a third party administrator.

9

(b) A person licensed as an insurance producer as required by ORS 744.053

10

and authorized to transact life or health insurance in this state, whose ac-

11

tivities are limited exclusively to the sale of insurance and whose activities

12

do not include the activities of a third party administrator.

13

(c) An employer acting as a third party administrator on behalf of:

14

(A) Its employees;

15

(B) The employees of one or more subsidiary or affiliated corporations of

16 17 18 19 20

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.

21

(e) An insurer that is authorized to transact insurance in this state with

22

respect to a policy issued and delivered in and pursuant to the laws of this

23

state or another state.

24 25

(f) A creditor acting on behalf of its debtors with respect to insurance covering a debt between the creditor and its debtors.

26

(g) A trust and the trustees, agents and employees of the trust, when

27

acting pursuant to the trust, if the trust is established in conformity with

28

29 U.S.C. 186.

29

(h) A trust exempt from taxation under section 501(a) of the Internal

30

Revenue Code, its trustees and employees acting pursuant to the trust, or a

31

voluntary employees beneficiary association described in section 501(c) of the [114]


LC 1914 11/14/12 1

Internal Revenue Code, its agents and employees and a custodian and the

2

custodian’s agents and employees acting pursuant to a custodian account

3

meeting the requirements of section 401(f) of the Internal Revenue Code.

4

(i) A financial institution that is subject to supervision or examination

5

by federal or state financial institution regulatory authorities, or a mortgage

6

lender, to the extent the financial institution or mortgage lender collects and

7

remits premiums to licensed insurance producers or authorized insurers in

8

connection with loan payments.

9

(j) A company that issues credit cards and advances for and collects pre-

10

miums or charges from its credit card holders who have authorized col-

11

lection. The exemption under this paragraph applies only if the company does

12

not adjust or settle claims.

13

(k) A person who adjusts or settles claims in the normal course of prac-

14

tice or employment as an attorney at law. The exemption under this sub-

15

section applies only if the person does not collect charges or premiums in

16

connection with life insurance or health insurance coverage.

17

(L) A person who acts solely as an administrator of one or more bona fide

18

employee benefit plans established by an employer or an employee organiza-

19

tion, or both, for which the Insurance Code is preempted pursuant to the

20

Employee Retirement Income Security Act of 1974. A person to whom this

21

paragraph applies must comply with the requirements of ORS 744.714.

22

[(m) The Oregon Medical Insurance Pool Board, established under ORS

23

735.600 to 735.650, and the administering insurer or insurers for the board, for

24

services provided pursuant to ORS 735.600 to 735.650.]

25

[(n)] (m) An entity or association owned by or composed of like employers

26

who administer partially or fully self-insured plans for employees of the em-

27

ployers or association members.

28

[(o)] (n) A trust established by a cooperative body formed between cities,

29

counties, districts or other political subdivisions of this state, or between

30

any combination of such entities, and the trustees, agents and employees

31

acting pursuant to the trust. [115]


LC 1914 11/14/12 1 2 3 4 5 6 7 8

[(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

9

(c) In the case of any group policy or plan of insurance serviced by the

10

third party administrator, the lesser of five percent or 100 certificate holders

11

reside in this state.

12

SECTION 95. ORS 746.600 is amended to read:

13

746.600. As used in ORS 746.600 to 746.690:

14

(1)(a) “Adverse underwriting decision� means any of the following actions

15

with respect to insurance transactions involving insurance coverage that is

16

individually underwritten:

17

(A) A declination of insurance coverage.

18

(B) A termination of insurance coverage.

19

(C) Failure of an insurance producer to apply for insurance coverage with

20

a specific insurer that the insurance producer represents and that is re-

21

quested by an applicant.

22 23 24 25

(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:

26

(i) Placement by an insurer or insurance producer of a risk with a resi-

27

dual market mechanism, an unauthorized insurer or an insurer that special-

28

izes in substandard risks.

29 30 31

(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 [116]


LC 1914 11/14/12 1

insurance in connection with the underwriting of insurance. For purposes

2

of this sub-subparagraph, the imposition of a service fee is not a charge.

3

(b) “Adverse underwriting decision” does not mean any of the following

4

actions, but the insurer or insurance producer responsible for the occurrence

5

of the action must nevertheless provide the applicant or policyholder with

6

the specific reason or reasons for the occurrence:

7 8 9 10

(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.

11

(C) The rescission of a policy.

12

(2) “Affiliate of” a specified person or “person affiliated with” a specified

13

person means a person who directly, or indirectly, through one or more in-

14

termediaries, controls, or is controlled by, or is under common control with,

15

the person specified.

16

(3) “Applicant” means a person who seeks to contract for insurance cov-

17

erage, other than a person seeking group insurance coverage that is not in-

18

dividually underwritten.

19

(4) “Consumer” means an individual, or the personal representative of the

20

individual, who seeks to obtain, obtains or has obtained one or more insur-

21

ance products or services from a licensee that are to be used primarily for

22

personal, family or household purposes, and about whom the licensee has

23

personal information.

24

(5) “Consumer report” means any written, oral or other communication

25

of information bearing on a natural person’s creditworthiness, credit stand-

26

ing, credit capacity, character, general reputation, personal characteristics

27

or mode of living that is used or expected to be used in connection with an

28

insurance transaction.

29 30 31

(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 [117]


LC 1914 11/14/12 1

consumer reports;

2

(b) Obtains information primarily from sources other than insurers; and

3

(c) Furnishes consumer reports to other persons.

4

(7) “Control” means, and the terms “controlled by” or “under common

5

control with” refer to, the possession, directly or indirectly, of the power to

6

direct or cause the direction of the management and policies of a person,

7

whether through the ownership of voting securities, by contract other than

8

a commercial contract for goods or nonmanagement services, or otherwise,

9

unless the power of the person is the result of a corporate office held in, or

10

an official position held with, the controlled person.

11

(8) “Covered entity” means:

12

(a) A health insurer;

13

(b) A health care provider that transmits any health information in elec-

14

tronic form to carry out financial or administrative activities in connection

15

with a transaction covered by ORS 746.607 or by rules adopted under ORS

16

746.608; or

17

(c) A health care clearinghouse.

18

(9) “Credit history” means any written or other communication of any

19 20 21 22 23

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.

24

(10) “Customer” means a consumer who has a continuing relationship

25

with a licensee under which the licensee provides one or more insurance

26

products or services to the consumer that are to be used primarily for per-

27

sonal, family or household purposes.

28

(11) “Declination of insurance coverage” or “decline coverage” means a

29

denial, in whole or in part, by an insurer or insurance producer of an ap-

30

plication for requested insurance coverage.

31

(12) “Health care” means care, services or supplies related to the health [118]


LC 1914 11/14/12 1

of an individual.

2

(13) “Health care operations” includes but is not limited to:

3

(a) Quality assessment, accreditation, auditing and improvement activ-

4

ities;

5

(b) Case management and care coordination;

6

(c) Reviewing the competence, qualifications or performance of health

7

care providers or health insurers;

8

(d) Underwriting activities;

9

(e) Arranging for legal services;

10

(f) Business planning;

11

(g) Customer services;

12

(h) Resolving internal grievances;

13

(i) Creating deidentified information; and

14

(j) Fundraising.

15

(14) “Health care provider” includes but is not limited to:

16

(a) A psychologist, occupational therapist, regulated social worker, pro-

17

fessional counselor or marriage and family therapist licensed or otherwise

18

authorized to practice under ORS chapter 675 or an employee of the psy-

19

chologist, occupational therapist, regulated social worker, professional

20

counselor or marriage and family therapist;

21

(b) A physician, podiatric physician and surgeon, physician assistant or

22

acupuncturist licensed under ORS chapter 677 or an employee of the physi-

23

cian, podiatric physician and surgeon, physician assistant or acupuncturist;

24 25 26 27 28 29

(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;

30

(f) A speech-language pathologist or audiologist licensed under ORS

31

chapter 681 or an employee of the speech-language pathologist or audiologist; [119]


LC 1914 11/14/12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

(g) An emergency medical services provider licensed 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 688.815 or an employee of the respiratory care practitioner; (p) A polysomnographic technologist licensed under ORS 688.819 or an employee of the polysomnographic technologist; (q) A pharmacist licensed under ORS chapter 689 or an employee of the pharmacist; (r) A dietitian licensed under ORS 691.405 to 691.485 or an employee of the dietitian; (s) A funeral service practitioner licensed under ORS chapter 692 or an employee of the funeral service practitioner;

27

(t) A health care facility as defined in ORS 442.015;

28

(u) A home health agency as defined in ORS 443.005;

29

(v) A hospice program as defined in ORS 443.850;

30

(w) A clinical laboratory as defined in ORS 438.010;

31

(x) A pharmacy as defined in ORS 689.005; [120]


LC 1914 11/14/12 1

(y) A diabetes self-management program as defined in ORS 743.694; and

2

(z) Any other person or entity that furnishes, bills for or is paid for health

3 4 5

care in the normal course of business. (15) “Health information” means any oral or written information in any form or medium that:

6

(a) Is created or received by a covered entity, a public health authority,

7

a life insurer, a school, a university or a health care provider that is not a

8

covered entity; and

9 10 11

(b) Relates to: (A) The past, present or future physical or mental health or condition of an individual;

12

(B) The provision of health care to an individual; or

13

(C) The past, present or future payment for the provision of health care

14

to an individual.

15

(16) “Health insurer” means[:]

16

[(a)] an insurer who offers:

17

[(A)] (a) A health benefit plan as defined in ORS 743.730;

18

[(B)] (b) A short term health insurance policy, the duration of which does

19

not exceed six months including renewals;

20

[(C)] (c) A student health insurance policy;

21

[(D)] (d) A Medicare supplemental policy; or

22

[(E)] (e) A dental only policy.

23

[(b) The Oregon Medical Insurance Pool operated by the Oregon Medical

24

Insurance Pool Board under ORS 735.600 to 735.650.]

25

(17) “Homeowner insurance” means insurance for residential property

26

consisting of a combination of property insurance and casualty insurance

27

that provides coverage for the risks of owning or occupying a dwelling and

28

that is not intended to cover an owner’s interest in rental property or com-

29

mercial exposures.

30

(18) “Individual” means a natural person who:

31

(a) In the case of life or health insurance, is a past, present or proposed [121]


LC 1914 11/14/12 1 2 3

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;

4

(c) Is a past, present or proposed policyowner;

5

(d) Is a past or present applicant;

6

(e) Is a past or present claimant; or

7

(f) Derived, derives or is proposed to derive insurance coverage under an

8 9 10 11 12

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

13

(b) Identifiable to an individual, including demographic information that

14

identifies the individual, or for which there is a reasonable basis to believe

15

the information can be used to identify an individual, and that relates to:

16 17

(A) The past, present or future physical or mental health or condition of an individual;

18

(B) The provision of health care to an individual; or

19

(C) The past, present or future payment for the provision of health care

20

to an individual.

21

(20) “Institutional source” means a person or governmental entity that

22

provides information about an individual to an insurer, insurance producer

23

or insurance-support organization, other than:

24

(a) An insurance producer;

25

(b) The individual who is the subject of the information; or

26

(c) A natural person acting in a personal capacity rather than in a busi-

27

ness or professional capacity.

28

(21) “Insurance producer” or “producer” means a person licensed by the

29

Director of the Department of Consumer and Business Services as a resident

30

or nonresident insurance producer.

31

(22) “Insurance score” means a number or rating that is derived from an [122]


LC 1914 11/14/12 1

algorithm, computer application, model or other process that is based in

2

whole or in part on credit history.

3

(23)(a) “Insurance-support organization” means a person who regularly

4

engages, in whole or in part, in assembling or collecting information about

5

natural persons for the primary purpose of providing the information to an

6

insurer or insurance producer for insurance transactions, including:

7 8

(A) The furnishing of consumer reports to an insurer or insurance producer for use in connection with insurance transactions; and

9

(B) The collection of personal information from insurers, insurance pro-

10

ducers or other insurance-support organizations for the purpose of detecting

11

or preventing fraud, material misrepresentation or material nondisclosure in

12

connection with insurance underwriting or insurance claim activity.

13 14

(b) “Insurance-support organization” does not mean insurers, insurance producers, governmental institutions or health care providers.

15

(24) “Insurance transaction” means any transaction that involves insur-

16

ance primarily for personal, family or household needs rather than business

17

or professional needs and that entails:

18 19

(a) The determination of an individual’s eligibility for an insurance coverage, benefit or payment; or

20

(b) The servicing of an insurance application, policy or certificate.

21

(25) “Insurer” has the meaning given that term in ORS 731.106.

22

(26) “Investigative consumer report” means a consumer report, or portion

23

of a consumer report, for which information about a natural person’s char-

24

acter, general reputation, personal characteristics or mode of living is ob-

25

tained through personal interviews with the person’s neighbors, friends,

26

associates, acquaintances or others who may have knowledge concerning

27

such items of information.

28

(27) “Licensee” means an insurer, insurance producer or other person

29

authorized or required to be authorized, or licensed or required to be li-

30

censed, pursuant to the Insurance Code.

31

(28) “Loss history report” means a report provided by, or a database [123]


LC 1914 11/14/12 1

maintained by, an insurance-support organization or consumer reporting

2

agency that contains information regarding the claims history of the indi-

3

vidual property that is the subject of the application for a homeowner in-

4

surance policy or the consumer applying for a homeowner insurance policy.

5

(29) “Nonaffiliated third party” means any person except:

6

(a) An affiliate of a licensee;

7

(b) A person that is employed jointly by a licensee and by a person that

8 9

is not an affiliate of the licensee; and (c) As designated by the director by rule.

10

(30) “Payment” includes but is not limited to:

11

(a) Efforts to obtain premiums or reimbursement;

12

(b) Determining eligibility or coverage;

13

(c) Billing activities;

14

(d) Claims management;

15

(e) Reviewing health care to determine medical necessity;

16

(f) Utilization review; and

17

(g) Disclosures to consumer reporting agencies.

18

(31)(a) “Personal financial information” means:

19

(A) Information that is identifiable with an individual, gathered in con-

20

nection with an insurance transaction from which judgments can be made

21

about the individual’s character, habits, avocations, finances, occupations,

22

general reputation, credit or any other personal characteristics; or

23 24

(B) An individual’s name, address and policy number or similar form of access code for the individual’s policy.

25

(b) “Personal financial information” does not mean information that a

26

licensee has a reasonable basis to believe is lawfully made available to the

27

general public from federal, state or local government records, widely dis-

28

tributed media or disclosures to the public that are required by federal, state

29

or local law.

30

(32) “Personal information” means:

31

(a) Personal financial information; [124]


LC 1914 11/14/12 1

(b) Individually identifiable health information; or

2

(c) Protected health information.

3

(33) “Personal insurance” means the following types of insurance products

4

or services that are to be used primarily for personal, family or household

5

purposes:

6

(a) Private passenger automobile coverage;

7

(b) Homeowner, mobile homeowners, manufactured homeowners, condo-

8 9 10 11

minium owners and renters coverage; (c) Personal dwelling property coverage; (d) Personal liability and theft coverage, including excess personal liability and theft coverage; and

12

(e) Personal inland marine coverage.

13

(34) “Personal representative” includes but is not limited to:

14

(a) A person appointed as a guardian under ORS 125.305, 419B.370,

15

419C.481 or 419C.555 with authority to make medical and health care deci-

16

sions;

17

(b) A person appointed as a health care representative under ORS 127.505

18

to 127.660 or 127.700 to 127.737 to make health care decisions or mental

19

health treatment decisions;

20 21

(c) A person appointed as a personal representative under ORS chapter 113; and

22

(d) A person described in ORS 746.611.

23

(35) “Policyholder” means a person who:

24

(a) In the case of individual policies of life or health insurance, is a cur-

25 26 27 28 29

rent 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.

30

(36) “Pretext interview” means an interview wherein the interviewer, in

31

an attempt to obtain personal information about a natural person, does one [125]


LC 1914 11/14/12 1

or more of the following:

2

(a) Pretends to be someone the interviewer is not.

3

(b) Pretends to represent a person the interviewer is not in fact repre-

4

senting.

5

(c) Misrepresents the true purpose of the interview.

6

(d) Refuses upon request to identify the interviewer.

7

(37) “Privileged information” means information that is identifiable with

8 9 10

an individual and that: (a) Relates to a claim for insurance benefits or a civil or criminal proceeding involving the individual; and

11

(b) Is collected in connection with or in reasonable anticipation of a claim

12

for insurance benefits or a civil or criminal proceeding involving the indi-

13

vidual.

14

(38)(a) “Protected health information” means individually identifiable

15

health information that is transmitted or maintained in any form of elec-

16

tronic or other medium by a covered entity.

17 18 19 20

(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);

21

(B) Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); or

22

(C) Employment records held by a covered entity in its role as employer.

23

(39) “Residual market mechanism” means an association, organization or

24

other entity involved in the insuring of risks under ORS 735.005 to 735.145,

25

737.312 or other provisions of the Insurance Code relating to insurance ap-

26

plicants who are unable to procure insurance through normal insurance

27

markets.

28

(40) “Termination of insurance coverage” or “termination of an insurance

29

policy” means either a cancellation or a nonrenewal of an insurance policy,

30

in whole or in part, for any reason other than the failure of a premium to

31

be paid as required by the policy. [126]


LC 1914 11/14/12 1

(41) “Treatment� includes but is not limited to:

2

(a) The provision, coordination or management of health care; and

3

(b) Consultations and referrals between health care providers.

4

SECTION 96. ORS 748.603 is amended to read:

5

748.603. (1) Societies are governed by this chapter and are exempt from

6

all other provisions of the insurance laws of this state unless expressly des-

7

ignated therein, or unless specifically made applicable by this chapter.

8

(2) ORS 705.137, 705.139, 731.004 to 731.026, 731.036 to 731.136, 731.146 to

9

731.156, 731.162, 731.166, 731.170, 731.216 to 731.268, 731.296, 731.324, 731.328,

10

731.354, 731.356, 731.358, 731.378, 731.380, 731.381, 731.382, 731.385, 731.386,

11

731.390, 731.394, 731.396, 731.398, 731.402, 731.406, 731.410, 731.422 to 731.434,

12

731.446 to 731.454, 731.488, 731.504, 731.508, 731.509, 731.510, 731.511, 731.512,

13

731.592, 731.594, 731.730, 731.731, 731.735, 731.737, 731.750, 731.804, 731.844 to

14

731.992, 731.870, 732.245, 732.250, 732.320, 732.325, 733.010 to 733.050, 733.080,

15

733.140 to 733.210, 733.220, 733.510, 733.652 to 733.658, 733.730 to 733.750,

16

[735.600 to 735.650,] 742.001, 742.003, 742.005, 742.007, 742.009, 742.013 to

17

742.021, 742.028, 742.038, 742.041, 742.046, 742.051, 742.150 to 742.162 and

18

744.700 to 744.740 and ORS chapters 734, 743 and 743A apply to fraternal

19

benefit societies to the extent not inconsistent with the express provisions

20

of this chapter.

21

(3) For the purposes of this subsection and subsection (2) of this section,

22

fraternal benefit societies shall be deemed insurers, and benefit certificates

23

issued by fraternal benefit societies shall be deemed policies.

24

(4) Every society authorized to do business in this state shall be subject

25

to the provisions of ORS chapter 746 relating to unfair trade practices.

26

However, nothing in ORS chapter 746 shall be construed as applying to or

27

affecting the right of any society to determine its eligibility requirements for

28

membership, or be construed as applying to or affecting the offering of ben-

29

efits exclusively to members or persons eligible for membership in the society

30

by a subsidiary corporation or affiliated organization of the society.

31

SECTION 97. ORS 750.055, as amended by section 3, chapter 21, Oregon [127]


LC 1914 11/14/12 1

Laws 2012, is amended to read:

2

750.055. (1) The following provisions of the Insurance Code apply to

3

health care service contractors to the extent not inconsistent with the ex-

4

press provisions of ORS 750.005 to 750.095:

5

(a) ORS 705.137, 705.139, 731.004 to 731.150, 731.162, 731.216 to 731.362,

6

731.382, 731.385, 731.386, 731.390, 731.398 to 731.430, 731.428, 731.450, 731.454,

7

731.488, 731.504, 731.508, 731.509, 731.510, 731.511, 731.512, 731.574 to 731.620,

8

731.592, 731.594, 731.640 to 731.652, 731.730, 731.731, 731.735, 731.737, 731.750,

9

731.752, 731.804, 731.844 to 731.992, 731.870 and 743.061.

10 11 12 13

(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.

14

(d) ORS chapter 734.

15

(e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065, 742.150 to 742.162,

16

742.400, 742.520 to 742.540, 743.010, 743.013, 743.018 to 743.030, 743.050, 743.100

17

to 743.109, 743.402, 743.472, 743.492, 743.495, 743.498, 743.499, 743.522, 743.523,

18

743.524, 743.526, 743.527, 743.528, 743.529, 743.549 to 743.552, 743.560, 743.600

19

to 743.610, 743.650 to 743.656, 743.764, 743.804, 743.807, 743.808, 743.814 to

20

743.839, 743.842, 743.845, 743.847, 743.854, 743.856, 743.857, 743.858, 743.859,

21

743.861, 743.862, 743.863, 743.864, 743.894, 743.911, 743.912, 743.913, 743.917,

22

743A.010,

743A.012,

743A.020,

743A.034,

743A.036,

743A.048,

743A.058,

23

743A.062,

743A.064,

743A.065,

743A.066,

743A.068,

743A.070,

743A.080,

24

743A.084,

743A.088,

743A.090,

743A.100,

743A.104,

743A.105,

743A.110,

25

743A.140,

743A.141,

743A.144,

743A.148,

743A.160,

743A.164,

743A.168,

26

743A.170, 743A.175, 743A.184, 743A.185, 743A.188, 743A.190 and 743A.192 and

27

section 2, chapter 21, Oregon Laws 2012.

28 29

(f) The provisions of ORS chapter 744 relating to the regulation of insurance producers.

30

(g) ORS 746.005 to 746.140, 746.160, 746.220 to 746.370, 746.600, 746.605,

31

746.607, 746.608, 746.610, 746.615, 746.625, 746.635, 746.650, 746.655, 746.660, [128]


LC 1914 11/14/12 1

746.668, 746.670, 746.675, 746.680 and 746.690.

2

(h) ORS 743A.024, except in the case of group practice health maintenance

3

organizations that are federally qualified pursuant to Title XIII of the Public

4

Health Service Act unless the patient is referred by a physician associated

5

with a group practice health maintenance organization.

6

[(i) ORS 735.600 to 735.650.]

7

[(j)] (i) ORS 743.680 to 743.689.

8

[(k)] (j) ORS 744.700 to 744.740.

9

[(L)] (k) ORS 743.730 to 743.773.

10

[(m)] (L) ORS 731.485, except in the case of a group practice health

11

maintenance organization that is federally qualified pursuant to Title XIII

12

of the Public Health Service Act and that wholly owns and operates an in-

13

house drug outlet.

14 15

(2) For the purposes of this section, health care service contractors shall be deemed insurers.

16

(3) Any for-profit health care service contractor organized under the laws

17

of any other state that is not governed by the insurance laws of the other

18

state is subject to all requirements of ORS chapter 732.

19

(4) The Director of the Department of Consumer and Business Services

20

may, after notice and hearing, adopt reasonable rules not inconsistent with

21

this section and ORS 750.003, 750.005, 750.025 and 750.045 that are deemed

22

necessary for the proper administration of these provisions.

23 24

SECTION 98. Section 1, chapter 101, Oregon Laws 2012, is amended to read:

25

Sec. 1. (1) Notwithstanding ORS 291.229, a state agency that employs

26

more than 100 employees and has not, by [the effective date of this 2012 Act]

27

April 11, 2012, attained a ratio of at least 11 to 1 of employees of the state

28

agency who are not supervisory employees to supervisory employees:

29

(a) May not fill the position of a supervisory employee until the agency

30

has increased the agency’s ratio of employees to supervisory employees so

31

that the ratio is at least one additional employee to supervisory employees; [129]


LC 1914 11/14/12 1

and

2

(b) Shall, not later than October 31, 2012, lay off or reclassify the number

3

of supervisory employees necessary to attain the increase in the ratio speci-

4

fied in paragraph (a) of this subsection if the increase in that ratio is not

5

attained under paragraph (a) of this subsection or through attrition.

6

(2) Notwithstanding ORS 291.229, a state agency that employs more than

7

100 employees and has complied with the requirements of subsection (1) of

8

this section, but has not attained a ratio of at least 11 to 1 of employees of

9

the state agency who are not supervisory employees to supervisory employ-

10

ees:

11

(a) May not fill the position of a supervisory employee until the agency

12

has increased the agency’s ratio of employees to supervisory employees by

13

at least one additional employee; and

14

(b) Not later than October 31 of each subsequent year, shall lay off or

15

reclassify the number of supervisory employees necessary to increase the

16

agency’s ratio of employees to supervisory employees so that the ratio is at

17

least one additional employee to supervisory employees.

18

(3) Layoffs or reclassifications required under this section must be made

19

in accordance with the terms of any applicable collective bargaining agree-

20

ment. A supervisory employee who is reclassified into a classified position

21

pursuant to this section shall be compensated in the salary range for the

22

classified position unless otherwise provided by an applicable collective

23

bargaining agreement.

24

(4) Upon application from a state agency, the Oregon Department of Ad-

25

ministrative Services may grant a state agency an exception from the re-

26

quirements of subsections (1) to (3) of this section if the department

27

determines that the exception is warranted due to unique or emergency cir-

28

cumstances. The department shall report all exceptions granted under this

29

subsection to the Joint Committee on Ways and Means, the Joint Interim

30

Committee on Ways and Means or the Emergency Board.

31

(5) As used in this section: [130]


LC 1914 11/14/12 1

(a)(A) “State agency” means all state officers, boards, commissions, de-

2

partments, institutions, branches, agencies, divisions and other entities,

3

without regard to the designation given to those entities, that are within the

4

executive department of government as described in section 1, Article III of

5

the Oregon Constitution.

6

(B) “State agency” does not include:

7

(i) The legislative department as defined in ORS 174.114;

8

(ii) The judicial department as defined in ORS 174.113;

9

(iii) The Public Defense Services Commission;

10 11

(iv) The Secretary of State and the State Treasurer in the performance of the duties of their constitutional offices;

12

(v) Semi-independent state agencies listed in ORS 182.454;

13

(vi) The Oregon Tourism Commission;

14

(vii) The Oregon Film and Video Office;

15

(viii) The Oregon University System;

16

(ix) The Oregon Health and Science University;

17

(x) The Travel Information Council;

18

(xi) Oregon Corrections Enterprises;

19

(xii) The Oregon State Lottery Commission;

20

(xiii) The State Accident Insurance Fund Corporation;

21

[(xiv) The Oregon Health Insurance Exchange Corporation;]

22

[(xv)] (xiv) The Oregon Utility Notification Center;

23

[(xvi)] (xv) Oregon Community Power;

24

[(xvii)] (xvi) The Citizens’ Utility Board;

25

[(xviii)] (xvii) A special government body as defined in ORS 174.117;

26

[(xix)] (xviii) Any other public corporation created under a statute of this

27 28 29 30 31

state and specifically designated as a public corporation; and [(xx)] (xix) Any other semi-independent state agency denominated by statute as a semi-independent state agency. (b) “Supervisory employee” has the meaning given that term in ORS 243.650. [131]


LC 1914 11/14/12 APPROPRIATION

1 2 3

SECTION 99. There is appropriated to the Oregon Health Authority

4

for deposit in the Affordable Health Care for All Oregon Fund estab-

5

lished by section 24 of this 2013 Act, for the biennium beginning July

6

1, 2013, out of the General Fund, the amount of $_______ for the pur-

7

poses of the Affordable Health Care for All Oregon Board and admin-

8

istering the Affordable Health Care for All Oregon Plan.

9

REPEALS

10 11 12

SECTION 100. (1) ORS 414.825, 414.826, 414.828, 414.831, 414.839,

13

414.841, 414.842, 414.844, 414.846, 414.848, 414.851, 414.852, 414.854, 414.856,

14

414.858, 414.861, 414.862, 414.864, 414.866, 414.868, 414.870, 414.872, 735.600,

15

735.605, 735.610, 735.612, 735.614, 735.615, 735.616, 735.620, 735.625, 735.630,

16

735.635, 735.640, 735.645, 735.650, 735.700, 735.701, 735.702, 735.703, 735.705,

17

735.707, 735.709, 735.710, 735.712, 741.001, 741.002, 741.025, 741.027, 741.029,

18

741.031, 741.101, 741.105, 741.201, 741.220, 741.222, 741.250, 741.255, 741.300,

19

741.310, 741.340, 741.381, 741.390, 741.500, 741.510, 741.520, 741.540, 741.900,

20

743.822, 743.826 and 746.222 and sections 1, 3, 4 and 5, chapter 47, Oregon

21

Laws 2010, are repealed.

22 23

(2) Section 2, chapter 47, Oregon Laws 2010, as amended by section 22, chapter 70, Oregon Laws 2011, is repealed.

24

CAPTIONS

25 26 27

SECTION 101. The unit captions used in this 2013 Act are provided

28

only for the convenience of the reader and do not become part of the

29

statutory law of this state or express any legislative intent in the

30

enactment of this 2013 Act.

31

[132]


LC 1914 11/14/12 OPERATIVE DATES AND EMERGENCY CLAUSE

1 2 3

SECTION 102. (1) Sections 5 to 9 and 27 to 46 of this 2013 Act and

4

the amendments to ORS 413.032, 430.315, 442.015, 442.315 and 442.325 by

5

sections 11 to 13, 54 and 61 of this 2013 Act become operative January

6

1, 2016.

7

(2) Sections 1 to 4 of this 2013 Act, the amendments to ORS 65.957,

8

192.556, 243.105, 243.125, 243.135, 243.160, 243.275, 243.215, 243.860, 243.864,

9

243.866, 243.868, 243.886, 291.055, 411.402, 413.011, 413.017, 413.032, 413.037,

10

413.201, 414.041, 414.231, 433.443, 705.145, 731.036, 734.790, 743.402, 743.730,

11

743.748, 743.766, 743.767, 743.769, 743A.001, 743A.012, 743A.070, 743A.080,

12

743A.100, 743A.104, 743A.105, 743A.108, 743A.110, 743A.120, 743A.124,

13

743A.141, 743A.144, 743A.148, 743A.160, 743A.168, 743A.170, 743A.175,

14

743A.184, 743A.188, 743A.190, 743A.192,744.704, 746.600, 748.603 and 750.055

15

and section 1, chapter 867, Oregon Laws 2009, by sections 14 to 23, 47

16

to 53, 55 to 60 and 62 to 98 of this 2013 Act and the repeal of ORS

17

414.825, 414.826, 414.828, 414.831, 414.839, 414.841, 414.842, 414.844, 414.846,

18

414.848, 414.851, 414.852, 414.854, 414.856, 414.858, 414.861, 414.862, 414.864,

19

414.866, 414.868, 414.870, 414.872, 735.600, 735.605, 735.610, 735.612, 735.614,

20

735.615, 735.616, 735.620, 735.625, 735.630, 735.635, 735.640, 735.645, 735.650,

21

735.700, 735.701, 735.702, 735.703, 735.705, 735.707, 735.709, 735.710, 735.712,

22

741.001, 741.002, 741.025, 741.027, 741.029, 741.031, 741.101, 741.105, 741.201,

23

741.220, 741.222, 741.250, 741.255, 741.300, 741.310, 741.340, 741.381. 741.390,

24

741.500, 741.510, 741.520, 741.540, 741.900, 743.822, 743.826 and 746.222 and

25

sections 1, 2, 3, 4 and 5, chapter 47, Oregon Laws 2010, by section 100

26

of this 2013 Act become operative January 1, 2017.

27

SECTION 103. This 2013 Act being necessary for the immediate

28

preservation of the public peace, health and safety, an emergency is

29

declared to exist, and this 2013 Act takes effect on its passage.

30

[133]

Affordable Health Care for All Oregon Plan (Draft)  

A proposed bill for universal health care in Oregon.

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