Enrolled bill

This bill defines a retainer medical practice as a medical practice that provides a predetermined, defined set of primary care services pursuant to a retainer medical agreement. Retainer medical practices certified by the Department of Consumer and Business Services (DCBS) are exempt from the Insurance Code. The department may certify a retainer medical practice if it has never been licensed as an insurer or similar entity in this or any other state and is not controlled by an insurer or similar entity. Retainer medical practices:

• Must provide only primary care and must limit the scope of services provided or the number of patients served to an amount the practice can serve in a timely manner;
• May not bill an insurer, a self-insured plan or the state medical assistance program for a service provided by the practice as part of its retainer medical agreement;
• Must be financially responsible and have the necessary business experience or expertise to operate the practice;
• Must give required written disclosures;
• May not use misleading, deceptive or false statements in marketing, advertising, promotional, sales or informational materials regarding the practice or in communications with patients or prospective patients;
• May not engage in dishonest, fraudulent or illegal conduct in any business or profession;
• May not discriminate based on race, religion, gender, sexual identity, sexual preference or health status.

The bill gives DCBS the authority to investigate a practice and deny, suspend, revoke, or refuse to renew a certificate, and allows a practice to contest this order. The bill provides DCBS rulemaking authority to establish a certification process.

• Effective Date: June 23, 2011
• Applicability: Rules implementing SB 86 took effect Jan. 1, 2012

Enrolled bill

This bill requires the Department of Consumer and Business Services to adopt by rule prompt payment requirements for long-term care insurance, includingdefinitions "claim" and "clean claim." The bill defines "benefit trigger" as a condition of payment in a long-term care insurance policy based on an insured's cognitive impairment or inability to perform an activity of daily living. SB 88 requires DCBS to adopt by rule internal and external procedures to determine whether benefit triggers have been met. Long-term care policies must include information about dispute resolution and the appeal process for settling disputes in this area.

• Effective Date: May 19, 2011
• Operative Date: July 1, 2012
• Applicability: Long-term care insurance policies issued or renewed on or after July 1, 2012

Enrolled bill

Senate Bill 89 eliminates inconsistencies between Oregon's Insurance Code and the Affordable Care Act (ACA), allowing Oregon to avoid federal preemption of its insurance laws. One of the major purposes of this legislation is to implement provisions required by federal law, many of which have been effective since Sept. 23, 2010. To avoid federal preemption, SB 89 makes changes to the Insurance Code, including:

• Requiring that health benefit plans cover, without cost sharing, preventive services, such as co-payments, co-insurance, and deductibles;
• Prohibiting new individual plans from denying coverage to children based on health conditions; and
• Prohibiting insurers from rescinding a health benefit plan unless the insured commits fraud or makes an intentional misrepresentation of material fact.

SB 89 makes other changes to the Insurance Code not specifically required by the Affordable Care Act. These changes include:

• Important consumer protections that give the families of Oregonians who lose their jobs or have their hours reduced the ability to choose to continue to pay for and receive their group health insurance coverage.
• Consumer protections that improve the notice that issuers of individual health benefit plans provide when coverage is cancelled or nonrenewed, including when coverage is cancelled for reported death of the policyholder.
• Giving the Department of Consumer and Business Services the ability to enforce the ACA to ensure Oregon consumers receive the full benefit of the law;
• Prohibiting rescission for fraudulent actions or intentional material misrepresentations committed by an insurance agent or other representative of an insurance company; and
• Making technical corrections to the Insurance Code, such as replacing references to "CHAMPUS" with "TRICARE" (Civilian health care coverage for military personnel, retirees, and dependents).

• Effective Date: June 23, 2011
• Operative Date: June 23, 2011, except amendments to ORS 743.730 by section 49 of the bill which become operative Jan. 2, 2014
• Applicability: There are three applicability provisions:
  1. Sections 2 and 4 and the amendments to statutes and session laws by sections 5, 6, 7 to 9, 12, 14 to 17 and 19 to 45 apply to policies or certificates issued or renewed on or after Sept. 23, 2010, and in effect on or after Sept. 23, 2010.
  2. Section 4a applies to health benefit plans issued or renewed on or after Sept. 23, 2010.
  3. The amendments to ORS 743.610 by sections 6b and 6c apply to group health insurance policies issued or renewed before, on or after Sept. 23, 2010.

Enrolled bill

The federal Patient Protection and Affordable Care Act requires certain health benefit plans to meet federal requirements to be offered through the Oregon Health Insurance Exchange. This bill requires insurers who sell coverage in the individual or small group markets in or outside of the Exchange to offer a bronze and silver plan, under which the insurer covers 60 or 70 percent, respectively, of the full actuarial benefits included in the plan. DCBS is required to design standardized versions of the bronze and silver plans that are offered by all insurers to make it easier for consumers to compare plans. The bill prohibits the offer of catastrophic plans outside of the Exchange. The bill's delayed operative date permits DCBS to take any necessary action to implement the bill on Jan. 2, 2014.

• Effective Date: Jan. 1, 2012
• Operative Date: Jan. 2, 2014

Enrolled bill

This bill requires the Oregon Health Authority to convene a stakeholder workgroup to recommend uniform standards related to eligibility inquiry and response, claim submission, payment remittance advice, claims payment or electronic funds transfer, claims status inquiry and response, claims attachments, prior authorizations, provider credentialing, or other health care financial an administrative transactions identified by the workgroup. These uniform standards apply to health insurers, prepaid managed care health services organizations, third party administrators, self-insurance plans, health care clearing houses and any other person identified by DCBS that processes health care financial and administrative transactions. Once uniform standards are established DCBS may adopt these standards by rule.

• Effective Date: May 23, 2011

Enrolled bill

This bill creates the Oregon Health Insurance Exchange (Cover Oregon) as a public corporation. It also establishes the Exchange's mission, including the triple aim of better health, better care, and lower costs; empowering Oregonians in choosing health insurance; improving quality, public health and mitigating health disparities; accountability to the public; and encouraging development of new, innovative health insurance products.

The bill gives the Exchange powers and duties including:

• providing information to consumers to help make informed decision about insurance, including grading plans on quality and cost;
• providing an electronic calculator to determine the cost of coverage after tax credits;
• decertifying health plans that do not meet federal and state criteria;
• promoting fair competition;
• establishing open enrollment periods;
• providing enrollment assistance;
• linking consumers to tax credits to make coverage affordable;
• facilitating enrollment for medical assistance programs if a person or family is eligible; and
• providing exemptions to the individual responsibility requirement if affordable coverage is not available.

Beginning Jan. 1, 2014, individuals and employers with 50 or fewer employees may purchase comprehensive health insurance through the Exchange. Beginning Jan. 1, 2016, employers with up to 100 employees may purchase insurance through the Exchange. The Exchange will adopt criteria for certifying qualified health plans which may be offered in the Exchange. The Exchange may limit the number of plans that are offered in the Exchange so long as that limit applies to all insurers. The Exchange will create a streamlined eligibility enrollment process for both insurance purchased through the Exchange as well as for medical assistance programs such as the Oregon Health Plan. Plans sold in the Exchange and outside of the Exchange must be priced the same.

The Exchange may charge fees to participating insurers and state programs to pay for administration of the exchange. Section 17 sets limits on those fees of 3-5 percent of the premium, depending on the number of enrollees in the plan. Section 18 creates an account in the State Treasury for exchange funds.

• Effective Date: June 17, 2011


• Operative Date: There are three operative date provisions in the bill:
  1. Section 11 becomes operative upon Legislative approval of formal business plans or Jan. 1, 2016 (see 2012 legislation HB 4164 effective March 8, 2012)
  
  
  2. Section 5 is repealed Jan. 2, 2016
  
  
  3. Section 10 is repealed Jan. 2, 2014

Enrolled bill

This bill requires the Oregon Medical Insurance Pool Board to issue assessments for costs, as determined by DCBS, of any program of reinsurance for children's health insurance coverage that DCBS adopts by rule.

• Effective Date: May 23, 2011

Enrolled bill

This bill limits the way insurance companies can make provider networks available to third parties. It does not apply to managed care or discount medical plan organizations; the state medical assistance program; independent practice associations; or self-funded, employer-sponsored health insurance. Applicable insurance companies must be certified by DCBS and cannot contract with a third party to provide health care services and discounted rates unless:

• the provider network contract specifically authorizes the third party contract and
• the third party contract requires the third party to comply with the provider network contract.

Insurance companies must also comply with certain record-keeping and notification requirements.

This bill requires DCBS to register entities other than insurers with a certificate of authority; managed care or discount medical plan organizations; the state medical assistance program; independent practice associations; or self-funded, employer-sponsored health insurance that contract with others for access to a provider network. The bill prohibits a third party from leasing a provider network unless the original provider network contract between the lessor and the provider network specifically authorizes the leasing of the network and the leasing contract obligates the third party to comply with all of the terms of the original network contract.

SB 634 requires those providing access to provider networks to:

• Establish a website - updated at least every 90 days, a toll-free telephone number, or other readily available mechanism to identify the names of all persons granted access to the provider network.
• Provide all information necessary for the third party to comply with the terms of the provider network contract;
• Require that the third party provide the contractual source of any discounted payment with the payment;
• Notify a third party of the termination of a provider network contract no later than 30 days prior to the termination; and
• Require third parties to cease claiming a discount under a terminated provider network contract.

The bill allows a provider to refuse to accept a discounted payment as payment in full if there is no contractual basis for the payment or the discount violates the above requirements.

After the effective date, DCBS may take any action necessary to implement this bill on the operative date.

• Effective Date: June 28, 2011
• Operative Date: Jan. 1, 2012
• Applicability: Contracts entered into or renewed on or after Jan. 1, 2012

Enrolled bill

This bill relates to expanded practice dental hygienists - a dental hygienist that has advanced experience and can practice without the direct supervision of a dentist. If the expanded practice dental hygienist has entered into a provider contract with the insurer, and the insurer provides an insurance policy covering services performed by a dentist, the insurer must also provide coverage for the expanded practice dental hygienist. Insurers are not required to enter into contracts with expanded practice dental hygienists. DCBS must adopt rules that require health insurers to report reimbursement of services provided by expanded practice dental hygienist.

The bill also allows the Oregon Health Authority to approve pilot projects related to innovative practices in oral health care delivery systems.

• Effective Date: Aug. 2, 2011
• Operative Date: Jan. 1, 2012
• Applicability: Provisions related to applications for expanded practice dental hygienist apply only to applications submitted on or after Jan. 1, 2012
• Repeal Date: Section 15 establishing pilot projects related to innovative practices in oral health care delivery systems is repealed on Jan. 2, 2018

Enrolled bill

This bill requires a health benefit plan, including a multiple employer welfare arrangement, to cover telemedical services formedically necessary diabetes treatments that would be covered if provided in person. SB 787 defines telemedical to mean delivered through a two-way video communication that allows a health professional to interact with a patient or a parent, guardian, or another health professional on behalf of the patient.The bill specifically states that telemedical includes but is not limited to "video, audio, Voice over Internet Protocol, or transmission of telemetry. It prohibits a health benefit plan from distinguishing between originating sites that are rural and urban in providing coverage and allows a health benefit plan to subject coverage of telemedical services to all terms and conditions of the plan applicable to comparable coverage of benefits provided in person, including deductible, copayment, and coinsurance requirements. SB 787 does not require a health benefit plan to reimburse a provider for a health service not otherwise covered.

• Effective Date: Jan. 1, 2012
• Applicability: Health benefit plans contracted for or renewed on or after January 1, 2012

Enrolled bill

This bill amends the Oregon Life and Health Guaranty Association laws. The Association guarantees funds for consumers to pay for certain expenses if an insurance company becomes insolvent and is unable to pay claims. The bill increases coverage limits to $300,000 for disability policies, $300,000 for long-term policies, $500,000 for basic hospital, medical and surgical insurance or major medical insurance, and $250,000 for structured settlement annuities. The bill also increases the aggregate limit for basic hospital, medical and surgical insurance or major medical insurance to $500,000. The bill authorizes the association to increase its annual operating assessment for member insurance companies from $150 to $300. The bill adopts the most recent changes to the National Association of Insurance Commissioner model act, which will align Oregon more closely with laws of other states and make operation of the guaranty fund more efficient.

• Effective Date: May 27, 2011
• Applicability: New limits apply to coverage provided by the Oregon Life and Health Insurance Guaranty Association for a member insurer first placed under an order of rehabilitation, or first placed under an order of liquidation if no order of rehabilitation was previously entered, on or after May 27, 2011.

Enrolled bill

This bill adds Oregon to the IIPRC, which allows Oregon to participate in a nationwide process for reviewing and approving four insurance products: life, annuities, disability, and long-term care. Joining the IIPRC benefits both Oregon and consumers by streamlining the approval process for the covered insurance products, while maintaining high consumer protection and providing consumers with products that may not otherwise be available. Oregon also has the ability to opt out of products that do not meet strong consumer protection standards.

• Effective Date: Jan. 1, 2012
• Applicability: Forms filed with DCBS on and after Jan. 1, 2012

Enrolled bill

This bill defines a mastectomy that must be covered by insurance as the surgical removal of all or part of a breast or a breast tumor suspected to be malignant.

• Effective Date: Jan. 1, 2012

Enrolled bill

This bill replaces the managed health care system with the coordinated health care system, which is intended to ensure consumers receive quality and affordable health care. The bill requires the Oregon Health Authority to coordinate with DCBS to collect and analyze health care cost data and make recommendations to the Legislature about how to contain costs.

• Effective Date: July 1, 2011
• Operative Date: The bill has a number of separate operative dates.

NOTE: See also HB 2679 under Property and Casualty Insurance for certain health insurance amendments.