70th OREGON LEGISLATIVE ASSEMBLY--1999 Regular Session
Enrolled
Senate Bill 460
Sponsored by COMMITTEE ON PUBLIC AFFAIRS
CHAPTER ................
AN ACT
Relating to workers' compensation; creating new provisions;
amending ORS 656.012, 656.018, 656.214, 656.245 and 656.313 and
section 66, chapter 332, Oregon Laws 1995, and section 3,
chapter 380, Oregon Laws 1997; and repealing sections 4a, 5a,
16a, 25a, 27a, 38a, 42a and 55a, chapter 332, Oregon Laws 1995.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Sections 4a, 5a, 16a, 25a, 27a, 38a, 42a and
55a, chapter 332, Oregon Laws 1995 (amending ORS 656.012,
656.018, 656.212, 656.245, 656.260, 656.313, 656.340 and
656.726), are repealed. + }
SECTION 2. Section 66, chapter 332, Oregon Laws 1995, is
amended to read:
{ + Sec. 66. + } (1) Notwithstanding any other provision of
law,
{ - this Act - } { + chapter 332, Oregon Laws 1995, + }
applies to all claims or causes of action existing or arising on
or after { - the effective date of this Act - } { + June 7,
1995 + }, regardless of the date of injury or the date a claim is
presented, and { - this Act - } { + chapter 332, Oregon Laws
1995, + } is intended to be fully retroactive unless a specific
exception is stated in { - this Act - } { + chapter 332,
Oregon Laws 1995 + }.
(2) The amendments to ORS 656.204 and 656.265 by sections 13
and 29 { - of this Act - } { + , chapter 332, Oregon Laws
1995, + } and the amendments to ORS 656.210 (2)(a) by section 15
{ - of this Act - } { + , chapter 332, Oregon Laws 1995, + }
apply only to injuries occurring on or after { - the effective
date of this Act - } { + June 7, 1995 + }.
(3) Sections 8 and 9 { - of this Act - } { + , chapter 332,
Oregon Laws 1995, + } and the amendments to ORS 656.054, 656.248
and 656.622 by sections 7, 26 and 49 { - of this Act - } { + ,
chapter 332, Oregon Laws 1995, + } become operative January 1,
1996.
(4) The amendments to ORS 656.268 (4), (5), (6) and (9),
656.319 (4) and 656.726 (3)(f) by sections 30, 39 and 55 { - of
this Act - } { + , chapter 332, Oregon Laws 1995, + } shall
apply only to claims that become medically stationary on or after
{ - the effective date of this Act - } { + June 7, 1995 + }.
(5)(a) The amendments to statutes by { - this Act - } { +
chapter 332, Oregon Laws 1995, + } and new sections added to ORS
chapter 656 by
Enrolled Senate Bill 460 (SB 460-A) Page 1
{ - this Act - } { + chapter 332, Oregon Laws 1995, + } do
not apply to any matter for which an order or decision has become
final on or before { - the effective date of this Act - } { +
June 7, 1995 + }.
(b) Notwithstanding paragraph (a) of this subsection, the
amendments to ORS 656.262 (6) creating new paragraph (c) and the
amendments to the subsection designated (10) by section 28
{ - of this Act - } { + , chapter 332, Oregon Laws 1995, + }
apply to all claims without regard to any previous order or
closure.
(6) The amendments to statutes by { - this Act - } { +
chapter 332, Oregon Laws 1995, + } and new sections added to ORS
chapter 656 by
{ - this Act - } { + chapter 332, Oregon Laws 1995, + } do
not extend or shorten the procedural time limitations with regard
to any action on a claim taken prior to { - the effective date
of this Act - } { + June 7, 1995 + }.
(7) The amendments to ORS 656.506 by section 63 { - of this
Act - } { + , chapter 332, Oregon Laws 1995, + } first become
operative October 1, 1995.
{ - (8) The amendments to ORS 656.313 by section 38a of this
Act apply to orders issued on or after January 1, 2001. - }
{ - (9) The amendments to ORS 656.340 by section 42a of this
Act apply to claims for injuries or aggravations made on or after
January 1, 2001. - }
{ - (10) The amendments to ORS 656.212 by section 16a of this
Act apply to all claims regardless of the date of injury for
benefits payable on or after January 1, 2001. - }
{ - (11) The amendments to ORS 656.726 by section 55a of this
Act apply to claims that become medically stationary on or after
January 1, 2001. - }
{ - (12) The amendments to ORS 656.012 and 656.018 by
sections 4a and 5a of this Act apply to all claims or causes of
action arising on or after January 1, 2001. - }
{ - (13) The amendments to ORS 656.245 and 656.260 by
sections 25a and 27a of this Act apply to medical services
provided on or after January 1, 2001. - }
SECTION 3. ORS 656.012 is amended to read:
656.012. (1) The Legislative Assembly finds that:
(a) The performance of various industrial enterprises necessary
to the enrichment and economic well-being of all the citizens of
this state will inevitably involve injury to some of the workers
employed in those enterprises; { + and + }
(b) The method provided by the common law for compensating
injured workers involves long and costly litigation, without
commensurate benefit to either the injured workers or the
employers, and often requires the taxpayer to provide expensive
care and support for the injured workers and their
dependents { + . + } { - ; and - }
{ - (c) An exclusive, statutory system of compensation will
provide the best societal measure of those injuries that bear a
sufficient relationship to employment to merit incorporation of
their costs into the stream of commerce. - }
(2) In consequence of these findings, the objectives of the
Workers' Compensation Law are declared to be as follows:
(a) To provide, regardless of fault, sure, prompt and complete
medical treatment for injured workers and fair, adequate and
reasonable income benefits to injured workers and their
dependents;
Enrolled Senate Bill 460 (SB 460-A) Page 2
(b) To provide a fair and just administrative system for
delivery of medical and financial benefits to injured workers
that reduces litigation and eliminates the adversary nature of
the compensation proceedings, to the greatest extent practicable;
(c) To restore the injured worker physically and economically
to a self-sufficient status in an expeditious manner and to the
greatest extent practicable; { + and + }
(d) To encourage maximum employer implementation of accident
study, analysis and prevention programs to reduce the economic
loss and human suffering caused by industrial accidents { + . + }
{ - ; and - }
{ - (e) To provide the sole and exclusive source and means by
which subject workers, their beneficiaries and anyone otherwise
entitled to receive benefits on account of injuries or diseases
arising out of and in the course of employment shall seek and
qualify for remedies for such conditions. - }
(3) In recognition that the goals and objectives of this
Workers' Compensation Law are intended to benefit all citizens,
it is declared that the provisions of this law shall be
interpreted in an impartial and balanced manner.
SECTION 4. ORS 656.018 is amended to read:
656.018. (1)(a) The liability of every employer who satisfies
the duty required by ORS 656.017 (1) is exclusive and in place of
all other liability arising out of { + compensable + } injuries
{ - , diseases, symptom complexes or similar conditions arising
out of and in the course of employment that are sustained by - }
{ + to the + } subject workers, the workers' beneficiaries and
anyone otherwise entitled to recover damages from the employer on
account of such
{ - conditions - } { + injuries + } or claims resulting
therefrom, specifically including claims for contribution or
indemnity asserted by third persons from whom damages are sought
on account of such
{ - conditions - } { + injuries + }, except as specifically
provided otherwise in this chapter.
(b) This subsection shall not apply to claims for indemnity or
contribution asserted by a railroad, as defined in ORS 824.020,
or by a corporation, individual or association of individuals
which is subject to regulation pursuant to ORS chapter 757 or
759.
(c) Except as provided in paragraph (b) of this subsection, all
agreements or warranties contrary to the provisions of paragraph
(a) of this subsection entered into after July 19, 1977, are
void.
(2) The rights given to a subject worker and the beneficiaries
of the subject worker { - under this chapter for injuries,
diseases, symptom complexes or similar conditions arising out of
and in the course of employment - } { + for compensable
injuries under this chapter + } are in lieu of any remedies they
might otherwise have for such injuries { - , diseases, symptom
complexes or similar conditions - } against the worker's
employer under ORS 654.305 to 654.335 or other laws, common law
or statute, except to the extent the worker is expressly given
the right under this chapter to bring suit against the employer
of the worker for an injury { - , disease, symptom complex or
similar condition - } .
(3) The exemption from liability given an employer under this
section is also extended to the employer's insurer, the
self-insured employer's claims administrator, the Department of
Consumer and Business Services, and the contracted agents,
Enrolled Senate Bill 460 (SB 460-A) Page 3
employees, officers and directors of the employer, the employer's
insurer, the self-insured employer's claims administrator and the
department, except that the exemption from liability shall not
apply:
(a) Where the injury { - , disease, symptom complex or similar
condition - } is proximately caused by willful and unprovoked
aggression by the person otherwise exempt under this subsection;
(b) Where the worker and the person otherwise exempt under this
subsection are not engaged in the furtherance of a common
enterprise or the accomplishment of the same or related
objectives; or
(c) Where the injury { - , disease, symptom complex or similar
condition - } is proximately caused by failure of the employer
to comply with the notice posted pursuant to ORS 654.082.
(4) The exemption from liability given an employer under this
section applies to a worker leasing company and the client to
whom workers are provided when the worker leasing company and the
client comply with ORS 656.850 (3).
(5)(a) The exemption from liability given an employer under
this section applies to a temporary service provider, as that
term is used in ORS 656.850, and also extends to the client to
whom workers are provided when the temporary service provider
complies with ORS 656.017.
(b) The exemption from liability given a client under paragraph
(a) of this subsection is also extended to the client's insurer,
the self-insured client's claims administrator, the department,
and the contracted agents, employees, officers and directors of
the client, the client's insurer, the self-insured client's
claims administrator and the department, except that the
exemption from liability shall not apply:
(A) When the injury, disease, symptom complex or similar
condition is proximately caused by willful and unprovoked
aggression by the person otherwise exempt under this subsection;
(B) When the worker and the person otherwise exempt under this
subsection are not engaged in the furtherance of a common
enterprise or the accomplishment of the same or related
objectives; or
(C) When the injury, disease, symptom complex or similar
condition is proximately caused by failure of the client to
comply with the notice posted pursuant to ORS 654.082.
(6) Nothing in this chapter shall prohibit payment, voluntarily
or otherwise, to injured workers or their beneficiaries in excess
of the compensation required to be paid under this chapter.
{ - (7) The exclusive remedy provisions and limitation on
liability provisions of this chapter apply to all injuries and to
diseases, symptom complexes or similar conditions of subject
workers arising out of and in the course of employment whether or
not they are determined to be compensable under this chapter. - }
SECTION 5. { + The amendments to ORS 656.012 and 656.018 by
sections 3 and 4 of this 1999 Act become operative on December
31, 2004. + }
SECTION 6. Section 3, chapter 380, Oregon Laws 1997, is amended
to read:
{ + Sec. 3. + } (1) Notwithstanding the method of calculating
permanent partial disability benefit amounts provided in ORS
656.214 (2), for injuries occurring during the period beginning
January 1, 1998, and ending { - December 31, 2000 - } { + on
the effective date of this 1999 Act + }, the worker shall receive
Enrolled Senate Bill 460 (SB 460-A) Page 4
$454 for each degree stated against the disability as provided in
ORS 656.214 (2) to (4).
(2) Notwithstanding the method of calculating permanent partial
disability benefit amounts provided in ORS 656.214 { - (5) - }
{ + (6) + }, for injuries occurring during the period beginning
January 1, 1998, and ending { - December 31, 2000 - } { + on
the effective date of this 1999 Act + }, the worker shall receive
an amount equal to:
(a) When the number of degrees stated against the disability as
provided in ORS 656.214 { - (5) - } { + (6) + } is equal to
or less than 64, $137.80 times the number of degrees.
(b) When the number of degrees stated against the disability as
provided in ORS 656.214 { - (5) - } { + (6) + } is more than
64 but equal to or less than 160, $137.80 times 64 plus $243.80
times the number of degrees in excess of 64.
(c) When the number of degrees stated against the disability as
provided in ORS 656.214 { - (5) - } { + (6) + } is more than
160, $137.80 times 64 plus $243.80 times 96 plus $662.50 times
the number of degrees in excess of 160.
(3) Benefits referred to in this section shall be paid on the
basis of the benefit amount in effect on the date of injury.
SECTION 7. ORS 656.214 is amended to read:
656.214. (1) As used in this section:
(a) 'Loss' includes permanent and complete or partial loss of
use.
(b) 'Permanent partial disability' means the loss of either one
arm, one hand, one leg, one foot, loss of hearing in one or both
ears, loss of one eye, one or more fingers, or any other injury
known in surgery to be permanent partial disability.
(2) When permanent partial disability results from an injury,
the criteria for the rating of disability shall be the permanent
loss of use or function of the injured member due to the
industrial injury. The worker shall receive { - $347.51 - }
{ + $454 + } for each degree stated against such disability in
subsections (2) to (4) of this section as follows:
(a) For the loss of one arm at or above the elbow joint, 192
degrees, or a proportion thereof for losses less than a complete
loss.
(b) For the loss of one forearm at or above the wrist joint, or
the loss of one hand, 150 degrees, or a proportion thereof for
losses less than a complete loss.
(c) For the loss of one leg, at or above the knee joint, 150
degrees, or a proportion thereof for losses less than a complete
loss.
(d) For the loss of one foot, 135 degrees, or a proportion
thereof for losses less than a complete loss.
(e) For the loss of a great toe, 18 degrees, or a proportion
thereof for losses less than a complete loss; of any other toe,
four degrees, or a proportion thereof for losses less than a
complete loss.
(f) For partial or complete loss of hearing in one ear, that
percentage of 60 degrees which the loss bears to normal monaural
hearing.
(g) For partial or complete loss of hearing in both ears, that
proportion of 192 degrees which the combined binaural hearing
loss bears to normal combined binaural hearing. For the purpose
of this paragraph, combined binaural hearing loss shall be
calculated by taking seven times the hearing loss in the less
damaged ear plus the hearing loss in the more damaged ear and
dividing that amount by eight. In the case of individuals with
Enrolled Senate Bill 460 (SB 460-A) Page 5
compensable hearing loss involving both ears, either the method
of calculation for monaural hearing loss or that for combined
binaural hearing loss shall be used, depending upon which allows
the greater award of disability.
(h) For partial or complete loss of vision of one eye, that
proportion of 100 degrees which the loss of monocular vision
bears to normal monocular vision. For the purposes of this
paragraph, the term 'normal monocular vision' shall be considered
as Snellen 20/20 for distance and Snellen 14/14 for near vision
with full sensory field.
(i) For partial loss of vision in both eyes, that proportion of
300 degrees which the combined binocular visual loss bears to
normal combined binocular vision. In all cases of partial loss of
sight, the percentage of said loss shall be measured with maximum
correction. For the purpose of this paragraph, combined binocular
visual loss shall be calculated by taking three times the visual
loss in the less damaged eye plus the visual loss in the more
damaged eye and dividing that amount by four. In the case of
individuals with compensable visual loss involving both eyes,
either the method of calculation for monocular visual loss or
that for combined binocular visual loss shall be used, depending
upon which allows the greater award of disability.
(j) For the loss of a thumb, 48 degrees, or a proportion
thereof for losses less than a complete loss.
(k) For the loss of a first finger, 24 degrees, or a proportion
thereof for losses less than a complete loss; of a second finger,
22 degrees, or a proportion thereof for losses less than a
complete loss; of a third finger, 10 degrees, or a proportion
thereof for losses less than a complete loss; of a fourth finger,
6 degrees, or a proportion thereof for losses less than a
complete loss.
(3) The loss of one phalange of a thumb, including the adjacent
epiphyseal region of the proximal phalange, is considered equal
to the loss of one-half of a thumb. The loss of one phalange of a
finger, including the adjacent epiphyseal region of the middle
phalange, is considered equal to the loss of one-half of a
finger. The loss of two phalanges of a finger, including the
adjacent epiphyseal region of the proximal phalange of a finger,
is considered equal to the loss of 75 percent of a finger. The
loss of more than one phalange of a thumb, excluding the
epiphyseal region of the proximal phalange, is considered equal
to the loss of an entire thumb. The loss of more than two
phalanges of a finger, excluding the epiphyseal region of the
proximal phalange of a finger, is considered equal to the loss of
an entire finger. A proportionate loss of use may be allowed for
an uninjured finger or thumb where there has been a loss of
effective opposition.
(4) A proportionate loss of the hand may be allowed where
disability extends to more than one digit, in lieu of ratings on
the individual digits.
(5) In all cases of injury resulting in permanent partial
disability, other than those described in subsections (2) to (4)
of this section, the criteria for rating of disability shall be
the permanent loss of earning capacity due to the compensable
injury. Earning capacity is to be calculated using the standards
specified in ORS 656.726 (3)(f). The number of degrees of
disability shall be a maximum of 320 degrees determined by the
extent of the disability compared to the worker before such
injury and without such disability.
Enrolled Senate Bill 460 (SB 460-A) Page 6
(6) For injuries for which the disability is determined
pursuant to subsection (5) of this section, the worker shall
receive an amount equal to:
(a) When the number of degrees stated against the disability is
equal to or less than { - 96, $117.47 - } { + 64, $137.80 + }
times the number of degrees.
(b) When the number of degrees stated against the disability is
more than { - 96 - } { + 64 + } but equal to or less than
{ - 192, $117.47 times 96 plus $137.05 times the number of
degrees in excess of 96 - } { + 160, $137.80 times 64 plus
$243.80 times the number of degrees in excess of 64 + }.
(c) When the number of degrees stated against the disability is
more than { - 192, $117.47 times 96 plus $137.05 times 96 plus
$347.51 times the number of degrees in excess of 192 - } { +
160, $137.80 times 64 plus $243.80 times 96 plus $662.50 times
the number of degrees in excess of 160 + }.
(7) All permanent disability contemplates future waxing and
waning of symptoms of the condition. The results of waxing and
waning of symptoms may include, but are not limited to, loss of
earning capacity, periods of temporary total or temporary partial
disability, or inpatient hospitalization.
SECTION 8. { + Section 9 of this 1999 Act is added to and made
a part of ORS chapter 656. + }
SECTION 9. { + (1) Notwithstanding the method of calculating
permanent partial disability benefit amounts provided in ORS
656.214 (2), for injuries occurring during the period beginning
January 1, 2000, and ending December 31, 2004, the worker shall
receive $511.29 for each degree stated against the disability as
provided in ORS 656.214 (2) to (4).
(2) Notwithstanding the method of calculating permanent partial
disability benefit amounts provided in ORS 656.214 (6), for
injuries occurring during the period beginning January 1, 2000,
and ending December 31, 2004, the worker shall receive an amount
equal to:
(a) When the number of degrees stated against the disability as
provided in ORS 656.214 (6) is equal to or less than 64, $153.00
times the number of degrees.
(b) When the number of degrees stated against the disability as
provided in ORS 656.214 (6) is more than 64 but equal to or less
than 160, $267.44 times 64 plus $153.00 times the number of
degrees in excess of 64.
(c) When the number of degrees stated against the disability as
provided in ORS 656.214 (6) is more than 160, $153.00 times 64
plus $267.44 times 96 plus $709.79 times the number of degrees in
excess of 160.
(3) Benefits referred to in this section shall be paid on the
basis of the benefit amount in effect on the date of injury. + }
SECTION 10. ORS 656.245 is amended to read:
656.245. (1)(a) For every compensable injury, the insurer or
the self-insured employer shall cause to be provided medical
services for conditions caused in material part by the injury for
such period as the nature of the injury or the process of the
recovery requires, subject to the limitations in ORS 656.225,
including such medical services as may be required after a
determination of permanent disability. In addition, for
consequential and combined conditions described in ORS 656.005
(7), the insurer or the self-insured employer shall cause to be
provided only those medical services directed to medical
conditions caused in major part by the injury.
Enrolled Senate Bill 460 (SB 460-A) Page 7
(b) Compensable medical services shall include medical,
surgical, hospital, nursing, ambulances and other related
services, and drugs, medicine, crutches and prosthetic
appliances, braces and supports and where necessary, physical
restorative services. A pharmacist or dispensing physician shall
dispense generic drugs to the worker in accordance with ORS
689.515. The duty to provide such medical services continues for
the life of the worker.
(c) Notwithstanding any other provision of this chapter,
medical services after the worker's condition is medically
stationary are not compensable except for the following:
(A) Services provided to a worker who has been determined to be
permanently and totally disabled.
(B) Prescription medications.
(C) Services necessary to administer prescription medication or
monitor the administration of prescription medication.
(D) Prosthetic devices, braces and supports.
(E) Services necessary to monitor the status, replacement or
repair of prosthetic devices, braces and supports.
(F) Services provided pursuant to an accepted claim for
aggravation under ORS 656.273.
(G) Services provided pursuant to an order issued under ORS
656.278.
(H) Services that are necessary to diagnose the worker's
condition.
(I) Life-preserving modalities similar to insulin therapy,
dialysis and transfusions.
(J) With the approval of the insurer or self-insured employer,
palliative care that the worker's attending physician referred to
in ORS 656.005 (12)(b)(A) prescribes and that is necessary to
enable the worker to continue current employment or a vocational
training program. If the insurer or self-insured employer does
not approve, the attending physician or the worker may request
approval from the Director of the Department of Consumer and
Business Services for such treatment. The director may order a
medical review by a physician or panel of physicians pursuant to
ORS 656.327 (3) to aid in the review of such treatment. The
decision of the director is subject to the contested case and
review provisions of ORS 183.310 to 183.550.
(K) With the approval of the director, curative care arising
from a generally recognized, nonexperimental advance in medical
science since the worker's claim was closed that is highly likely
to improve the worker's condition and that is otherwise justified
by the circumstances of the claim. The decision of the director
is subject to the contested case and review provisions of ORS
183.310 to 183.550.
(L) Curative care provided to a worker to stabilize a temporary
and acute waxing and waning of symptoms of the worker's
condition.
(d) Except for services provided under a managed care contract,
out-of-pocket expense reimbursement to receive care from the
attending physician shall not exceed the amount required to seek
care from an appropriate attending physician of the same
specialty who is in a medical community geographically closer to
the worker's home. For the purposes of this paragraph, all
physicians within a metropolitan area are considered to be part
of the same medical community.
(2)(a) The worker may choose an attending doctor or physician
within the State of Oregon. The worker may choose the initial
attending physician and may subsequently change attending
Enrolled Senate Bill 460 (SB 460-A) Page 8
physician two times without approval from the director. If the
worker thereafter selects another attending physician, the
insurer or self-insured employer may require the director's
approval of the selection and, if requested, the director shall
determine with the advice of one or more physicians, whether the
selection by the worker shall be approved. The decision of the
director is subject to a contested case review under ORS 183.310
to 183.550. The worker also may choose an attending doctor or
physician in another country or in any state or territory or
possession of the United States with the prior approval of the
insurer or self-insured employer.
(b) A medical service provider who is not a member of a managed
care organization is subject to the following provisions:
(A) A medical service provider who is not qualified to be an
attending physician may provide compensable medical service to an
injured worker for a period of 30 days from the date of injury or
occupational disease or for 12 visits, whichever first occurs,
without the authorization of an attending physician. Thereafter,
medical service provided to an injured worker without the written
authorization of an attending physician is not compensable.
(B) A medical service provider who is not an attending
physician cannot authorize the payment of temporary disability
compensation. Except as otherwise provided in this chapter, only
the attending physician at the time of claim closure may make
findings regarding the worker's impairment for the purpose of
evaluating the worker's disability.
(3) Notwithstanding any other provision of this chapter, the
director, by rule, upon the advice of the committee created by
ORS 656.794 and upon the advice of the professional licensing
boards of practitioners affected by the rule, may exclude from
compensability any medical treatment the director finds to be
unscientific, unproven, outmoded or experimental. The decision of
the director is subject to a contested case review under ORS
183.310 to 183.550.
(4) Notwithstanding subsection (2)(a) of this section, when a
self-insured employer or the insurer of an employer contracts
with a managed care organization certified pursuant to ORS
656.260 for medical services required by this chapter to be
provided to injured workers:
(a) Those workers who are subject to the contract shall receive
medical services in the manner prescribed in the contract.
Workers subject to the contract include those who are receiving
medical treatment for an accepted compensable injury or
occupational disease, regardless of the date of injury or
medically stationary status, on or after the effective date of
the contract. If the managed care organization determines that
the change in provider would be medically detrimental to the
worker, the worker shall not become subject to the contract until
the worker is found to be medically stationary, the worker
changes physicians or the managed care organization determines
that the change in provider is no longer medically detrimental,
whichever event first occurs. A worker becomes subject to the
contract upon the worker's receipt of actual notice of the
worker's enrollment in the managed care organization, or upon the
third day after the notice was sent by regular mail by the
insurer or self-insured employer, whichever event first occurs. A
worker shall not be subject to a contract after it expires or
terminates without renewal { - , except that workers with open
claims at the time of such expiration or termination shall remain
subject to the contract for that claim until closure - } . { + A
Enrolled Senate Bill 460 (SB 460-A) Page 9
worker may continue to treat with the attending physician under
an expired or terminated managed care organization contract if
the physician agrees to comply with the rules, terms and
conditions regarding services performed under any subsequent
managed care organization contract to which the worker is
subject. + } A worker shall not be subject to a contract if the
worker's primary residence is more than 100 miles outside the
managed care organization's certified geographical area. Each
such contract must comply with the certification standards
provided in ORS 656.260. However, a worker may receive immediate
emergency medical treatment that is compensable from a medical
service provider who is not a member of the managed care
organization. Insurers or self-insured employers who contract
with a managed care organization for medical services shall give
notice to the workers of eligible medical service providers and
such other information regarding the contract and manner of
receiving medical services as the director may prescribe.
Notwithstanding any provision of law or rule to the contrary, a
worker of a noncomplying employer is considered to be subject to
a contract between the State Accident Insurance Fund Corporation
as a processing agent or the assigned claims agent and a managed
care organization.
(b)(A) For initial or aggravation claims filed after June 7,
1995, the insurer or self-insured employer may require an injured
worker, on a case-by-case basis, immediately to receive medical
services from the managed care organization.
(B) If the insurer or self-insured employer gives notice that
the worker is required to receive treatment from the managed care
organization, the insurer or self-insured employer must guarantee
that any reasonable and necessary services so received, that are
not otherwise covered by health insurance, will be paid as
provided in ORS 656.248, even if the claim is denied, until the
worker receives actual notice of the denial or until three days
after the denial is mailed, whichever event first occurs. The
worker may elect to receive care from a primary care physician
who agrees to the conditions of ORS 656.260 (4)(g). However,
guarantee of payment is not required by the insurer or
self-insured employer if this election is made.
(C) If the insurer or self-insured employer does not give
notice that the worker is required to receive treatment from the
managed care organization, the insurer or self-insured employer
is under no obligation to pay for services received by the worker
unless the claim is later accepted.
(D) If the claim is denied, the worker may receive medical
services after the date of denial from sources other than the
managed care organization until the denial is reversed.
Reasonable and necessary medical services received from sources
other than the managed care organization after the date of claim
denial must be paid as provided in ORS 656.248 by the insurer or
self-insured employer if the claim is finally determined to be
compensable.
(5) Notwithstanding any other provision of this chapter, the
director, by rule, shall authorize nurse practitioners certified
by the Oregon State Board of Nursing and physician assistants
registered by the Board of Medical Examiners for the State of
Oregon who practice in areas served by Type A or Type B rural
hospitals described in ORS 442.470 to authorize the payment of
temporary disability compensation for injured workers for a
period not to exceed 30 days from the date of the first visit on
the claim. In addition, the director, by rule, may authorize such
Enrolled Senate Bill 460 (SB 460-A) Page 10
practitioners and assistants who practice in areas served by a
Type C rural hospital described in ORS 442.470 to authorize such
payment.
(6) If a claim for medical services is disapproved for any
reason other than the formal denial of the compensability of the
underlying claim and this disapproval is disputed, the injured
worker, the insurer or self-insured employer shall request
administrative review by the director pursuant to this section,
ORS 656.260 or 656.327. The decision of the director is subject
to the contested case review provisions of ORS 183.310 to
183.550.
SECTION 11. ORS 656.313 is amended to read:
656.313. (1)(a) Filing by an employer or the insurer of a
request for hearing on a reconsideration order before the
Hearings Division, a request for Workers' Compensation Board
review or court appeal or request for review of an order of the
Director of the Department of Consumer and Business Services
regarding vocational assistance stays payment of the compensation
appealed, except for:
(A) Temporary disability benefits that accrue from the date of
the order appealed from until closure under ORS 656.268, or until
the order appealed from is itself reversed, whichever event first
occurs;
(B) Permanent total disability benefits that accrue from the
date of the order appealed from until the order appealed from is
reversed; { - and - }
(C) Death benefits payable to a surviving spouse prior to
remarriage, to children or dependents that accrue from the date
of the order appealed from until the order appealed from is
reversed { - . - } { + ; and
(D) Vocational benefits for services for vocational evaluation
and help in directly obtaining employment as provided by ORS
656.340 (7) and for services related to the development of plans
for return to work, as provided by ORS 656.340 (9). No plan for
return to work may be implemented until the vocational order on
appeal has become final. + }
(b) If ultimately found payable under a final order, benefits
withheld under this subsection shall accrue interest at the rate
provided in ORS 82.010 from the date of the order appealed from
through the date of payment. The board shall expedite review of
appeals in which payment of compensation has been stayed under
this section.
(2) If the board or court subsequently orders that compensation
to the claimant should not have been allowed or should have been
awarded in a lesser amount than awarded, the claimant shall not
be obligated to repay any such compensation which was paid
pending the review or appeal.
(3) If an insurer or self-insured employer denies the
compensability of all or any portion of a claim submitted for
medical services, the insurer or self-insured employer shall send
notice of the denial to each provider of such medical services
and to any provider of health insurance for the injured worker.
After receiving notice of the denial, a medical service provider
may submit medical reports and bills for the disputed medical
services to the provider of health insurance for the injured
worker. The health insurance provider shall pay all such bills in
accordance with the limits, terms and conditions of the policy.
If the injured worker has no health insurance, such bills may be
submitted to the injured worker. A provider of disputed medical
services shall make no further effort to collect disputed medical
Enrolled Senate Bill 460 (SB 460-A) Page 11
service bills from the injured worker until the issue of
compensability of the medical services has been finally
determined.
(4)(a) When the compensability issue has been finally
determined or when disposition or settlement of the claim has
been made pursuant to ORS 656.236 or 656.289 (4), the insurer or
self-insured employer shall notify each affected service provider
and health insurance provider of the results of the disposition
or settlement.
(b) If the services are determined to be compensable, the
insurer or self-insured employer shall reimburse each health
insurance provider for the amount of claims paid by the health
insurance provider pursuant to this section. Such reimbursement
shall be in addition to compensation or medical benefits the
worker receives. Medical service reimbursement shall be paid
directly to the health insurance provider.
(c) If the services are settled pursuant to ORS 656.289 (4),
the insurer or self-insured employer shall reimburse, out of the
settlement proceeds, each medical service provider for billings
received by the insurer or self-insured employer on and before
the date on which the terms of settlement are agreed as specified
in the settlement document that are not otherwise partially or
fully reimbursed.
(d) Reimbursement under this section shall be made only for
medical services related to the claim that would be compensable
under this chapter if the claim were compensable and shall be
made at one-half the amount provided under ORS 656.248. In no
event shall reimbursement made to medical service providers
exceed 40 percent of the total present value of the settlement
amount, except with the consent of the worker. If the settlement
proceeds are insufficient to allow each medical service provider
the reimbursement amount authorized under this subsection, the
insurer or self-insured employer shall reduce each provider's
reimbursement by the same proportional amount. Reimbursement
under this section shall not prevent a medical service provider
or health insurance provider from recovering the balance of
amounts owing for such services directly from the worker.
(5) As used in this section, 'health insurance' has the meaning
for that term provided in ORS 731.162.
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Passed by Senate February 8, 1999
...........................................................
Secretary of Senate
...........................................................
President of Senate
Passed by House February 22, 1999
...........................................................
Speaker of House
Enrolled Senate Bill 460 (SB 460-A) Page 12
Received by Governor:
......M.,............., 1999
Approved:
......M.,............., 1999
...........................................................
Governor
Filed in Office of Secretary of State:
......M.,............., 1999
...........................................................
Secretary of State
Enrolled Senate Bill 460 (SB 460-A) Page 13