Chapter 547 Oregon Laws 1999
Session Law
AN ACT
SB 414
Relating to health benefit
plans offered to small employers; creating new provisions; amending ORS
414.019, 414.021, 414.024, 414.712, 653.715, 653.745, 653.747 and 743.730; and
repealing ORS 653.717, 653.748, 653.750, 653.755, 653.765, 653.775 and 653.785.
Be It Enacted by the People of the State of Oregon:
SECTION 1.
ORS 653.715 is amended to read:
653.715. It is the intent of the Legislative Assembly by
enactment of ORS 653.705 to 653.850 to increase access to health insurance [by developing a program employing
preventative and primary care and then to minimize the medical care cost shifts
caused by the providing of uncompensated care by hospitals] and health care by providing:
(1) Information about health
benefit plans and the premiums charged for those plans to self-employed
individuals and small employers in Oregon;
(2) Direct assistance to
health insurance agents and health insurance consumers regarding health benefit
plans; and
(3) A central source for
information about resources for health care and health insurance.
SECTION 2.
ORS 653.745 is amended to read:
653.745. (1) In carrying out its duties under ORS 653.705 to
653.850, the Insurance Pool Governing Board shall:
(a) Enter into contracts for administration of ORS 653.705 to
653.850 including collection of premiums and paying carriers.
[(b) Enter into contracts
with carriers or health care providers for health care insurance or services,
including contracts where final payment may be reduced if usage is below a
level fixed in the contract.]
[(c)] (b) Retain consultants and employ
staff.
[(d) Set premium rates
for employees and employers.]
[(e) Perform other duties
to provide low cost insurance plans of types likely to be purchased by eligible
employers.]
[(2) Notwithstanding any
other benefit plan contracted for and offered by the board, the board shall
contract for a health benefit plan or plans best designed to meet the needs and
provide for the welfare of eligible employees and employers.]
[(3) The board may
approve more than one carrier for each type of plan contracted for and offered
but the number of carriers shall be held to a number consistent with adequate
service to eligible employees and family members.]
[(4) Where appropriate
for a contracted and offered health benefit plan, the board shall provide
options under which an eligible employee may arrange coverage for family
members of the employee.]
[(5) In developing any
health benefit plan, the board may provide an option of additional coverage for
eligible employees and family members at an additional cost or premium.]
[(6) Transfer of
enrollment from one plan to another shall be open to all eligible employees and
family members under rules adopted by the board.]
[(7) If the board
requests less service than is otherwise required by state law, a carrier is not
required to offer such service.]
[(8)] (2) The board [shall have authority to] may
employ whatever means are reasonably necessary to carry out the purposes of ORS
653.705 to 653.850. Such authority [shall
include] includes but is not
limited to authority to seek clarification, amendment, modification, suspension
or termination of any agreement or contract which in the board's judgment
requires such action.
[(9) The board by order
may terminate the participation of any employer if for a period of three months
the employer fails to perform any action required by ORS 653.705 to 653.850 or
by board rule.]
SECTION 3.
ORS 653.747 is amended to read:
653.747. (1) The
Insurance Pool Governing Board shall encourage increased health insurance
coverage among small employers:
(a) By providing information, benefit comparisons, premium
comparisons and technical assistance on obtaining employee benefits and on
incentives including, but not limited to, information on the pretax health
benefit options allowed under section 125 of the United States Internal Revenue
Code; and
(b) By using other
means necessary to market [such] health benefit plan coverage to small
employers.
(2) The Insurance Pool
Governing Board shall provide information about other resources for accessing
health care and shall assist consumers in accessing those resources.
SECTION 4.
ORS 414.019 is amended to read:
414.019. As used in ORS 414.018 to 414.024, 414.042, 414.107,
414.710, 414.720[,] and 653.747 [and 653.775], as of November 4, 1993, "Oregon Health
Plan" means chapter 815, Oregon Laws 1993, and the seven pieces of
legislation enacted during the 1987, 1989 and 1991 legislative sessions, the
goal of which is to assure Oregonians access to health care coverage, including
the high-risk pool created by chapter 838, Oregon Laws 1989, the employer-based
coverage reforms contained in chapter 591, Oregon Laws 1987, chapter 381,
Oregon Laws 1989, and chapter 916, Oregon Laws 1991, the cost containment and
technology assessments contained in chapter 470, Oregon Laws 1991, and the
prioritization and medical assistance reforms contained in chapter 836, Oregon
Laws 1989, and chapter 753, Oregon Laws 1991.
SECTION 5.
ORS 414.021 is amended to read:
414.021. (1) The Administrator of the Office for Oregon Health
Plan Policy and Research shall be responsible for analyzing and reporting on
the implementation of the elements of the Oregon Health Plan that are assigned
to various state agencies, including but not limited to the Department of Human
Resources and the Department of Consumer and Business Services, and shall
administer the Health Services Commission, the Health Resources Commission and
the Oregon Health Council. Pursuant to the responsibilities described in this
subsection, the administrator may review and monitor the progress of the
various activities that comprise Oregon's efforts to reform health care through
state-funded and employer-based coverage. Except for administration of the
Health Services Commission, the Health Resources Commission and the Oregon
Health Council and as specifically authorized in ORS 414.018 to 414.024,
414.042, 414.107, 414.710, 414.720[,]
and 653.747 [and 653.775], the administrator shall not be responsible for the
day-to-day operations of the Oregon Health Plan, but shall exercise such
oversight responsibilities as are necessary to further the Oregon Health Plan's
goals.
(2) The administrator shall be responsible for the activities
necessary to implement the plans and programs described in sections 4 and 7,
chapter 815, Oregon Laws 1993, that are intended to expand voluntary health
care coverage to Oregonians.
(3) The administrator shall employ such staff or utilize such
state agency personnel as are necessary to fulfill the responsibilities and
duties of the administrator. In addition, the administrator may contract with
third parties for technical and administrative services necessary to carry out
Oregon Health Plan activities where contracting promotes economy, avoids
duplication of effort and makes best use of available expertise. The
administrator may call upon other state agencies to provide available
information as necessary to assist the administrator in meeting the responsibilities
under ORS 414.018 to 414.024, 414.042, 414.107, 414.710, 414.720[,] and
653.747 [and 653.775]. The
information shall be supplied as promptly as circumstances permit.
(4) The Oregon Health Council shall serve as the primary
advisory committee to the administrator, the Governor and the Legislative
Assembly. The administrator also may appoint other technical or advisory
committees to assist the Oregon Health Council in formulating its advice.
Individuals appointed to any technical or other advisory committee shall serve
without compensation for their services as members, but may be reimbursed for
their travel expenses pursuant to ORS 292.495.
(5) The administrator may apply for, receive and accept grants,
gifts and other payments, including property and services, from any
governmental or other public or private entity or person and may make
arrangements for the use of these receipts, including the undertaking of
special studies and other projects relating to health care costs and access to
health care.
(6) The directors of the Departments of Human Resources and
Consumer and Business Services and other state agency personnel responsible for
implementing elements of the Oregon Health Plan shall cooperate fully with the
administrator in carrying out their responsibilities under the Oregon Health
Plan.
(7) All health policy advisory committees reporting to the
Office for Oregon Health Plan Policy and Research and all advisory task forces
on health policy appointed by the administrator shall report directly to the
Oregon Health Council.
SECTION 6.
ORS 414.024 is amended to read:
414.024. In the selection of any area of the state for the
initial operation of the programs authorized by ORS 414.018 to 414.024,
414.042, 414.107, 414.710, 414.720[,]
and 653.747 [and 653.775], the Administrator of the Office for Oregon Health
Plan Policy and Research shall take into account the levels and rates of
unemployment in different areas of the state, the need to provide basic health
care coverage to a population reasonably representative of the portion of the
state's population that lacks such coverage and the need for geographic,
demographic and economic diversity.
SECTION 7.
ORS 414.712 is amended to read:
414.712. Within six months after obtaining the necessary federal
waivers or January 1, 1995, whichever is later, the Department of Human
Resources shall provide medical assistance under ORS 414.705 to 414.750 to
eligible persons who are aged and described in ORS chapter 413 or who are blind
or disabled and described in ORS chapter 412 and to children described in ORS
414.025 (2)(f), (i), (j), (k) and (m), 418.001 to 418.034, 418.187 to 418.970
and 657A.020 to 657A.530 and those mental health and chemical dependency
services recommended according to standards of medical assistance set pursuant
to chapter 836, Oregon Laws 1989, and according to the schedule of
implementation established by the Legislative Assembly. In providing medical
assistance services described in ORS 414.018 to 414.024, 414.042, 414.107,
414.710, 414.720[,] and 653.747 [and 653.775], the Department of Human Resources shall also provide
the following:
(1) Ombudsman services for eligible persons who are aged and
described in ORS chapter 413 or who are blind or disabled and described in ORS
chapter 412. An ombudsman shall serve as a patient's advocate whenever the
patient or a physician or other medical personnel serving the patient is
reasonably concerned about access to, quality of or limitations on the care
being provided by a health care provider. Patients shall be informed of the
availability of an ombudsman.
(2) Case management services in each health care provider
organization for those eligible persons who are aged and described in ORS
chapter 413 or who are blind or disabled and described in ORS chapter 412. Case
managers shall be trained in and shall exhibit skills in communication with and
sensitivity to the unique health care needs of people who are elderly and those
with disabilities. Case managers shall be reasonably available to assist
patients served by the organization with the coordination of the patient's
health care services at the reasonable request of the patient or a physician or
other medical personnel serving the patient. Patients shall be informed of the
availability of case managers.
(3) A mechanism, established by rule, for soliciting consumer
opinions and concerns regarding accessibility to and quality of the services of
each health care provider.
(4) A choice of available medical plans and, within those
plans, choice of a primary care provider.
(5) Due process procedures for any individual whose request for
medical assistance coverage for any treatment or service is denied or is not
acted upon with reasonable promptness. These procedures shall include an
expedited process for cases in which a patient's medical needs require swift
resolution of a dispute.
SECTION 8.
ORS 743.730 is amended to read:
743.730. As used in ORS 743.730 to 743.773:
(1) "Actuarial certification" means a written
statement by a member of the American Academy of Actuaries or other individual
acceptable to the Director of the Department of Consumer and Business Services
that a carrier is in compliance with the provisions of ORS 743.736, 743.760 or
743.761, based upon the person's examination, including a review of the
appropriate records and of the actuarial assumptions and methods used by the
carrier in establishing premium rates for small employer and portability health
benefit plans.
(2) "Affiliate" of, or person "affiliated"
with, a specified person means any carrier who, directly or indirectly through
one or more intermediaries, controls or is controlled by or is under common
control with a specified person. For purposes of this definition,
"control" has the meaning given that term in ORS 732.548.
(3) "Affiliation period" means, under the terms of a
group health benefit plan issued by a health care service contractor, a period:
(a) That is applied uniformly and without regard to any health
status related factors to an enrollee or late enrollee in lieu of a preexisting
conditions provision;
(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
(d) That begins on the enrollee's or late enrollee's first date
of eligibility for coverage and runs concurrently with any eligibility waiting
period under the plan.
(4) "Basic health benefit plan" means a health
benefit plan for small employers that is required to be offered by all small
employer carriers and approved by the Director of the Department of Consumer
and Business Services in accordance with ORS 743.736.
(5) "Bona fide association" means an association that
meets the requirements of 42 U.S.C. 300gg-11 as amended and in effect on July
1, 1997.
(6) "Carrier" means any person who provides health
benefit plans in this state, including a licensed insurance company, a health
care service contractor, a health maintenance organization, an association or
group of employers that provides benefits by means of a multiple employer
welfare arrangement or any other person or corporation responsible for the
payment of benefits or provision of services.
(7) "Committee" means the Health Insurance Reform
Advisory Committee created under ORS 743.745.
(8) "Creditable coverage" means prior health care
coverage as defined in 42 U.S.C. 300gg as amended and in effect on July 1,
1997.
(9) "Department" means the Department of Consumer and
Business Services.
(10) "Dependent" means the spouse or child of an
eligible employee, subject to applicable terms of the health benefit plan
covering the employee.
(11) "Director" means the Director of the Department
of Consumer and Business Services.
(12) "Eligible employee" means an employee of a small
employer who works on a regularly scheduled basis, with a normal work week of
17.5 or more hours. The employer may determine hours worked for eligibility
between 17.5 and 40 hours per week subject to rules of the carrier. The term
includes sole proprietors, partners of a partnership or independent contractors
if they are included as employees under a health benefit plan of a small
employer but does not include employees who work on a temporary, seasonal or
substitute basis. Employees who have been employed by the small employer for
fewer than 90 days are not eligible employees unless the small employer so
allows.
(13) "Group eligibility waiting period" means, with
respect to a group health benefit plan, the period of employment or membership
with the group that a prospective enrollee must complete before plan coverage
begins.
(14) "Enrollee" means an employee, dependent of the
employee or an individual otherwise eligible for a group, individual or
portability health benefit plan who has enrolled for coverage under the terms
of the plan.
(15) "Exclusion period" means a period during which
specified treatments or services are excluded from coverage.
(16) "Financially impaired" means a member that is
not insolvent and is:
(a) Considered by the Director of the Department of Consumer
and Business Services 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.
(17)(a) "Geographic average rate" means the
arithmetical average of the lowest premium and the corresponding highest
premium to be charged by a carrier in a geographic area established by the
director for the carrier's:
(A) Small employer group health benefit plans;
(B) Individual health benefit plans; or
(C) Portability health benefit plans.
(b) "Geographic average rate" does not include
premium differences that are due to differences in benefit design or family
composition.
(18)(a) "Health benefit plan" means any hospital
expense, medical expense or hospital or medical expense policy or certificate,
health care service contractor or health maintenance organization subscriber
contract, any plan provided by a multiple employer welfare arrangement or by
another benefit arrangement defined in the federal Employee Retirement Income
Security Act of 1974, as amended.
(b) "Health benefit plan" does not include coverage
for accident only, specific disease or condition only, credit, disability
income, coverage of Medicare services pursuant to contracts with the Federal
Government, Medicare supplement insurance policies, coverage of CHAMPUS
services pursuant to contracts with the Federal Government, benefits delivered
through a flexible spending arrangement established pursuant to section 125 of
the Internal Revenue Code of 1986, as amended, when the benefits are provided
in addition to a group health benefit plan, long term care insurance, hospital
indemnity only, short term health insurance policies (the duration of which
does not exceed six months including renewals), student accident and health
insurance policies, dental only, vision only, a policy of stop-loss coverage
that meets the requirements of ORS 742.065, coverage issued as a supplement to
liability insurance, insurance arising out of a workers' compensation or
similar law, automobile medical payment insurance or insurance under which
benefits are payable with or without regard to fault and that is statutorily
required to be contained in any liability insurance policy or equivalent self-insurance.
(c) Nothing in this subsection shall be construed to regulate
any employee welfare benefit plan that is exempt from state regulation because
of the federal Employee Retirement Income Security Act of 1974, as amended.
(19) "Health statement" means any information that is
intended to inform the carrier or agent of the health status of an enrollee or
prospective enrollee in a health benefit plan. "Health statement"
includes the standard health statement developed by the Health Insurance Reform
Advisory Committee.
(20) "Implementation of chapter 836, Oregon Laws
1989" means that the Health Services Commission has prepared a priority
list, the Legislative Assembly has enacted funding of the list and all
necessary federal approval, including waivers, has been obtained.
(21) "Initial enrollment period" means a period of at
least 30 days following commencement of the first eligibility period for an
individual.
(22) "Insurance Pool Governing Board" means the
Insurance Pool Governing Board established by ORS 653.725.
(23) "Late enrollee" means an individual who enrolls
in a group health benefit plan subsequent to the initial enrollment period
during which the individual was eligible for coverage but declined to enroll.
However, an eligible individual shall not be considered a late enrollee if:
(a) The individual qualifies for a special enrollment period in
accordance with 42 U.S.C. 300gg as amended and in effect on July 1, 1997;
(b) The individual applies for coverage during an open
enrollment period;
(c) A court has ordered that coverage be provided for a spouse
or minor child under a covered employee's health benefit plan and request for
enrollment is made within 30 days after issuance of the court order; or
(d) The individual is employed by an employer who offers
multiple health benefit plans and the individual elects a different health
benefit plan during an open enrollment period.
(24) "Multiple employer welfare arrangement" means a
multiple employer welfare arrangement as defined in section 3 of the federal
Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. 1002,
that is subject to ORS 750.301 to 750.341.
(25) "Oregon Medical Insurance Pool" means the pool
created under ORS 735.610.
(26) "Preexisting conditions provision" means a
health benefit plan provision applicable to an enrollee or late enrollee that
excludes coverage for services, charges or expenses incurred during a specified
period immediately following enrollment for a condition for which medical
advice, diagnosis, care or treatment was recommended or received during a
specified period immediately preceding enrollment. For purposes of ORS 743.730
to 743.773:
(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
(c) A preexisting conditions provision shall not be applied to
a newborn child or adopted child who obtains coverage in accordance with ORS
743.707.
(27) "Premium" includes insurance premiums or other
fees charged for a health benefit plan, including the costs of benefits paid or
reimbursements made to or on behalf of enrollees covered by the plan.
(28) "Rating period" means the 12-month calendar
period for which premium rates established by a carrier are in effect, as
determined by the carrier.
(29) "Small employer" means any person, firm,
corporation, partnership or association actively engaged in business that, on
at least 50 percent of its working days during the preceding year, employed no
more than 25 eligible employees and no fewer than two eligible employees, the
majority of whom are employed within this state, and in which a bona fide
partnership, independent contractor or employer-employee relationship exists.
"Small employer" includes companies that are eligible to file a
consolidated tax return pursuant to ORS 317.715. ["Small employer" does not include small employers that
purchase coverage through the Insurance Pool Governing Board.]
(30) "Small employer carrier" means any carrier that
offers health benefit plans covering eligible employees of one or more small
employers. A fully insured multiple employer welfare arrangement otherwise
exempt under ORS 750.303 (4) may elect to be a small employer carrier governed
by the provisions of ORS 743.733 to 743.737.
(31) "Standard health benefit plan" means a small
employer health benefit plan that is approved by the Director of the Department
of Consumer and Business Services pursuant to ORS 743.736 that offers health
services substantially similar to those offered through the Medicaid reform
program under chapter 836, Oregon Laws 1989, as funded by the Legislative
Assembly.
(32) "Individual coverage waiting period" means a
period in an individual health benefit plan during which no premiums shall be
collected and health benefit plan coverage issued is not effective.
SECTION 9. ORS 653.717, 653.748, 653.750, 653.755,
653.765, 653.775 and 653.785 are repealed.
SECTION 10. The amendments to ORS 653.715, 653.745,
653.747 and 743.730 and the repeal of ORS 653.717, 653.748, 653.750, 653.755,
653.765, 653.775 and 653.785 by sections 1, 2, 3, 8 and 9 of this 1999 Act do
not become operative until July 1, 2000.
SECTION 11. The Administrator of the Oregon Medical
Insurance Pool and the Insurance Pool Governing Board may take any action
before the operative date of sections 1, 2, 3, 8 and 9 of this 1999 Act that is
necessary to enable the administrator to effect, on and after the operative
date of sections 1, 2, 3, 8 and 9 of this 1999 Act, the orderly and efficient
alteration of duties of the Insurance Pool Governing Board.
Approved by the Governor
July 8, 1999
Filed in the office of
Secretary of State July 8, 1999
Effective date October 23,
1999
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