Bill Text: OR SB366 | 2013 | Regular Session | Introduced

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Bill Title: Relating to payments by insurers to providers.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Failed) 2013-07-08 - In committee upon adjournment. [SB366 Detail]

Download: Oregon-2013-SB366-Introduced.html

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     77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session

NOTE:  Matter within  { +  braces and plus signs + } in an
amended section is new. Matter within  { -  braces and minus
signs - } is existing law to be omitted. New sections are within
 { +  braces and plus signs + } .

LC 2387

                         Senate Bill 366

Sponsored by Senator BATES (Presession filed.)

                             SUMMARY

The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.

  Requires insurers to pay indemnities under health insurance
policy directly to providers of health services.

                        A BILL FOR AN ACT
Relating to payments by insurers to providers; creating new
  provisions; and amending ORS 743.531, 743A.014, 743A.024 and
  743A.048.
Be It Enacted by the People of the State of Oregon:
  SECTION 1.  { + Section 2 of this 2013 Act is added to and made
a part of the Insurance Code. + }
  SECTION 2.  { + Except as provided in ORS 743.543 and 743.550,
an insurer shall pay indemnities for the cost of hospital,
nursing, medical or surgical services pursuant to a group health
insurance policy to the provider of the services. The amount of
any payment may not exceed the amount of the benefit provided by
the policy with respect to the service and may not exceed the
charge billed by the provider. + }
  SECTION 3. ORS 743.531 is amended to read:
  743.531.   { - (1) A group health insurance policy may on
request by the group policyholder provide that all or any portion
of any indemnities provided by such policy on account of
hospital, nursing, medical or surgical services may, at the
insurer's option, be paid directly to the hospital or person
rendering such services. However, the amount of any such payment
shall not exceed the amount of benefit provided by the policy
with respect to the service or billing of the provider of aid.
The amount of such payments pursuant to one or more assignments
shall not exceed the amount of expenses incurred on account of
such hospitalization or medical or surgical aid. - }
    { - (2) Nothing in this section is intended to authorize an
insurer to: - }
    { - (a) Furnish or provide directly services of hospitals or
physicians and surgeons; or - }
    { - (b) Direct, participate in or control the selection of
the specific hospital or physician and surgeon from whom the
insured secures services or who exercises medical or dental
professional judgment. - }
    { - (3) - }  { +  (1) + }   { - Nothing in subsection (2) of
this section prevents an insurer from negotiating and
entering - }   { + An insurer may negotiate and enter + } into
contracts for alternative rates of payment with providers  { + to
provide services covered by a group health insurance policy + }
and   { - offering - }  { +  may offer + } the benefit of such
alternative rates to insureds who select such providers. An
insurer may utilize such contracts by offering a choice of plans
at the time an insured enrolls, one of which provides benefits
only for services by members of a particular provider
organization with whom the insurer has an agreement. If an
insured chooses such a plan, benefits are payable only for
services rendered by a member of that provider organization,
unless such services were requested by a member of such
organization or are rendered as the result of an emergency.
    { - (4) - }  { +  (2) + }   { - Payment so made - }
 { + Benefits paid by an insurer to a provider under subsection
(1) of this section + } shall discharge the insurer's obligation
with respect to the amount of insurance so paid.
    { - (5) - }  { +  (3) + } Insurers shall provide group
policyholders with a current roster of institutional and
professional providers under contract to provide services at
alternative rates under their group policy and shall also make
such lists available for public inspection during regular
business hours at the insurer's principal office within this
state.
  SECTION 4. ORS 743A.014 is amended to read:
  743A.014. Any insurance policy issued or issued for delivery in
this state that provides coverage for ambulance care and
transportation shall provide that payments will be made
 { - jointly - }  { + :
  (1) + } To the provider of the ambulance care and
transportation and to the insured, unless the policy provides for
direct payment to the provider.
   { +  (2) Except as provided in ORS 743.543 and 743.550, if the
policy is a group health insurance policy, directly to the
provider of the ambulance care and transportation. + }
  SECTION 5. ORS 743A.024 is amended to read:
  743A.024. Whenever any individual or group health insurance
policy or blanket health insurance policy described in ORS
743.534 (3) provides for payment or reimbursement for any service
within the lawful scope of service of a clinical social worker
licensed under ORS 675.530:
  (1) The insured under the policy shall be entitled to the
services of a clinical social worker licensed under ORS 675.530,
upon referral by a physician or psychologist.
  (2)   { - The insured under the policy shall be entitled to
have payment or reimbursement made to the insured or on behalf of
the insured for the services performed. - }  The payment or
reimbursement shall be in accordance with the benefits provided
in the policy and shall be computed in the same manner whether
performed by a physician, by a psychologist or by a clinical
social worker, according to the customary and usual fee of
clinical social workers in the area served. { +  Except as
provided in ORS 743.543 and 743.550, if the policy is a group
health insurance policy, the insurer shall pay or reimburse the
clinical social worker directly. + }
  SECTION 6. ORS 743A.048 is amended to read:
  743A.048. Whenever any provision of any individual or group
health insurance policy or contract provides for payment or
reimbursement for any service which is within the lawful scope of
a psychologist licensed under ORS 675.010 to 675.150:
  (1) The insured under such policy or contract shall be free to
select, and shall have direct access to, a psychologist licensed
under ORS 675.010 to 675.150, without supervision or referral by
a physician or another health practitioner, and wherever such
psychologist is authorized to practice.
  (2)   { - The insured under such policy or contract shall be
entitled to have payment or reimbursement made to the insured or
on the insured's behalf for the services performed. - }  Such
payment or reimbursement shall be in accordance with the benefits
provided in the policy and shall be the same whether performed by
a physician or a psychologist licensed under ORS 675.010 to
675.150.  { +  Except as provided in ORS 743.543 and 743.550, if
the policy is a group health insurance policy, the insurer shall
pay or reimburse the psychologist directly. + }
  SECTION 7.  { + Sections 1 and 2 of this 2013 Act and the
amendments to ORS 743.531, 743A.014, 743A.024 and 743A.048 by
sections 3 to 6 of this 2013 Act apply to indemnities paid on
claims presented on or after the effective date of this 2013
Act. + }
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