Bill Text: OR SB437 | 2013 | Regular Session | Introduced

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Bill Title: Relating to out-of-network health care providers; declaring an emergency.

Spectrum: Partisan Bill (Democrat 3-0)

Status: (Failed) 2013-07-08 - In committee upon adjournment. [SB437 Detail]

Download: Oregon-2013-SB437-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 1665

                         Senate Bill 437

Sponsored by Senator STEINER HAYWARD; Senator SHIELDS,
  Representative REARDON (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 insurer to reimburse out-of-network providers of
emergency services at prescribed rates. Requires in-network
health care facility to notify enrollee if services will be
provided by out-of-network providers and of estimated costs of
services provided by out-of-network providers.
  Declares emergency, effective on passage.

                        A BILL FOR AN ACT
Relating to out-of-network health care providers; and declaring
  an emergency.
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.  { + (1) As used in this section:
  (a) 'Emergency services' has the meaning given that term in ORS
743A.012.
  (b) 'Health care facility' has the meaning given that term in
ORS 442.015.
  (c) 'In-network' means a health care provider has a medical
services contract with an insurer to provide health services to
enrollees in health benefit plans offered by the insurer.
  (d) 'Nonemergency' means a patient's life or health would not
be jeopardized by delaying treatment until a disclosure required
by subsection (4) of this section is made.
  (e) 'Out-of-network' means a health care provider does not have
a medical services contract with an insurer to provide health
services to enrollees in health benefit plans offered by the
insurer.
  (f) 'Timely' means soon enough to allow an enrollee to evaluate
cost information before treatment is initiated.
  (2) An insurer shall reimburse an out-of-network provider for
emergency services at the greater of the following amounts:
  (a) The rate paid to in-network providers for the emergency
services, less the copayment or coinsurance amount imposed on the
enrollee for in-network services. If the insurer pays different
rates to different in-network providers for the same service, the
insurer shall pay the median of all of the rates, less the
copayment or coinsurance amount imposed on the enrollee for
in-network services.

  (b) The rate paid to out-of-network providers for the emergency
services, less the copayment or coinsurance amount imposed on the
enrollee for in-network services.
  (c) The Medicare rate for the emergency services, less any
copayment or coinsurance amount imposed on the enrollee for
in-network services.
  (3)(a) A provider may not bill an enrollee for the difference
between reimbursement calculated in accordance with subsection
(2) of this section and the usual and customary charge of the
provider for the emergency services.
  (b) If the emergency services are provided at an in-network
health care facility, a provider may bill the facility for the
difference between the reimbursement calculated in accordance
with subsection (2) of this section and the usual and customary
charge of the provider for the emergency services.
  (4) A health care facility that is an in-network provider for
an insurer shall, with respect to an enrollee in a health benefit
plan offered by the insurer:
  (a) Provide all nonemergency services using only in-network
providers; or
  (b) If the health care facility cannot provide all nonemergency
services using only in-network providers, timely notify the
enrollee:
  (A) That specified services will be provided by out-of-network
providers;
  (B) Of the estimated out-of-pocket costs to the enrollee of the
services to be provided by out-of-network providers; and
  (C) Of the enrollee's right to decline the services to be
provided by out-of-network providers.
  (5) A health care facility shall report to the Department of
Consumer and Business Services all notices made under subsection
(4)(b) of this section within five business days of the date the
enrollee was notified. The facility shall exclude protected
health information from the report and shall include:
  (a) A description of each service that the health care facility
was unable to provide using in-network providers;
  (b) The name of the insurer; and
  (c) Any other information prescribed by the department by
rule. + }
  SECTION 3.  { + Section 2 of this 2013 Act applies to health
benefit plans issued or renewed on or after the effective date of
this 2013 Act. + }
  SECTION 4.  { + This 2013 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2013 Act takes effect on its
passage. + }
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