Bill Text: OR HB4153 | 2012 | Regular Session | Engrossed

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Bill Title: Relating to health care delivery; declaring an emergency.

Spectrum: Slight Partisan Bill (Democrat 2-1)

Status: (Failed) 2012-03-05 - In committee upon adjournment. [HB4153 Detail]

Download: Oregon-2012-HB4153-Engrossed.html

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     76th OREGON LEGISLATIVE ASSEMBLY--2012 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 138

                           A-Engrossed

                         House Bill 4153
                 Ordered by the House February 6
           Including House Amendments dated February 6

Sponsored by Representative FREEMAN, 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.

    { - Establishes criteria for coordinated care organizations.
Requires that community advisory council be convened for each
organization and specifies duties of council. Prescribes
actuarially sound global budgeting process. Creates metrics and
scoring committee to establish outcomes measures. - }
    { - Establishes Oregon Defensive Medicine Task Force to make
recommendation for legislative concept to address practice of
defensive medicine. - }
    { - Makes coordinated care organizations public bodies for
purposes of Oregon Tort Claims Act. - }
   { +  Provides legislative approval of Oregon Health Authority
proposals for coordinated care organizations. Requires authority
to report quarterly to legislative committees on implementation
of coordinated care organization model of health care delivery.
Authorizes sharing and use of information between Department of
Consumer and Business Services and authority for specified
purposes. Prohibits discrimination against types of providers by
coordinated care organizations and specified managed care
organizations. + }
  Makes technical and conforming amendments.
  Declares emergency, effective on passage.

                        A BILL FOR AN ACT
Relating to health care delivery; creating new provisions;
  amending ORS 414.033, 414.632, 414.635, 414.740 and 416.540 and
  sections 14, 62, 63 and 64, chapter 602, Oregon Laws 2011; and
  declaring an emergency.
Be It Enacted by the People of the State of Oregon:

                               { +
LEGISLATIVE APPROVAL OF COORDINATED CARE + }
                               { +
ORGANIZATION PROPOSAL + }

  SECTION 1.  { + The Legislative Assembly approves the proposals
presented by the Oregon Health Authority as required by section
13, chapter 602, Oregon Laws 2011. + }
  SECTION 2. Section 14, chapter 602, Oregon Laws 2011, is
amended to read:
   { +  Sec. 14. + } (1) Notwithstanding ORS   { - 414.725 and
414.737 - }  { + 414.631 and 414.651 + }, in any area of the
state where a coordinated care organization has not been
certified, the Oregon Health Authority shall continue to contract
with one or more prepaid managed care health services
organizations, as defined in ORS 414.736, that serve the area and
that are in compliance with contractual obligations owed to the
state or local government.
  (2) Prepaid managed care health services organizations
contracting with the authority under this section are subject to
the applicable requirements for, and are permitted to exercise
the rights of, coordinated care organizations under
 { - sections 4, 6, 8, 10 and 12 of this 2011 Act and - }  ORS
414.153,  { + 414.625, 414.635, 414.638, 414.651, 414.655,
414.679, + } 414.712,   { - 414.725, - }  414.728, 414.743,
414.746, 414.760, 416.510 to 416.610, 441.094, 442.464, 655.515,
659.830 and 743.847.
  (3) The authority may amend contracts that are in place on
  { - the effective date of this 2011 Act - }   { + July 1,
2011, + } to allow prepaid managed care health services
organizations that meet the criteria   { - approved by the
Legislative Assembly under section 13 of this 2011 Act - }  { +
adopted by the authority under ORS 414.625 + } to become
coordinated care organizations.
  (4) The authority shall continue to renew the contracts of
prepaid managed care health services organizations that have a
contract with the authority on   { - the effective date of this
2011 Act - }  { +  July 1, 2011, + } until the earlier of the
date the prepaid managed care health services organization
becomes a coordinated care organization or July 1, 2014.
Contracts with prepaid managed care health services organizations
must terminate no later than July 1, 2017.
  (5) The authority shall continue to renew contracts or ensure
that counties renew contracts with providers of residential
chemical dependency treatment until the provider enters into a
contract with a coordinated care organization but no later than
July 1, 2013.
  (6) Notwithstanding   { - sections 4 (1)(g) and 6 (2) of this
2011 Act - }   { + ORS 414.625 (1)(g) and 414.655 (2) + }, the
authority shall allow for a period of transition to the full
adoption of health information technology by coordinated care
organizations and patient centered primary care homes. The
authority shall explore options for assisting providers and
coordinated care organizations in funding their use of health
information technology.
  SECTION 3. Section 62, chapter 602, Oregon Laws 2011, is
amended to read:
   { +  Sec. 62. + }   { - (1) - }  The Oregon Health Authority
may not implement any   { - provisions of this 2011 Act that
require - }  { +  provision of chapter 602, Oregon Laws 2011,
that requires + } federal approval { + , + } or that
 { - require - }  { +  requires + } federal approval to receive
federal financial participation { + , + } until the authority has
received the  { +  federal + } approval.
    { - (2) Until the authority has received the approval of the
Legislative Assembly under section 13 of this 2011 Act, the
authority may not: - }
    { - (a) Adopt by rule the qualification criteria for a
coordinated care organization under section 4 of this 2011 Act or
contract with a coordinated care organization; - }
    { - (b) Adopt by rule a global budgeting process or establish
global budgets for coordinated care organizations; or - }
    { - (c) Implement a process for financial reporting by
coordinated care organizations or establish financial reporting
requirements under ORS 414.725 (1)(c). - }
  SECTION 4. Section 63, chapter 602, Oregon Laws 2011, is
amended to read:
   { +  Sec. 63. + } The amendments to   { - section 8 of this
2011 Act - }  { +  ORS 414.635 + } by section 9   { - of this
2011 Act - }  { + , chapter 602, Oregon Laws 2011, + } become
operative   { - January 1, 2014 - }  { +  on the effective date
of this 2012 Act + }.
  SECTION 5. ORS 414.635, as amended by section 9, chapter 602,
Oregon Laws 2011, is amended to read:
  414.635. (1) The Oregon Health Authority shall adopt by rule
safeguards for members enrolled in coordinated care organizations
that protect against underutilization of services and
inappropriate denials of services. In addition to any other
consumer rights and responsibilities established by law, each
member:
  (a) Must be encouraged to be an active partner in directing the
member's health care and services and not a passive recipient of
care.
  (b) Must be educated about the coordinated care approach being
used in the community and how to navigate the coordinated health
care system.
  (c) Must have access to advocates, including qualified peer
wellness specialists where appropriate, personal health
navigators, and qualified community health workers who are part
of the member's care team to provide assistance that is
culturally and linguistically appropriate to the member's need to
access appropriate services and participate in processes
affecting the member's care and services.
  (d) Shall be encouraged within all aspects of the integrated
and coordinated health care delivery system to use wellness and
prevention resources and to make healthy lifestyle choices.
  (e) Shall be encouraged to work with the member's care team,
including providers and community resources appropriate to the
member's needs as a whole person.
  (2) The authority shall establish and maintain an enrollment
process for individuals who are dually eligible for Medicare and
Medicaid that promotes continuity of care and that allows the
member to disenroll from a coordinated care organization that
fails to promptly provide adequate services and:
  (a) To enroll in another coordinated care organization of the
member's choice; or
  (b) If another organization is not available, to receive
Medicare-covered services on a fee-for-service basis.
  (3) Members and their providers and coordinated care
organizations have the right to appeal decisions about care and
services through the authority in an expedited manner and in
accordance with the contested case procedures in ORS chapter 183.
  (4) A health care entity may not unreasonably refuse to
contract with an organization seeking to form a coordinated care
organization if the participation of the entity is necessary for
the organization to qualify as a coordinated care organization.
  (5) A health care entity may refuse to contract with a
coordinated care organization if the reimbursement established
for a service provided by the entity under the contract is below
the reasonable cost to the entity for providing the service.
  (6) A health care entity that unreasonably refuses to contract
with a coordinated care organization may not receive
fee-for-service reimbursement from the authority for services
that are available through a coordinated care organization either
directly or by contract.
  (7) The authority shall maintain the process  { - , approved by
the Legislative Assembly, - }  for resolving disputes involving
an entity's refusal to contract with a coordinated care
organization under subsections (4) and (5) of this section. The
process must include the use of an independent third party
arbitrator.
  (8) A coordinated care organization may not unreasonably refuse
to contract with a licensed health care provider.
  (9) The authority shall:
  (a) Monitor and enforce consumer rights and protections within
the Oregon Integrated and Coordinated Health Care Delivery System
and ensure a consistent response to complaints of violations of
consumer rights or protections.
  (b) Monitor and report on the statewide health care
expenditures and recommend actions appropriate and necessary to
contain the growth in health care costs incurred by all sectors
of the system.

                               { +
IMPLEMENTATION OF OREGON INTEGRATED + }
                               { +
AND COORDINATED CARE DELIVERY SYSTEM + }

  SECTION 6.  { + (1) The Department of Consumer and Business
Services and the Oregon Health Authority may enter into
agreements governing the disclosure of information reported to
the department by insurers with certificates of authority to
transact insurance in this state.
  (2) The authority may use information disclosed under
subsection (1) of this section for the purpose of carrying out
ORS 414.625, 414.635, 414.638, 414.645 and 414.651. + }
  SECTION 7.  { + Section 8 of this 2012 Act is added to and made
a part of ORS chapter 414. + }
  SECTION 8.  { + (1) A fully capitated health plan, physician
care organization or coordinated care organization may not
discriminate in the participation or reimbursement of any health
care provider based on the provider's license or certification if
the provider is acting within the scope of the provider's license
or certification. A plan or organization must give written notice
containing the reasons for its action if the plan or organization
declines the participation of any provider or group of providers.
  (2) Subsection (1) of this section does not:
  (a) Require a plan or organization to contract with more
providers than are necessary to meet the needs of its members;
  (b) Preclude the plan or organization from using different
reimbursement amounts for different specialties or different
practitioners in the same specialty; or
  (c) Preclude the plan or organization from establishing
measures that are designed to maintain the quality of services
and control costs and are consistent with the plan's or
organization's responsibilities to its members. + }
  SECTION 9. Section 8 of this 2012 Act is amended to read:
   { +  Sec. 8. + } (1) A   { - fully capitated health plan,
physician care organization or - }  coordinated care organization
may not discriminate in the participation or reimbursement of any
health care provider based on the provider's license or
certification if the provider is acting within the scope of the
provider's license or certification.   { - A plan or - }  { +
An + } organization must give written notice containing the
reasons for its action if the   { - plan or - } organization
declines the participation of any provider or group of providers.
  (2) Subsection (1) of this section does not:
  (a) Require   { - a plan or - }  { +  an + } organization to
contract with more providers than are necessary to meet the needs
of its members;
  (b) Preclude the   { - plan or - }  organization from using
different reimbursement amounts for different specialties or
different practitioners in the same specialty; or

  (c) Preclude the   { - plan or - }  organization from
establishing measures that are designed to maintain the quality
of services and control costs and are consistent with the
 { - plan's or - } organization's responsibilities to its
members.
  SECTION 10.  { + The amendments to section 8 of this 2012 Act
by section 9 of this 2012 Act become operative July 1, 2017. + }
  SECTION 11.  { + In each calendar quarter, the Oregon Health
Authority shall report to the appropriate committees or interim
committees of the Legislative Assembly on the implementation of
the Oregon Integrated and Coordinated Care Delivery System. + }
  SECTION 12.  { + Section 11 of this 2012 Act is repealed July
1, 2017. + }

                               { +
TECHNICAL CORRECTIONS AND CONFORMING AMENDMENTS + }

  SECTION 13. Section 64, chapter 602, Oregon Laws 2011, as
amended by section 70, chapter 602, Oregon Laws 2011, is amended
to read:
   { +  Sec. 64. + } (1) ORS 414.705 is repealed.
  (2) Sections 13  { - , 14 - }  and 17   { - of this 2011
Act - }  { + , chapter 602, Oregon Laws 2011, + } are repealed
January 2, 2014.
  (3) ORS 414.610, 414.630, 414.640, 414.736, 414.738, 414.739
and 414.740 are repealed July 1, 2017.
   { +  (4) Section 14, chapter 602, Oregon Laws 2011, as amended
by section 2 of this 2012 Act, is repealed July 1, 2017. + }
  SECTION 14. ORS 414.033 is amended to read:
  414.033. The Oregon Health Authority may:
  (1) Subject to the allotment system provided for in ORS 291.234
to 291.260, expend such sums as are required to be expended in
this state to provide medical assistance. Expenditures for
medical assistance include, but are not limited to, expenditures
for deductions, cost sharing, enrollment fees, premiums or
similar charges imposed with respect to hospital insurance
benefits or supplementary health insurance benefits, as
established by federal law.
  (2) Enter into agreements with, join with or accept grants from
 { - , - }  the federal government for cooperative research and
demonstration projects for public welfare purposes, including,
but not limited to, any project for:
  (a) Providing medical assistance to individuals who are dually
eligible for Medicare and Medicaid using  { + global or + }
alternative payment methodologies or integrated and coordinated
health care and services; or
  (b) Evaluating service delivery systems.
  SECTION 15. ORS 414.632 is amended to read:
  414.632. (1) Subject to the Oregon Health Authority obtaining
any necessary authorization from the Centers for Medicare and
Medicaid Services   { - under section 17, chapter 602, Oregon
Laws 2011 - } , coordinated care organizations that meet the
criteria adopted under ORS 414.625 are responsible for providing
covered Medicare and Medicaid services, other than
Medicaid-funded long term care services, to members who are
dually eligible for Medicare and Medicaid in addition to medical
assistance recipients.
  (2) An individual who is dually eligible for Medicare and
Medicaid shall be permitted to enroll in and remain enrolled in
a:
  (a) Program of all-inclusive care for the elderly, as defined
in 42 C.F.R. 460.6; and
  (b)   { - A - }  Medicare Advantage plan, as defined in 42
C.F.R.  422.2, until the plan is fully integrated into a
coordinated care organization.

  (3) Except for the enrollment in coordinated care organizations
of individuals who are dually eligible for Medicare and Medicaid,
the rights and benefits of Medicare beneficiaries under Title
XVIII of the Social Security Act shall be preserved.
  SECTION 16. ORS 414.740 is amended to read:
  414.740. (1) Notwithstanding ORS 414.738 (1), the Oregon Health
Authority shall contract under ORS 414.651 with a prepaid group
practice health plan that serves at least 200,000 members in this
state and that has been issued a certificate of authority by the
Department of Consumer and Business Services as a health care
service contractor to provide health services as described in ORS
  { - 414.705 (1)(b) - }  { +  414.025 (8)(b) + }, (c), (d), (e),
(g) and (j). A health plan may also contract with the authority
on a prepaid capitated basis to provide the health services
described in ORS
  { - 414.705 (1)(k) - }  { +  414.025 (8)(k) + } and (L). The
authority may accept financial contributions from any public or
private entity to help implement and administer the contract. The
authority shall seek federal matching funds for any financial
contributions received under this section.
  (2) In a designated area, in addition to the contract described
in subsection (1) of this section, the authority shall contract
with prepaid managed care health services organizations to
provide health services under ORS 414.631, 414.651 and 414.688 to
414.750.
  SECTION 17. ORS 416.540 is amended to read:
  416.540. (1) Except as provided in subsection (2) of this
section and in ORS 416.590, the Department of Human Services and
the Oregon Health Authority shall have a lien upon the amount of
any judgment in favor of a recipient or amount payable to the
recipient under a settlement or compromise for all assistance
received by such recipient from the date of the injury of the
recipient to the date of satisfaction of such judgment or payment
under such settlement or compromise.
  (2) The lien does not attach to the amount of any judgment,
settlement or compromise to the extent of attorney's fees, costs
and expenses incurred by a recipient in securing such judgment,
settlement or compromise and to the extent of medical, surgical
and hospital expenses incurred by the recipient on account of the
personal injuries for which the recipient had a claim.
  (3) The authority may assign the lien described in subsection
(1) of this section to a prepaid managed care health services
organization or a coordinated care organization for medical costs
incurred by a recipient:
  (a) During a period for which the authority paid a capitation
or enrollment fee or a payment using   { - an alternative - }
 { +  a global + } payment methodology; and
  (b) On account of the personal injury for which the recipient
had a claim.
  (4) A prepaid managed care health services organization or a
coordinated care organization to which the authority has assigned
a lien shall notify the authority no later than 10 days after
filing notice of a lien.
  (5) For the purposes of ORS 416.510 to 416.610, the authority
may designate the prepaid managed care health services
organization or the coordinated care organization to which a lien
is assigned as its designee.
  (6) If the authority and a prepaid managed care health services
organization or a coordinated care organization both have filed a
lien, the authority's lien shall be satisfied first.
  SECTION 18.  { + ORS 414.631, 414.651 and 414.688 to 414.750
are added to and made a part of ORS chapter 414. + }

                               { +
CAPTIONS + }

  SECTION 19.  { + The unit captions used in this 2012 Act are
provided only for the convenience of the reader and do not become
part of the statutory law of this state or express any
legislative intent in the enactment of this 2012 Act. + }

                               { +
EMERGENCY CLAUSE + }

  SECTION 20.  { + This 2012 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2012 Act takes effect on
its passage. + }
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