ORS 743B.470
Medicaid not considered in coverage eligibility determination

  • claims for services paid for by medical assistance
  • prohibited ground for denial of enrollment of child
  • insurer duties

(1)

For the purposes of this section:

(a)

“Health insurer” or “insurer” means an employee benefit plan, self-insured plan, managed care organization or group health plan, a third party administrator, fiscal intermediary or pharmacy benefit manager of the plan or organization, or other party that is by statute, contract or agreement legally responsible for payment of a claim for a health care item or service.

(b)

“Medicaid” means medical assistance provided under 42 U.S.C. 1396a (section 1902 of the Social Security Act).

(2)

A health insurer is prohibited from considering the availability or eligibility for medical assistance in this or any other state under Medicaid when considering eligibility for coverage or making payments under its group or individual plan for eligible enrollees, subscribers, policyholders or certificate holders.

(3)

To the extent that payment for covered expenses has been made under the state Medicaid program for health care items or services furnished to an individual, in any case when a third party has a legal liability to make payments, the state is considered to have acquired the rights of the individual to payment by any other party for those health care items or services.

(4)

An insurer may not deny a claim submitted by the state Medicaid agency, a prepaid managed care health services organization, as defined in ORS 414.025 (Definitions for ORS chapters 411, 413 and 414), or a coordinated care organization, as defined in ORS 414.025 (Definitions for ORS chapters 411, 413 and 414), under subsection (3) of this section based on the date of submission of the claim, the type or format of the claim form or a failure to present proper documentation at the point of sale that is the basis of the claim if:

(a)

The claim is submitted by the agency, the prepaid managed care health services organization or the coordinated care organization within the three-year period beginning on the date on which the health care item or service was furnished; and

(b)

Any action by the agency, the prepaid managed care health services organization or the coordinated care organization to enforce its rights with respect to the claim is commenced within six years of the agency’s or organization’s submission of the claim.

(5)

An insurer must provide to the state Medicaid agency, a prepaid managed care health services organization or a coordinated care organization, upon request, the following information:

(a)

The period during which a Medicaid recipient, the spouse or dependents may be or may have been covered by the plan;

(b)

The nature of coverage that is or was provided by the plan; and

(c)

The name, address and identifying numbers of the plan.

(6)

An insurer may not deny enrollment of a child under the group or individual health plan of the child’s parent on the ground that:

(a)

The child was born out of wedlock;

(b)

The child is not claimed as a dependent on the parent’s federal tax return; or

(c)

The child does not reside with the child’s parent or in the insurer’s service area.

(7)

When a child has group or individual health coverage through an insurer of a noncustodial parent, the insurer must:

(a)

Provide such information to the custodial parent as may be necessary for the child to obtain benefits through that coverage;

(b)

Permit the custodial parent or the provider, with the custodial parent’s approval, to submit claims for covered services without the approval of the noncustodial parent; and

(c)

Make payments on claims submitted in accordance with paragraph (b) of this subsection directly to the custodial parent, the provider or, if a claim is filed by the state Medicaid agency, a prepaid managed care health services organization or a coordinated care organization, directly to the agency or the organization.

(8)

When a parent is required by a court or administrative order to provide health coverage for a child, and the parent is eligible for family health coverage, the insurer must:

(a)

Permit the parent to enroll, under the family coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions;

(b)

If the parent is enrolled but fails to make application to obtain coverage for the child, enroll the child under family coverage upon application of the child’s other parent, the state agency administering the Medicaid program or the state agency administering 42 U.S.C. 651 to 669, the child support enforcement program; and

(c)

Not disenroll or eliminate coverage of the child unless the insurer is provided satisfactory written evidence that:

(A)

The court or administrative order is no longer in effect; or

(B)

The child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of disenrollment.

(9)

An insurer may not impose requirements on a state agency that has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered for health benefits from the insurer if the requirements are different from requirements applicable to an agent or assignee of any other individual so covered.

(10)

The provisions of ORS 743A.001 (Automatic repeal of certain statutes on individual and group health insurance) do not apply to this section. [Formerly 743.847]

Source: Section 743B.470 — Medicaid not considered in coverage eligibility determination; claims for services paid for by medical assistance; prohibited ground for denial of enrollment of child; insurer duties, https://www.­oregonlegislature.­gov/bills_laws/ors/ors743B.­html.

743B.001
Definitions
743B.003
Purposes
743B.005
Definitions
743B.010
Issuance of group health benefit plan to affiliated group of employers
743B.011
Group health benefit plans subject to provisions of specified laws
743B.012
Requirement to offer all health benefit plans to small employers
743B.013
Requirements for small employer health benefit plans
743B.020
Eligible employees and small employers
743B.100
Department’s authority to regulate market
743B.102
Certifications and disclosure of coverage
743B.103
Use of health-related information
743B.104
Coverage in group health benefit plans
743B.105
Requirements for group health benefit plans other than small employer plans
743B.109
Short term health insurance policies
743B.110
Implementation of federal laws
743B.125
Individual health benefit plans
743B.126
Carrier marketing of individual health benefit plans
743B.127
Rules for ORS 743.022, 743B.125 and 743B.126
743B.128
Exceptions to requirement to actively market all plans
743B.129
Shortening period of exclusion following discontinued offering
743B.130
Requirement to offer bronze and silver plans
743B.195
Enforcement of Newborns’ and Mothers’ Health Protection Act of 1996
743B.197
Health Care Consumer Protection Advisory Committee
743B.200
Requirements for insurers offering managed health insurance
743B.202
Requirements for insurers offering managed health or preferred provider organization insurance
743B.204
Required managed health insurance contract provision
743B.220
Requirements for insurers that require designation of participating primary care physician
743B.222
Designation of women’s health care provider as primary care provider
743B.225
Continuity of care
743B.227
Referrals to specialists
743B.250
Required notices to applicants and enrollees
743B.252
External review
743B.253
Director to contract with independent review organizations to provide external review
743B.254
Required statements regarding external reviews
743B.255
Enrollee application for external review
743B.256
Duties of independent review organizations
743B.257
Civil penalty for failure to comply by insurer that agreed to be bound by decision
743B.258
Private right of action
743B.260
Claims and appeals of adverse benefit determinations under disability income insurance policies
743B.280
Definitions for ORS 743B.280 to 743B.285
743B.281
Estimate of costs for in-network procedure or service
743B.282
Estimate of costs for out-of-network procedure or service
743B.283
Submission of methodology used to determine insurer’s allowable charges
743B.284
Alternative mechanism for disclosure of costs and charges
743B.285
Rules
743B.287
Balance billing prohibited for health care facility services
743B.290
Hospital payment of copayment or deductible for insured patient
743B.300
Disclosure of differences in replacement health insurance policies
743B.310
Rescinding coverage
743B.320
Minimum grace period
743B.321
Applicability of ORS 743B.320
743B.323
Separate notice to policyholder required before cancellation of individual or group health insurance policy for nonpayment of premium
743B.324
Rules for certain notice requirements
743B.330
Notice to policyholder required for cancellation or nonrenewal of health benefit plan
743B.340
When group health insurance policies to continue in effect upon payment of premium by insured individual
743B.341
Continuation of benefits after termination of group health insurance policy
743B.342
Continuation of benefits after injury or illness covered by workers’ compensation
743B.343
Availability of continued coverage under group policy for surviving, divorced or separated spouse 55 or older
743B.344
Procedure for obtaining continuation of coverage under ORS 743B.343
743B.345
Premium for continuation of coverage under ORS 743B.344
743B.347
Continuation of coverage under group policy upon termination of membership in group health insurance policy
743B.400
Decisions regarding health care facility length of stay, level of care and follow-up care
743B.403
Insurer prohibited practices
743B.405
Medical services contract provisions
743B.406
Vision care providers
743B.407
Naturopathic physicians
743B.420
Prior authorization requirements
743B.422
Utilization review requirements for medical services contracts to which insurer not party
743B.423
Utilization review requirements for insurers offering health benefit plan
743B.424
Applicability
743B.425
Prior authorization prohibited for first 60 days of treatment for opioid or opiate withdrawal and for post-exposure prophylactic antiretroviral drugs
743B.427
Nonquantitative treatment limitations on coverage of behavioral health conditions
743B.450
Prompt payment of claims
743B.451
Refund of paid claims
743B.452
Interest on unpaid claims
743B.453
Underpayment of claims
743B.454
Claims submitted during credentialing period
743B.458
Performance-based incentive payments for primary care
743B.460
Conditions for restricting payments to only in-network providers
743B.462
Direct payments to providers
743B.470
Medicaid not considered in coverage eligibility determination
743B.475
Guidelines for coordination of benefits
743B.500
Selling and leasing of provider panels by contracting entity
743B.501
Registration of contracting entity
743B.502
Third party contracts for leasing of provider panels
743B.503
Additional requirements for third party contracts
743B.505
Provider networks
743B.550
Disclosure of information
743B.555
Confidential communications
743B.601
Synchronization of prescription drug refills
743B.602
Step therapy
743B.800
Risk adjustment procedures
743B.810
Enrollees covered by workers’ compensation
Green check means up to date. Up to date