ORS 743B.475
Guidelines for coordination of benefits

  • rules

The Director of the Department of Consumer and Business Services shall by rule establish guidelines for the coordination of benefits for individual and group health insurance, including:

(1)

The procedures by which persons insured under the policies are to be made aware of the existence of a coordination of benefits provision;

(2)

The benefits which may be subject to such a provision;

(3)

The effect of such a provision on the benefits provided;

(4)

Establishment of the order of benefit determination; and

(5)

Reasonable claim administration procedures to expedite claim payments. [Formerly 743.552]
Note: Sections 1, 3, 4 and 5, chapter 575, Oregon Laws 2015, provide:
Sec. 1. (1) As used in this section:

(a)

“Carrier” means an insurer that offers a health benefit plan, as defined in ORS 743B.005 (Definitions).

(b)

“Prominent carrier” means:

(A)

A carrier with annual premium income at a threshold, of no less than $50 million, established by the Department of Consumer and Business Services by rule.

(B)

The Public Employees’ Benefit Board.

(C)

The Oregon Educators Benefit Board.

(2)

All prominent carriers shall, and carriers other than prominent carriers may, report to the Department of Consumer and Business Services, no later than October 1 of each year, the proportion of the carrier’s total medical expenses that are allocated to primary care.

(3)

The department shall share with the Oregon Health Authority the information reported so that the authority may prepare the evaluation and report described in section 2, chapter 575, Oregon Laws 2015.

(4)

The department, in collaboration with the authority, shall adopt rules prescribing the primary care services for which costs must be reported under subsection (2) of this section. [2015 c.575 §1; 2017 c.489 §12]
Sec. 3. No later than February 1 of each year, the Oregon Health Authority and the Department of Consumer and Business Services shall report to the Legislative Assembly, in the manner provided in ORS 192.245 (Form of report to legislature):

(1)

The percentage of the medical expenses of carriers, coordinated care organizations, the Public Employees’ Benefit Board and the Oregon Educators Benefit Board that is allocated to primary care; and

(2)

How carriers, coordinated care organizations, the Public Employees’ Benefit Board and the Oregon Educators Benefit Board pay for primary care. [2015 c.575 §3; 2016 c.26 §7]
Sec. 4. (1) The Legislative Assembly declares that collaboration among insurers, purchasers and providers of health care to coordinate service delivery systems and develop innovative reimbursement methods in support of integrated and coordinated health care delivery is in the best interest of the public. The Legislative Assembly therefore declares its intent to exempt from state antitrust laws, and to provide immunity from federal antitrust laws through the state action doctrine, the activities specified in section 2 (2) of this 2015 Act, of the participants in the primary care payment reform collaborative, that might otherwise be constrained by such laws.

(2)

The Director of the Oregon Health Authority or the director’s designee shall engage in state supervision of the primary care payment reform collaborative to ensure that the activities and discussions of the participants in the collaborative are limited to the activities described in section 2 (2) of this 2015 Act.

(3)

Groups that include, but are not limited to, health insurance companies, health care centers, hospitals, health service organizations, employers, health care providers, health care facilities, state and local governmental entities and consumers may meet to facilitate the development, implementation and operation of the Primary Care Transformation Initiative in accordance with section 2 of this 2015 Act.

(4)

The Oregon Health Authority may conduct a survey of the entities and individuals specified in subsection (3) of this section to assist in the evaluation of the Primary Care Transformation Initiative.

(5)

A survey or meeting under subsection (3) or (4) of this section is not a violation of state antitrust laws and shall be considered state action for purposes of federal antitrust laws through the state action doctrine. [2015 c.575 §4]
Sec. 5. (1) Sections 1 to 4, chapter 575, Oregon Laws 2015, are repealed on December 31, 2027.

(2)

Section 3 of this 2017 Act is repealed on December 31, 2027. [2015 c.575 §5; 2016 c.26 §8; 2017 c.489 §19]

Source: Section 743B.475 — Guidelines for coordination of benefits; rules, 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
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