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]
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.