(1) Subject to funds available, the Department of Human Services may provide public subsidies for the purchase of health insurance coverage provided by public programs or private insurance, including but not limited to the Family Health Insurance Assistance Program, for currently uninsured individuals based on incomes up to 200 percent of the federal poverty level. The objective is to create a transition from dependence on public programs to privately financed health insurance.
(2) Public subsidies shall apply only to health benefit plans that meet or exceed the basic benchmark health benefit plan or plans established under ORS 735.733.
(3) Cost sharing shall be permitted and structured in such a manner to encourage appropriate use of preventive care and avoidance of unnecessary services.
(4) Cost sharing shall be based on an individual’s ability to pay and may not exceed the cost of purchasing a plan.
(5) The state may pay a portion of the cost of the subsidy, based on the individual’s income and other resources. [2001 c.898 §11; 2003 c.14 §206; 2003 c.684 §7; 2003 c.735 §9]
Note: See note under 414.825.
(Temporary provisions relating to Healthy Oregon Act)
Note: Sections 1 to 13 and 27, chapter 697, Oregon Laws 2007, provide:
Sec. 1. Sections 2 to 13 of this 2007 Act shall be known and may be cited as the Healthy Oregon Act. [2007 c.697 §1]
Sec. 2. As used in sections 2 to 13 of this 2007 Act, except as otherwise specifically provided or unless the context requires otherwise:
(1) “Accountable health plan” means a prepaid managed care health services organization described in ORS 414.725 or an entity that contracts with the Oregon Health Fund Board to provide a health benefit plan, as defined in ORS 743.730, through the Oregon Health Fund program.
(2) “Core health care safety net provider” means a safety net provider that is especially adept at serving persons who experience significant barriers to accessing health care, including homelessness, language and cultural barriers, geographic isolation, mental illness, lack of health insurance and financial barriers, and that has a mission or mandate to deliver services to persons who experience barriers to accessing care and serves a substantial share of persons without health insurance and persons who are enrolled in Medicaid or Medicare, as well as other vulnerable or special populations.
(3) “Defined set of essential health services” means the services:
(a) Identified by the Health Services Commission using the methodology in ORS 414.720 or an alternative methodology developed pursuant to section 9 (3)(c) of this 2007 Act; and
(b) Approved by the Oregon Health Fund Board.
(4) “Employer” has the meaning given that term in ORS 657.025.
(5) “Oregon Health Card” means the card issued by the Oregon Health Fund Board that verifies the eligibility of the holder to participate in the Oregon Health Fund program.
(6) “Oregon Health Fund” means the fund established in section 8 of this 2007 Act.
(7) “Oregon Health Fund Board” means the board established in section 5 of this 2007 Act.
(8) “Safety net provider” means providers that deliver health services to persons experiencing cultural, linguistic, geographic, financial or other barriers to accessing appropriate, timely, affordable and continuous health care services. “Safety net providers” includes health care safety net providers, core health care safety net providers, tribal and federal health care organizations and local nonprofit organizations, government agencies, hospitals and individual providers. [2007 c.697 §2]
Sec. 3. The Oregon Health Fund program shall be based on the following principles:
(1) Expanding access. The state Medicaid program, the Oregon State Children’s Health Insurance Program and the Family Health Insurance Assistance Program must be expanded to include the current uninsured population in Oregon to the greatest extent possible.
(2) Equity. All individuals must be eligible for and have timely access to at least the same set of essential and effective health services.
(3) Financing of the health care system must be equitable, broadly based and affordable.
(4) Population benefit. The public must set priorities to optimize the health of Oregonians.
(5) Responsibility for optimizing health must be shared by individuals, employers, health care systems and communities.
(6) Education is a powerful tool for health promotion. The health care system, health plans, providers and government must promote and engage in education activities for individuals, communities and providers.
(7) Effectiveness. The relationship between specific health interventions and their desired health outcomes must be backed by unbiased, objective medical evidence.
(8) Efficiency. The administration and delivery of health services must use the fewest resources necessary to produce the most effective health outcome.
(9) Explicit decision-making. Decision-making will be clearly defined and accessible to the public, including lines of accountability, opportunities for public engagement and how public input will be used in decision-making.
(10) Transparency. The evidence used to support decisions must be clear, understandable and observable to the public.
(11) Economic sustainability. Health service expenditures must be managed to ensure long-term sustainability, using efficient planning, budgeting and coordination of resources and reserves, based on public values and recognizing the impact that public and private health expenditures have on each other.
(12) Aligned financial incentives. Financial incentives must be aligned to support and invest in activities that will achieve the goals of the Oregon Health Fund program.
(13) Wellness. Health and wellness promotion efforts must be emphasized and strengthened.
(14) Community-based. The delivery of care and distribution of resources must be organized to take place at the community level to meet the needs of the local population, unless outcomes or cost can be improved at regional or statewide levels.
(15) Coordination. Collaboration, coordination and integration of care and resources must be emphasized throughout the health care system.
(16) The health care safety net is a key delivery system element for the protection of the health of Oregonians and the delivery of community-based care. [2007 c.697 §3]
Sec. 4. The intent of the Healthy Oregon Act is to develop an Oregon Health Fund program comprehensive plan, based upon the principles set forth in section 3 of this 2007 Act, that meets the intended goals of the program to:
(1) As a primary goal, cover the current uninsured population in Oregon through the expansion of the state Medicaid program, the Oregon State Children’s Health Insurance Program and the Family Health Insurance Assistance Program;
(2) Reform the health care delivery system to maximize federal and other public resources without compromising proven programs supported by federal law that ensure to vulnerable populations access to efficient and high quality care;
(3) Ensure that all Oregonians have timely access to and participate in a health benefit plan that provides high quality, effective, safe, patient-centered, evidence-based and affordable health care delivered at the lowest cost;
(4) Develop a method to finance the coverage of a defined set of essential health services for Oregonians that is not necessarily tied directly to employment;
(5) Allow the potential for employees, employers, individuals and unions to participate in the program, or to purchase primary coverage or offer, purchase or bargain for coverage of benefits beyond the defined set of essential health services;
(6) Allow for a system of public and private health care partnerships that integrate public involvement and oversight, consumer choice and competition within the health care market;
(7) Use proven models of health care benefits, service delivery and payments that control costs and overutilization, with emphasis on preventive care and chronic disease management using evidence-based outcomes and a health benefit model that promotes a primary care medical home;
(8) Provide services for dignified end-of-life care;
(9) Restructure the health care system so that payments for services are fair and proportionate among various populations, health care programs and providers;
(10) Fund a high quality and transparent health care delivery system that will be held to high standards of transparency and accountability and allows users and purchasers to know what they are receiving for their money;
(11) Ensure that funding for health care is equitable and affordable for all Oregon residents, especially the uninsured; and
(12) Ensure, to the greatest extent possible, that annual inflation in the cost of providing access to essential health care services does not exceed the increase in the cost of living for the previous calendar year, based on the Portland-Salem, OR-WA, Consumer Price Index for All Urban Consumers for All Items, as published by the Bureau of Labor Statistics of the United States Department of Labor. [2007 c.697 §4]
Sec. 5. (1) There is established within the Department of Human Services the Oregon Health Fund Board that shall be responsible for developing the Oregon Health Fund program comprehensive plan. The board shall consist of seven members appointed by the Governor, subject to confirmation by the Senate pursuant to section 4, Article III of the Oregon Constitution. The members of the board shall be selected based upon their ability to represent the best interests of Oregon as a whole. Members of the board shall have expertise, knowledge and experience in the areas of consumer advocacy, management, finance, labor and health care, and to the extent possible shall represent the geographic and ethnic diversity of the state. A majority of the board members must consist of individuals who do not receive or have not received within the past two years more than 50 percent of the individual’s income or the income of the individual’s family from the health care industry or the health insurance industry.
(2) Each board member shall serve for a term of four years. However, a board member shall serve until a successor has been appointed and qualified. A member is eligible for reappointment.
(3) If there is a vacancy for any cause, the Governor shall make an appointment to become effective immediately for the balance of the unexpired term.
(4) The board shall select one of its members as chairperson and another as vice chairperson, for such terms and with duties and powers necessary for the performance of the functions of such offices as the board determines.
(5) A majority of the members of the board constitutes a quorum for the transaction of business.
(6) Official action by the board requires the approval of a majority of the members of the board.
(7) A member of the board is not entitled to compensation for services as a member, but is entitled to expenses as provided in ORS 292.495 (2). [2007 c.697 §5]
Sec. 6. (1) Within 30 days after the effective date of this 2007 Act [June 28, 2007], the Governor shall appoint an executive director of the Oregon Health Fund Board who will be responsible for establishing the administrative framework for the board.
(2) The executive director appointed under this section may employ and shall fix the duties and amounts of compensation of persons necessary to carry out the provisions of sections 2 to 13 of this 2007 Act. Those persons shall serve at the pleasure of the executive director.
(3) The executive director shall serve at the pleasure of the Governor. [2007 c.697 §6]
Sec. 7. Except as otherwise provided by law, and except for ORS 279A.250 to 279A.290, the provisions of ORS chapters 279A, 279B and 279C do not apply to the Oregon Health Fund Board. [2007 c.697 §7]
Sec. 8. (1) The Oregon Health Fund is established separate and distinct from the General Fund. Interest earned from the investment of moneys in the Oregon Health Fund shall be credited to the fund. The Oregon Health Fund may include:
(a) Employer and employee health care contributions.
(b) Individual health care premium contributions.
(c) Federal funds from Title XIX or XXI of the Social Security Act, and state matching funds, that are made available to the fund, excluding Title XIX funds for long term care supports, services and administration, and reimbursements for graduate medical education costs pursuant to 42 U.S.C. 1395ww(h) and disproportionate share adjustments made pursuant to 42 U.S.C. 1396a(a)(13)(A)(iv).
(d) Contributions from the United States Government and its agencies for which the state is eligible provided for purposes that are consistent with the goals of the Oregon Health Fund program.
(e) Moneys appropriated to the Oregon Health Fund Board by the Legislative Assembly for carrying out the provisions of the Healthy Oregon Act.
(f) Interest earnings from the investment of moneys in the fund.
(g) Gifts, grants or contributions from any source, whether public or private, for the purpose of carrying out the provisions of the Healthy Oregon Act.
(2)(a) All moneys in the Oregon Health Fund are continuously appropriated to the Oregon Health Fund Board to carry out the provisions of the Healthy Oregon Act.
(b) The Oregon Health Fund shall be segregated into subaccounts as required by federal law. [2007 c.697 §8]
Sec. 9. (1)(a) The Oregon Health Fund Board shall establish a committee to examine the impact of federal law requirements on reducing the number of Oregonians without health insurance, improving Oregonians’ access to health care and achieving the goals of the Healthy Oregon Act, focusing particularly on barriers to reducing the number of uninsured Oregonians, including but not limited to:
(A) Medicaid requirements such as eligibility categories and household income limits;
(B) Federal tax code policies regarding the impact on accessing health insurance or self-insurance and the affect on the portability of health insurance;
(C) Emergency Medical Treatment and Active Labor Act regulations that make the delivery of health care more costly and less efficient; and
(D) Medicare policies that result in Oregon’s health care providers receiving significantly less than the national average Medicare reimbursement rate. The committee shall survey providers and determine how this and other Medicare policies and procedures affect costs, quality and access. The committee shall assess how an increase in Medicare reimbursement rates to Oregon providers would benefit Oregon in health care costs, quality and access to services, including improved access for persons with disabilities and improved access to long term care.
(b) With the approval of the Oregon Health Fund Board, the committee shall report its findings to the Oregon congressional delegation no later than July 31, 2008.
(c) The committee shall request that the Oregon congressional delegation:
(A) Participate in at least one hearing in each congressional district in this state on the impacts of federal policies on health care services; and
(B) Request congressional hearings in Washington, D.C.
(2) The Oregon Health Fund Board shall develop a comprehensive plan to achieve the Oregon Health Fund program goals listed in section 4 of this 2007 Act. The board shall establish subcommittees, organized to maximize efficiency and effectiveness and assisted, in the manner the board deems appropriate, by the Oregon Health Policy Commission, the Office for Oregon Health Policy and Research, the Health Services Commission and the Medicaid Advisory Committee, to develop proposals for the Oregon Health Fund program comprehensive plan. The proposals may address, but are not limited to, the following:
(a) Financing the Oregon Health Fund program, including but not limited to proposals for:
(A) A model for rate setting that ensures providers will receive fair and adequate compensation for health care services.
(B) Collecting employer and employee contributions and individual health care premium contributions, and redirecting them to the Oregon Health Fund.
(C) Implementing a health insurance exchange to serve as a central forum for uninsured individuals and businesses to purchase affordable health insurance.
(D) Taking best advantage of health savings accounts and similar vehicles for making health insurance more accessible to uninsured individuals.
(E) Addressing the issue of medical liability and medical errors including, but not limited to, consideration of a patients’ compensation fund.
(F) Requesting federal waivers under Titles XIX and XXI of the Social Security Act, or other federal matching funds that may be made available to implement the comprehensive plan and increase access to health care.
(G) Evaluating statutory and regulatory barriers to the provision of cost-effective services, including limitations on access to information that would enable providers to fairly evaluate contract reimbursement, the regulatory effectiveness of the certificate of need process, consideration of a statewide uniform credentialing process and the costs and benefits of improving the transparency of costs of hospital services and health benefit plans.
(b) Delivering health services in the Oregon Health Fund program, including but not limited to proposals for:
(A) An efficient and effective delivery system model that ensures the continued viability of existing prepaid managed care health services organizations, as described in ORS 414.725, to serve Medicaid populations.
(B) The design and implementation of a program to create a public partnership with accountable health plans to provide, through the use of an Oregon Health Card, health insurance coverage of the defined set of essential health services that meets standards of affordability based upon a calculation of how much individuals and families, particularly the uninsured, can be expected to spend for health insurance and still afford to pay for housing, food and other necessities. The proposal must ensure that each accountable health plan:
(i) Does not deny enrollment to qualified Oregonians eligible for Medicaid;
(ii) Provides coverage of the entire defined set of essential health services;
(iii) Will develop an information system to provide written information, and telephone and Internet access to information, necessary to connect enrollees with appropriate medical and dental services and health care advice;
(iv) Offers a simple and timely complaint process;
(v) Provides enrollees with information about the cost and quality of services offered by health plans and procedures offered by medical and dental providers;
(vi) Provides advance disclosure of the estimated out-of-pocket costs of a service or procedure;
(vii) Has contracts with a sufficient network of providers, including but not limited to hospitals and physicians, with the capacity to provide culturally appropriate, timely health services and that operate during hours that allow optimal access to health services;
(viii) Ensures that all enrollees have a primary care medical home;
(ix) Includes in its network safety net providers and local community collaboratives;
(x) Regularly evaluates its services, surveys patients and conducts other assessments to ensure patient satisfaction;
(xi) Has strategies to encourage enrollees to utilize preventive services and engage in healthy behaviors;
(xii) Has simple and uniform procedures for enrollees to report claims and for accountable health plans to make payments to enrollees and providers;
(xiii) Provides enrollment, encounter and outcome data for evaluation and monitoring purposes; and
(xiv) Meets established standards for loss ratios, rating structures and profit or nonprofit status.
(C) Using information technology that is cost-neutral or has a positive return on investment to deliver efficient, safe and quality health care and a voluntary program to provide every Oregonian with a personal electronic health record that is within the individual’s control, use and access and that is portable.
(D) Empowering individuals through education as well as financial incentives to assume more personal responsibility for their own health status through the choices they make.
(E) Establishing and maintaining a registry of advance directives and Physician Orders for Life-Sustaining Treatment (POLST) forms and a process for assisting a person who chooses to execute an advance directive in accordance with ORS 127.531 or a POLST form.
(F) Designing a system for regional health delivery.
(G) Combining, reorganizing or eliminating state agencies involved in health planning and policy, health insurance and the delivery of health care services and integrating and streamlining their functions and programs to maximize their effectiveness and efficiency. The subcommittee may consider, but is not limited to considering, the following state agencies, functions or programs:
(i) The Health Services Commission;
(ii) The Oregon Health Policy Commission;
(iii) The Health Resources Commission;
(iv) The Medicaid Advisory Committee;
(v) The Department of Human Services, including but not limited to the state Medicaid agency, the Office for Oregon Health Policy and Research, offices involved in health systems planning, offices involved in carrying out the duties of the department with respect to certificates of need under ORS 443.305 to 443.350 and the functions of the department under ORS chapter 430;
(vi) The Department of Consumer and Business Services;
(vii) The Oregon Patient Safety Commission;
(viii) The Office of Private Health Partnerships;
(ix) The Public Employees’ Benefit Board;
(x) The State Accident Insurance Fund Corporation; and
(xi) The Office of Rural Health.
(c) Establishing the defined set of essential health services, including but not limited to proposals for a methodology, consistent with the principles in section 3 of this 2007 Act, for determining and continually updating the defined set of essential health services. The Oregon Health Fund Board may delegate this function to the Health Services Commission established under ORS 414.715.
(d) The eligibility requirements and enrollment procedures for the Oregon Health Fund program, including, but not limited to, proposals for:
(A) Public subsidies of premiums or other costs under the program.
(B) Streamlined enrollment procedures, including:
(i) A standardized application process;
(ii) Requirements to ensure that enrollees demonstrate Oregon residency;
(iii) A process to enable a provider to enroll an individual in the Oregon Health Fund program at the time the individual presents for treatment to ensure coverage as of the date of the treatment; and
(iv) Permissible waiting periods, preexisting condition limitations or other administrative requirements for enrollment.
(C) A grievance and appeal process for enrollees.
(D) Standards for disenrollment and changing enrollment in accountable health plans.
(E) An outreach plan to educate the general public, particularly uninsured and underinsured persons, about the program and the program’s eligibility requirements and enrollment procedures.
(F) Allowing employers to offer health insurance coverage by insurers of the employer’s choice or to contract for coverage of benefits beyond the defined set of essential health services.
(3) On the effective date of this 2007 Act [June 28, 2007], the Oregon Health Policy Commission, the Office for Oregon Health Policy and Research, the Health Services Commission and the Medicaid Advisory Committee are directed to begin compiling data and conducting research to inform the decision-making of the subcommittees when they are convened. No later than February 1, 2008, the Oregon Health Policy Commission, the Office for Oregon Health Policy and Research, the Health Services Commission and the Medicaid Advisory Committee shall present reports containing data and recommendations to the subcommittees as follows:
(a) The Oregon Health Policy Commission shall report on the financing mechanism for the comprehensive plan;
(b) The Administrator of the Office for Oregon Health Policy and Research shall report on the health care delivery model of the comprehensive plan;
(c) The Health Services Commission shall report on the methodology for establishing the defined set of essential health services under the comprehensive plan; and
(d) The Medicaid Advisory Committee shall report on eligibility and enrollment requirements under the comprehensive plan.
(4) The membership of the subcommittees shall, to the extent possible, represent the geographic and ethnic diversity of the state and include individuals with actuarial and financial management experience, individuals who are providers of health care, including safety net providers, and individuals who are consumers of health care, including seniors, persons with disabilities and individuals with complex medical needs.
(5) Each subcommittee shall select one of its members as chairperson for such terms and with such duties and powers necessary for performance of the functions of those offices. Each chairperson shall serve as an ex officio member of the Oregon Health Fund Board. Chairpersons shall collaborate to integrate the committee recommendations to the extent possible.
(6) The committee and the subcommittees are public bodies for purposes of ORS chapter 192 and must provide reasonable opportunity for public testimony at each meeting.
(7) All agencies of state government, as defined in ORS 174.111, are directed to assist the committee, the subcommittees and the Oregon Health Fund Board in the performance of their duties and, to the extent permitted by laws relating to confidentiality, to furnish such information and advice as the members of the committees, the subcommittees and the Oregon Health Fund Board consider necessary to perform their duties.
(8) The Oregon Health Fund Board shall report to the Legislative Assembly not later than February 29, 2008. The report must describe the progress of the subcommittees and the board toward developing a comprehensive plan to:
(a) Decrease the number of children and adults without health insurance;
(b) Ensure universal access to health care;
(c) Contain health care costs; and
(d) Address issues regarding the quality of health care services.
(9) The Oregon Health Fund Board shall present a plan to the Legislative Assembly not later than February 1, 2008, for the design and implementation of the health insurance exchange described in subsection (2)(a)(C) of this section. [2007 c.697 §9]
Sec. 10. The Oregon Health Fund Board shall conduct public hearings on the draft Oregon Health Fund program comprehensive plan developed under section 9 of this 2007 Act and solicit testimony and input from advocates representing seniors, persons with disabilities, tribes, consumers of mental health services, low-income Oregonians, employers, employees, insurers, health plans and providers of health care including, but not limited to, physicians, dentists, oral surgeons, chiropractors, naturopaths, hospitals, clinics, pharmacists, nurses and allied health professionals. [2007 c.697 §10]
Sec. 11. (1) The Oregon Health Fund Board shall finalize the Oregon Health Fund program comprehensive plan developed under section 9 of this 2007 Act with due consideration to the information provided in the public hearings under section 10 of this 2007 Act and shall present the finalized comprehensive plan to the Governor, the Speaker of the House of Representatives and the President of the Senate no later than October 1, 2008. The board is authorized to submit the finalized comprehensive plan as a measure request directly to the Legislative Counsel upon the convening of the Seventy-fifth Legislative Assembly.
(2) Upon legislative approval of the comprehensive plan, the board is authorized to request federal waivers deemed necessary and appropriate to implement the comprehensive plan.
(3) Upon legislative approval of the comprehensive plan, the board is authorized immediately to implement any elements necessary to implement the plan that do not require legislative changes or federal approval. [2007 c.697 §11]
Sec. 12. (1) The Oregon Health Fund program comprehensive plan described in section 11 of this 2007 Act must ensure, except as provided in subsection (2) of this section, that a resident of Oregon who is not a beneficiary of a health benefit plan providing coverage of the defined set of essential health services and who is not eligible to be enrolled in a publicly funded medical assistance program providing primary care and hospital services participates in the Oregon Health Fund program. A resident of Oregon who is a beneficiary of a health benefit plan or enrolled in a medical assistance program described in this subsection may choose to participate in the program. An employee of an employer located in this state may participate in the program if Oregon is the location of the employee’s physical worksite, regardless of the employee’s state of residence.
(2) Oregon residents who are enrolled in commercial health insurance plans, self-insured programs, health plans funded by a Taft-Hartley trust, or state or local government health insurance pools may not be required to participate in the Oregon Health Fund Program. [2007 c.697 §12]
Sec. 13. (1) The Administrator of the Office for Oregon Health Policy and Research, in collaboration with the Oregon Health Research and Evaluation Collaborative and other persons with relevant expertise, shall be responsible for developing a plan for evaluating the implementation and outcomes of the legislation described in section 11 of this 2007 Act. The evaluation plan shall focus particularly on the individuals receiving health care covered through the state Medicaid program, the Oregon State Children’s Health Insurance Program and the Family Health Insurance Assistance Program and shall include measures of:
(a) Access to care;
(b) Access to health insurance coverage;
(c) Quality of care;
(d) Consumer satisfaction;
(e) Health status;
(f) Provider capacity;
(g) Population demand;
(h) Provider and consumer participation;
(i) Utilization patterns;
(j) Health outcomes;
(k) Health disparities;
(L) Financial impacts, including impacts on medical debt;
(m) The extent to which employers discontinue coverage due to the availability of publicly financed coverage or other employer responses;
(n) Impacts on the financing of health care and uncompensated care;
(o) Adverse selection, including migration to Oregon primarily for access to health care;
(p) Use of technology;
(q) Transparency of costs; and
(r) Impact on health care costs.
(2) The administrator shall develop recommendations for a model quality institute that shall:
(a) Develop and promote methods for improving collection, measurement and reporting of information on quality in health care;
(b) Provide leadership and support to further the development of widespread and shared electronic health records;
(c) Develop the capacity of the workforce to capitalize on health information technology;
(d) Encourage purchasers, providers and state agencies to improve system transparency and public understanding of quality in health care;
(e) Support the Oregon Patient Safety Commission’s efforts to increase collaboration and state leadership to improve health care safety; and
(f) Coordinate an effort among all state purchasers of health care and insurers to support delivery models and reimbursement strategies that will more effectively support infrastructure investments, integrated care and improved health outcomes. [2007 c.697 §13]
Sec. 27. Sections 1 to 13 of this 2007 Act are repealed on January 2, 2010. [2007 c.697 §27]Section: Previous 414.821 414.823 414.825 414.827 414.829 414.830 414.831 414.833 414.834 414.835 414.837 414.839 414.840 414.850 414.860 Next
Last modified: August 7, 2008