All insurers offering a health benefit plan in this state shall:
(1) Have a written policy that recognizes the rights of enrollees:
(a) To voice grievances about the organization or health care provided;
(b) To be provided with information about the organization, its services and the providers providing care;
(c) To participate in decision making regarding their health care; and
(d) To be treated with respect and recognition of their dignity and need for privacy.
(2) Provide a summary of policies on enrollees’ rights and responsibilities to all participating providers upon request and to all enrollees either directly or, in the case of group coverage, to the employer or other policyholder for distribution to enrollees.
(3) Have a timely and organized system for resolving grievances and appeals. The system shall include:
(a) A systematic method for recording all grievances and appeals, including the nature of the grievances, and significant actions taken;
(b) Written procedures explaining the grievance and appeal process, including a procedure to assist enrollees in filing written grievances;
(c) Written decisions in plain language justifying grievance determinations, including appropriate references to relevant policies, procedures and contract terms;
(d) Standards for timeliness in responding to grievances or appeals that accommodate the clinical urgency of the situation;
(e) Notice in all written decisions prepared pursuant to this subsection that the enrollee may file a complaint with the Director of the Department of Consumer and Business Services; and
(f) An appeal process for grievances that includes at least the following:
(A) Three levels of review, the second of which shall be by persons not previously involved in the dispute and the third of which shall provide external review pursuant to an external review program meeting the requirements of ORS 743.857, 743.859 and 743.861;
(B) Opportunity for enrollees and any representatives of the enrollees to appear before a review panel at either the first or second level of review. Representatives may include health care providers or any other persons chosen by the enrollee. The enrollee and insurer shall each provide advance notification of the number of representatives who will appear before the panel and the relationship of the representatives to the enrollee or insurer; and
(C) Written decisions in plain language justifying appeal determinations, including specific references to relevant provisions of the health benefit plan and related written corporate practices.
(4) If the insurer has a prescription drug formulary, have:
(a) A written procedure by which a provider with authority to prescribe drugs and medications may prescribe drugs and medications not included in the formulary. The procedure shall include the circumstances when a drug or medication not included in the formulary will be considered a covered benefit; and
(b) A written procedure to provide full disclosure to enrollees of any cost sharing or other requirements to obtain drugs and medications not included in the formulary.
(5) Furnish to all enrollees either directly or, in the case of a group policy, to the employer or other policyholder for distribution to enrollees written general information informing enrollees about services provided, access to services, charges and scheduling applicable to each enrollee’s coverage, including:
(a) Benefits and services included and how to obtain them, including any restrictions that apply to services obtained outside the insurer’s network or outside the insurer’s service area, and the availability of continuity of care as required by ORS 743.854;
(b) Provisions for referrals, if any, for specialty care, behavioral health services and hospital services and how enrollees may obtain the care or services;
(c) Provisions for after-hours and emergency care and how enrollees may obtain that care, including the insurer’s policy, if any, on when enrollees should directly access emergency care and use 9-1-1 services;
(d) Charges to enrollees, if applicable, including any policy on cost sharing for which the enrollee is responsible;
(e) Procedures for notifying enrollees of:
(A) A change in or termination of any benefit;
(B) If applicable, termination of a primary care delivery office or site; and
(C) If applicable, assistance available to enrollees affected by the termination of a primary care delivery office or site in selecting a new primary care delivery office or site;
(f) Procedures for appealing decisions adversely affecting the enrollee’s benefits or enrollment status;
(g) Procedures, if any, for changing providers;
(h) Procedures for voicing grievances, including the option of obtaining external review under the insurer’s program established pursuant to ORS 743.857, 743.859 and 743.861;
(i) A description of the procedures, if any, by which enrollees and their representatives may participate in the development of the insurer’s corporate policies and practices;
(j) Summary information on how the insurer makes decisions regarding coverage and payment for treatment or services, including a general description of any prior authorization and utilization review requirements that affect coverage or payment;
(k) A summary of criteria used to determine if a service or drug is considered experimental or investigational;
(L) Information about provider, clinic and hospital networks, if any, including a list of network providers and information about how the enrollee may obtain current information about the availability of individual providers, the hours the providers are available and a description of any limitations on the ability of enrollees to select primary and specialty care providers;
(m) A general disclosure of any risk-sharing arrangements the insurer has with physicians and other providers;
(n) A summary of the insurer’s procedures for protecting the confidentiality of medical records and other enrollee information;
(o) A description of any assistance provided to non-English-speaking enrollees;
(p) A summary of the insurer’s policies, if any, on drug prescriptions, including any drug formularies, cost sharing differentials or other restrictions that affect coverage of drug prescriptions;
(q) Notice of the enrollee’s right to file a complaint or seek other assistance from the Director of the Department of Consumer and Business Services; and
(r) Notice of the information that is available upon request pursuant to subsection (6) of this section and information that is available from the Department of Consumer and Business Services pursuant to ORS 743.804, 743.807, 743.814 and 743.817.
(6) Provide the following information upon the request of an enrollee or prospective enrollee:
(a) Rules related to the insurer’s drug formulary, if any, including information on whether a particular drug is included or excluded from the formulary;
(b) Provisions for referrals, if any, for specialty care, behavioral health services and hospital services and how enrollees may obtain the care or services;
(c) A copy of the insurer’s annual report on grievances and appeals as submitted to the department under subsection (9) of this section;
(d) A description of the insurer’s risk-sharing arrangements with physicians and other providers consistent with risk-sharing information required by the federal Health Care Financing Administration pursuant to 42 C.F.R. 417.124 (3)(b) as in effect on June 18, 1997;
(e) A description of the insurer’s efforts, if any, to monitor and improve the quality of health services;
(f) Information about any insurer procedures for credentialing network providers and how to obtain the names, qualifications and titles of the providers responsible for an enrollee’s care; and
(g) A description of the insurer’s external review program established pursuant to ORS 743.857, 743.859 and 743.861.
(7) Except as otherwise provided in this subsection, provide to enrollees, upon request, a written summary of information that the insurer may consider in its utilization review of a particular condition or disease to the extent the insurer maintains such criteria. Nothing in this section shall require an insurer to advise an enrollee how the insurer would cover or treat that particular enrollee’s disease or condition. Utilization review criteria that is proprietary shall be subject to verbal disclosure only.
(8) Provide the following information to an enrollee when the enrollee has filed a grievance:
(a) Detailed information on the insurer’s grievance and appeal procedures and how to use them;
(b) Information on how to access the complaint line of the Department of Consumer and Business Services; and
(c) Information explaining how an enrollee applies for external review of the insurer’s actions under the external review program established by the insurer pursuant to ORS 743.857.
(9) Provide annual summaries to the Department of Consumer and Business Services of the insurer’s aggregate data regarding grievances, appeals and applications for external review in a format prescribed by the department to ensure consistent reporting on the number, nature and disposition of grievances, appeals and applications for external review.
(10) Ensure that the confidentiality of specified patient information and records is protected, and to that end:
(a) Adopt and implement written confidentiality policies and procedures;
(b) State the insurer’s expectations about the confidentiality of enrollee information and records in medical service contracts; and
(c) Afford enrollees the opportunity to approve or deny the release of identifiable medical personal information by the insurer, except as otherwise permitted or required by law.
(11) Notify an enrollee of the enrollee’s rights under the health benefit plan at the time that the insurer notifies the enrollee of an adverse decision. The notification shall include:
(a) Notice of the right of the enrollee to apply for internal and external review of the adverse decision;
(b) A statement whether a decision by an independent review organization is binding on the insurer and enrollee;
(c) A statement that if the decision is not binding on the insurer and if the insurer does not comply with the decision, the enrollee may sue the insurer as provided in ORS 743.864; and
(d) Information on filing a complaint with the Director of the Department of Consumer and Business Services. [1997 c.343 §3; 2001 c.266 §15; 2003 c.87 §22]
Section: Previous 743.797 743.798 743.799 743.800 743.801 743.802 743.803 743.804 743.805 743.806 743.807 743.808 743.809 743.810 743.811 NextLast modified: August 7, 2008