| Oregon Patient Protection Act amendments
In the 2001 legislative session, Oregon passed House
Bill 3040 (HB 3040), which amends the Oregon Patient
Protection Act of 1996. HB 3040, effective July 1,
2002, mandates the following:
- Continuity of care. Continuity of care ensures
that a person undergoing a course of treatment is
entitled to continue care with his or her managed
care provider (under certain circumstances) for up
to 120 days after the physician or other provider
has left the managed care network. This is an extension
of our previous 90-day continuity of care policy.
Regence BCBSO has revised our procedures to allow
continuity of care for up to 120 days for qualifying
circumstances.
As a reminder, our procedure is to send a letter
to all members assigned to a PCP who terminates
their contract and members with open referrals to
a specialist who has terminated advising them of
the termination. In non-referral situations, we
will notify all members who have claims from the
terminated provider within the past 90 days. The
member may contact Customer Service if they wish
to continue seeing the physician for the 120 day
period. In this situation, we will contact the physician
office to request the continuation. To continue
seeing the member, the physician must agree to accept
the contracted fee schedule as payment in full,
share information such as treatment plans with Regence
BCBSO Oregon, and to follow our utilization management
policies and procedures.
- Standing referrals to specialists. Insurers
must have established procedures for allowing standing
referrals to specialists so a member does not need
to obtain repeated referrals for each visit to the
same specialist. Regence BCBSO procedures are in compliance
with this requirement.
- External review. Health plan members may
request review of denied claims from an independent,
external review organization contracted with the State
of Oregon. External reviews will be permitted on matters
pertaining to medical necessity, investigational or
experimental services and continuity of care. Regence
BCBSO already had external review as part of the member
appeal process prior to the passage of HB3040.
- Network adequacy. Oregon insurers were required
to submit a network adequacy report to the state for
managed care networks. HB 3040 placed an additional
requirement on insurers to submit similar reporting
for PPO networks.
- Limited right to sue. Members have a limited
right to sue when an insurer chooses to offer non-binding
external review and then refuses to comply with the
external review decision. Insurers who have agreed
to binding external review are subject to fines if
they fail to comply with their contracts. Regence
BCBSO decided to be bound by the independent review
organization’s decisions.
Exclusions: HB3040 does not apply
to First Choice Sixty-Five, Preferred Choice Sixty-Five,
Federal Employee Program (FEP), self-insured groups
and policies issued outside of Oregon (BlueCard).
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