Health Benefit Plans: Individual and Group

ORS 743B.470
Medicaid not considered in coverage eligibility determination

  • claims for services paid for by medical assistance
  • prohibited ground for denial of enrollment of child
  • insurer duties

(1)

For the purposes of this section:

(a)

“Health insurer” or “insurer” means an employee benefit plan, self-insured plan, managed care organization or group health plan, a third party administrator, fiscal intermediary or pharmacy benefit manager of the plan or organization, or other party that is by statute, contract or agreement legally responsible for payment of a claim for a health care item or service.

(b)

“Medicaid” means medical assistance provided under 42 U.S.C. 1396a (section 1902 of the Social Security Act).

(2)

A health insurer is prohibited from considering the availability or eligibility for medical assistance in this or any other state under Medicaid when considering eligibility for coverage or making payments under its group or individual plan for eligible enrollees, subscribers, policyholders or certificate holders.

(3)

To the extent that payment for covered expenses has been made under the state Medicaid program for health care items or services furnished to an individual, in any case when a third party has a legal liability to make payments, the state is considered to have acquired the rights of the individual to payment by any other party for those health care items or services.

(4)

An insurer may not deny a claim submitted by the state Medicaid agency, a prepaid managed care health services organization, as defined in ORS 414.025 (Definitions for ORS chapters 411, 413 and 414), or a coordinated care organization, as defined in ORS 414.025 (Definitions for ORS chapters 411, 413 and 414), under subsection (3) of this section based on the date of submission of the claim, the type or format of the claim form or a failure to present proper documentation at the point of sale that is the basis of the claim if:

(a)

The claim is submitted by the agency, the prepaid managed care health services organization or the coordinated care organization within the three-year period beginning on the date on which the health care item or service was furnished; and

(b)

Any action by the agency, the prepaid managed care health services organization or the coordinated care organization to enforce its rights with respect to the claim is commenced within six years of the agency’s or organization’s submission of the claim.

(5)

An insurer must provide to the state Medicaid agency, a prepaid managed care health services organization or a coordinated care organization, upon request, the following information:

(a)

The period during which a Medicaid recipient, the spouse or dependents may be or may have been covered by the plan;

(b)

The nature of coverage that is or was provided by the plan; and

(c)

The name, address and identifying numbers of the plan.

(6)

An insurer may not deny enrollment of a child under the group or individual health plan of the child’s parent on the ground that:

(a)

The child was born out of wedlock;

(b)

The child is not claimed as a dependent on the parent’s federal tax return; or

(c)

The child does not reside with the child’s parent or in the insurer’s service area.

(7)

When a child has group or individual health coverage through an insurer of a noncustodial parent, the insurer must:

(a)

Provide such information to the custodial parent as may be necessary for the child to obtain benefits through that coverage;

(b)

Permit the custodial parent or the provider, with the custodial parent’s approval, to submit claims for covered services without the approval of the noncustodial parent; and

(c)

Make payments on claims submitted in accordance with paragraph (b) of this subsection directly to the custodial parent, the provider or, if a claim is filed by the state Medicaid agency, a prepaid managed care health services organization or a coordinated care organization, directly to the agency or the organization.

(8)

When a parent is required by a court or administrative order to provide health coverage for a child, and the parent is eligible for family health coverage, the insurer must:

(a)

Permit the parent to enroll, under the family coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions;

(b)

If the parent is enrolled but fails to make application to obtain coverage for the child, enroll the child under family coverage upon application of the child’s other parent, the state agency administering the Medicaid program or the state agency administering 42 U.S.C. 651 to 669, the child support enforcement program; and

(c)

Not disenroll or eliminate coverage of the child unless the insurer is provided satisfactory written evidence that:

(A)

The court or administrative order is no longer in effect; or

(B)

The child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of disenrollment.

(9)

An insurer may not impose requirements on a state agency that has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered for health benefits from the insurer if the requirements are different from requirements applicable to an agent or assignee of any other individual so covered.

(10)

The provisions of ORS 743A.001 (Automatic repeal of certain statutes on individual and group health insurance) do not apply to this section. [Formerly 743.847]
Source

Last accessed
Jun. 26, 2021

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