Health Care Service Contractors
(1)“Claims” means any amount incurred by the insurer covering contracted benefits.
(2)“Complementary health services” means the following health care services:
(a)Chiropractic as defined in ORS 684.010 (Definitions);
(b)Naturopathic medicine as defined in ORS 685.010 (Definitions);
(c)Massage therapy as defined in ORS 687.011 (Definitions); or
(d)Acupuncture as defined in ORS 677.757 (Definitions for ORS 677.757 to 677.770).
(3)“Doctor” means any person lawfully licensed or authorized by statute to render any health care services.
(4)“Health care service contractor” means:
(a)Any corporation that is sponsored by or otherwise intimately connected with a group of doctors licensed by this state, or by a group of hospitals licensed by this state, or both, under contracts with groups of doctors or hospitals that include conditions holding the subscriber harmless in the event of nonpayment by the health care service contract as provided in ORS 750.095 (Requirements of contract between provider and subscriber), and that accepts prepayment for health care services; or
(b)Any person referred to in ORS 750.035 (Regulation of hospital care associations under prior law).
(5)“Health care services” means the furnishing of medicine, medical or surgical treatment, nursing, hospital service, dental service, optometrical service, complementary health services or any or all of the enumerated services or any other necessary services of like character, whether or not contingent upon sickness or personal injury, as well as the furnishing to any person of any and all other services and goods for the purpose of preventing, alleviating, curing or healing human illness, physical disability or injury.
(6)“Health maintenance organization” means any health care service contractor operated on a for-profit or not for-profit basis which:
(a)Qualifies under Title XIII of the Public Health Service Act; or
(b)(A) Provides or otherwise makes available to enrolled participants health care services, including at least the following basic health care services:
(i)Usual physician services;
(v)Emergency and preventive services; and
(B)Is compensated, except for copayments, for the provision of basic health care services listed in subparagraph (A) of this paragraph to enrolled participants on a predetermined periodic rate basis;
(C)Provides physicians’ services primarily directly through physicians who are either employees or partners of such organization, or through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis; and
(D)Employs the terms “health maintenance organization” or “HMO” in its name, contracts, literature or advertising media on or before July 13, 1985. [Formerly 742.010; 1973 c.515 §5; 1979 c.799 §1; 1985 c.747 §65; 1989 c.783 §4; 1991 c.958 §3; 2003 c.33 §1]
Notes of Decisions
These sections, covering health care contractors, made applicable to defendant, nonprofit provider of health care services, regulation by state law, as required by McCarran-Ferguson Act, 15 U.S.C. 1011 et seq. Klamath Lake Pharm. Assn. v. Klamath Medical Service Bureau, 507 F Supp 980 (1981)