2023 Oregon Revised Statutes › Volume : 18 - Financial Institutions, Insurance › Chapter 743A - Health Insurance: Reimbursement of Claims › Section 743A.260 - Inmates.

(1) As used in this section:
(a) "Detainee" means an insured who is:
(A) In the custody of a local supervisory authority pending the disposition of charges; or
(B) In a detention facility pending final adjudication by a juvenile court.
(b) "Detention facility" has the meaning given that term in ORS 419A.004.
(c) "Health benefit plan" has the meaning given that term in ORS 743B.005.
(d) "Supervisory authority" has the meaning given that term in ORS 144.087.
(2) Except as provided in subsection (4) of this section, an insurer offering a health benefit plan may not deny reimbursement for any service or supply covered by the plan or cancel the coverage of an insured under the plan on the basis that:
(a) The insured is a detainee;
(b) The insured receives publicly funded medical care while in the custody of a local supervisory authority or in a detention facility; or
(c) The care was provided to the insured by an employee or contractor of a county, a local supervisory authority or a detention facility, if the employee or contractor meets the credentialing criteria of the health benefit plan.
(3) An insurer shall reimburse a county for the costs of covered services or supplies provided to a detainee, in an amount that is no less than 115 percent of the Medicare rate for the service or supply.
(4) An insurer offering a health benefit plan may:
(a) Deny coverage for the treatment of injuries resulting from a violation of law;
(b) Exclude from any requirements for reporting quality outcomes or performance, any covered services provided to a detainee;
(c) Impose utilization controls under the health benefit plan that apply to services provided by in-network providers to insureds who are not in custody or in a detention facility, including a requirement for prior authorization;
(d) Impose the requirements for billing and medical coding for covered services provided to a detainee that the insurer imposes on other providers;
(e) Deny coverage of diagnostic tests or health evaluations required, as a matter of course, for all detainees;
(f) Limit coverage of hospital and ambulatory surgical center services provided to a detainee to services provided by in-network hospitals and ambulatory surgical centers; and
(g) Reimburse an out-of-network renal dialysis facility at either the in-network or the out-of-network rate paid by the insurer for dialysis provided to a detainee.
(5)(a) An insurer may not refuse to credential a health care provider who is an employee or contractor of a county, a local supervisory authority or a detention facility on the basis that the employee or contractor provides the services in a facility operated by the local supervisory authority or in a detention facility.
(b) If an insurer refuses to credential a health care provider who is an employee or contractor of a county, a local supervisory authority or a detention facility, the insurer must give written notice to the provider explaining the reasons for the refusal.
(6) This section does not:
(a) Impair any right of an employer to remove an employee from coverage under a health benefit plan;
(b) Release carriers from the requirement to coordinate benefits for persons who are insured by more than one carrier; or
(c) Limit an insurer’s right to rescind coverage in accordance with ORS 743B.310.
(7) A public body, as defined in ORS 174.109, may not pay health benefit plan premiums on behalf of a detainee. [2014 c.97 §2; 2017 c.329 §1]
Note:
See 743A.001.
Note:
743A.260 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.