Providence Health Plan v. Allen

Under ORS 750.005(4)(a), an entity is a health care service contractor when it is “‘intimately connected with a group of doctors [and hospitals] licensed by this state’ and provides all the medical benefits to the plan’s participants.”

Petitioner appealed from a grant of summary judgment in favor of Respondent. Petitioner assigned error to the trial court’s determination that Petitioner is a health insurer and therefore required to follow the reimbursement statutes governing insurers. On appeal, Petitioner argued that as a health care service contractor it is subject to the Insurance Code under ORS 744.700(3). However, in the present case, Petitioner was functioning as a third-party administrator for a self-insured health plan and was therefore exempt from the Insurance Code under ORS 744.704(1)(e). In response, Respondent argued that the agreement between Petitioner and the self-insurer identified Petitioner as a health care service contractor, subjecting Petitioner to the Insurance Code, including the reimbursement statutes. Under ORS 750.005(4)(a), an entity is a health care service contractor when it is “‘intimately connected with a group of doctors [and hospitals] licensed by this state’ and provides all the medical benefits to the plan’s participants.” The Court held that Petitioner was a health care contractor, as specified by the contract with the self-insurer and as defined by ORS 750.005(4)(a). As a health care contractor, the Court held that Petitioner must follow the reimbursement statutes as required by ORS 750.055(1).