justicedao/ipfs_state_laws huggingface dataset:
410-141-3601 MCE Assessment: General Administration (1) The purpose of these rules is to govern the administration, enforcement, and collection of the managed care assessment on MCEs. (2) MCEs shall pay an assessment on the gross amount of premium equivalents received during a calendar quarter: (a) The MCE assessment rate for the period beginning January 1, 2018 and ending December 31, 2019, is 1.5 percent; (b) The MCE assessment rate for the period beginning January 1, 2020 and ending December 31, 2026, is 2 percent. (3) MCE assessments imposed are in addition to and not in lieu of any assessment, surcharge, or other assessment imposed on an MCE. (4) The Authority may develop forms and reporting requirements and change the forms and reporting requirements as necessary to administer, enforce, and collect the assessments. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3605 MCE Assessment: Disclosure of Information (1) Except as otherwise required by law, the Authority may not publicly divulge or disclose the amount of income, expense, or other particulars set forth or disclosed in any report or return required in the administration of the assessments. Particulars include but are not limited to social security numbers, employer numbers, or other organization identification numbers, and any business records required to be submitted to or inspected by the Authority to allow it to determine the amount of any assessments, delinquencies, or deficiencies payable or paid, or otherwise administer, enforce, or collect a health care assessment to the extent that the information would be exempt from disclosure under ORS 192.345(5). (2) The Authority may: (a) Upon request, furnish any MCE or its authorized representative with a copy of the MCE's report filed with the Authority for any quarter, or with a copy of any other information filed by the MCE in connection with the report, or as the Authority considers necessary; (b) Publish information or statistics so classified as to prevent the identification of income or any particulars contained in any report or return; and (c) Disclose and give access to an officer or employee of the Authority or its designee, or to the authorized representatives of the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, the Controller General of the United States, the Oregon Secretary of State, the Oregon Department of Justice, the Oregon Department of Justice Medicaid Fraud Control Unit, and other employees of the state or federal government unless the Authority deems disclosure or access necessary or appropriate for the performance of official duties in the Authority’s administration, enforcement, or collection of these assessments. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3615 MCE Assessment: Filing an Amended Report (1) The claims for refunds or payments of additional MCE assessment must be submitted by the MCE on an Authority approved form. The MCE must provide all information required on the report. The Authority may audit the MCE, request additional information, or request an informal conference prior to granting a refund or as part of its review of a payment of a deficiency. (2) Claim for refund: (a) If the amount of the MCE assessment imposed is less than the amount paid by the MCE and the MCE does not then owe an assessment for any other calendar period, the Authority may refund the overpayment. In no event shall a refund applicable to a particular calendar quarter exceed the assessment amount actually paid by the MCE; (b) The MCE may file a claim for refund on an Authority approved form within 180 days after the end of the calendar quarter to which the claim for refund applies; (c) If there is an amount due from the MCE to the Authority for any past due assessments or penalties, any refund otherwise allowable shall first be applied to the unpaid assessments and penalties, and the Authority shall notify the MCE. (3) Payment of deficiency: (a) If the amount of the MCE assessment is more than the amount paid by the MCE, the MCE may file a corrected report and pay the deficiency at any time. The penalty under OAR 410-141-3635 shall stop accruing after the Authority receives full payment of the total deficiency for the calendar quarter; (b) If there is an error in the determination of the assessment due, the MCE may describe the circumstances of the late additional payment with the late filing of the amended report. The Authority, in its sole discretion, shall determine the penalty for such late additional payments pursuant to OAR 410-141-3635. (4) If the Authority discovers or identifies information that it determines could give rise to the issuance of a notice of proposed action or the issuance of a refund, the Authority shall issue notification pursuant to OAR 410-141-3640. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: 2017 HB 2391 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3620 MCE Assessment: Determining the Date Filed (1) For the purposes of these rules, any reports, requests, appeals, payments, or other response by the MCE must be either: (a) Received by the Authority before the close of business on the date due; or (b) If mailed, postmarked before midnight of the due date. (2) When the due date falls on a Saturday, Sunday, or legal holiday, the response is due on the next business day. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3625 MCE Assessment: Authority to Audit Records (1) The MCE must maintain financial records necessary and adequate to determine the amount of premium equivalents for any period for which an MCE assessment may be due. (2) The Authority may audit the MCE's records at any time for a period of five years following the date the assessment is due to verify or determine the premium equivalents for the MCE. (3) Any audit, finding, or position may be reopened if there is evidence of fraud, malfeasance, concealment, misrepresentation of material fact, omission of income, or collusion either by the MCE or by the MCE and an Authority representative. (4) The Authority may notify the MCE of a potential deficiency or issue a refund based upon its audit findings. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 55-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3630 MCE Assessment: Determining Assessment Liability on Failure to File (1) In the case of a failure by the MCE to file a report or to maintain necessary and adequate records, the Authority shall determine the MCE assessment liability according to the best of its information and belief. (2) Best of its information and belief means the Authority shall use evidence available to the Authority at the time of the determination on which a reasonable person would rely on to determine the assessment. (3) The Authority's determination of assessment liability shall be the basis for the assessment due in any notice of proposed action. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3635 MCE Assessment: Financial Penalty for Failure to File a Report or Failure to Pay Assessment When Due (1) An MCE that fails to file a report or pay an MCE assessment in full when due is subject to a penalty of up to $500 per day of delinquency. The penalty accrues from the date of delinquency, notwithstanding the date of any notice under these rules. (2) The total amount of penalty imposed under this section for each reporting period may not exceed five percent of the assessment for the reporting period for which the penalty is being imposed. (3) In determining the amount of the penalty, the Authority shall consider evidence, such as: (a) The MCE’s history of prior late payments and prior penalties; (b) The MCE’s actions to come into compliance; (c) The occurrence of unforeseeable circumstances against which it would have been unreasonable for the MCE to take precautions and which the MCE cannot avoid even by using its best efforts. Such circumstances include, but are not limited to, a natural disaster (e.g., earthquakes, floods, tornadoes), fires, an act of war (e.g., hostilities, invasion, terrorism, civil disorder), or other circumstances not within the reasonable control of the MCE; (d) In the case of a deficiency due to an error when the MCE files a timely original return and pays the assessment identified in the return, the nature and extent of the error, evidence of prior errors, and the MCE’s explanation of the circumstances related to the error. (4) The Authority shall collect any penalties imposed under this section and deposit the funds in the Health System Fund. (5) Penalties paid under this section are in addition to the MCE assessment. (6) If the Authority determines that an MCE is subject to a penalty under this section, the Authority shall issue a notice of proposed action as described in OAR 410-141-3640. (7) If an MCE requests a contested case hearing, the Director of the Authority, at the Director's sole discretion, may reduce the amount of penalty assessed. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3640 MCE Assessment: Notice of Proposed Action (1) Prior to issuing a notice of proposed action, the Authority shall notify the MCE of a potential deficiency or failure to report that could give rise to the imposition of a penalty. The Authority shall issue a 30-day notification letter within 30 calendar days of the report or payment due date. The MCE shall have 30 calendar days from the date of the notice to respond. The Authority may consider the response, if any, and any amended report under OAR 410-141-3615 in its notice of proposed action. In all cases that the Authority has determined that an MCE has an MCE assessment deficiency or failure to report, the Authority shall issue a notice of proposed action. The Authority may not issue a notice of proposed action if the issue is resolved satisfactorily within 59 days from the date of mailing the 30-day notification letter. (2) The Authority shall issue a notice of proposed action within 60 calendar days from the date of mailing the 30-day notification letter. (3) Contents of the notice of proposed action must include: (a) The applicable calendar quarter; (b) The basis for determining the corrected amount of assessment for the quarter; (c) The corrected assessment due for the quarter as determined by the Authority; (d) The amount of assessment paid for the quarter by the MCE; (e) The resulting deficiency, which is the difference between the amount received by the Authority for the calendar quarter and the corrected amount due as determined by the Authority; (f) Statutory basis for the penalty; (g) Amount of penalty per day of delinquency; (h) Date upon which the penalty began to accrue; (i) Date the penalty stopped accruing or circumstances under which the penalty will stop accruing; (j) The total penalty accrued up to the date of the notice; (k) Instructions for responding to the notice; and (L) A statement of the MCE's right to a hearing. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3645 MCE Assessment: Hearing Process (1) Any MCE that receives a notice of proposed action may request a contested case hearing pursuant to ORS 183.411 through 183.500. (2) The MCE may request a hearing by submitting a written request within 20 days of the date of the notice of proposed action. (3) Prior to the hearing, the MCE shall meet with the Authority for an informal conference: (a) The informal conference may be used to negotiate a written settlement agreement; (b) If the settlement agreement includes a reduction or waiver of penalties, the agreement must be approved and signed by the Director of the Authority. (4) Except as provided in section (5) of this rule, if the case proceeds to a hearing, the administrative law judge shall issue a proposed order with respect to the notice of proposed action. The Authority shall issue a final order. (5) Nothing in this section shall preclude the Authority and the MCE from agreeing to informal disposition of the contested case at any time. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3650 MCE Assessment: Final Order of Payment The Authority shall issue a final order of payment for deficiencies or penalties when: (1) The MCE did not make a timely request for a hearing; (2) Any part of the deficiency or penalty was upheld after a hearing; (3) Upon agreement of the MCE and the Authority. Statutory/Other Authority: ORS 413.042 & ORS 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3655 Assessment: Remedies Available after Final Order of Payment Any amounts due and owing under the final order of payment and any interest thereon may be recovered by Oregon as a debt to the state, using any available legal and equitable remedies which include but are not limited to: (1) Collection activities including but not limited to deducting the amount of the final deficiency or penalty from any sum then or later owed to the MCE by the Authority; (2) Every payment obligation shall bear interest at the statutory rate of interest in ORS 82.010 accruing from the date of the final order of payment and continuing until the payment obligation, including interest, has been discharged. Statutory/Other Authority: ORS 413.042 & 414.025 Statutes/Other Implemented: ORS 414.065 & 2017 HB 2391 History: DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3715 CCO Governance; Public Meetings and Transparency (1) CCOs shall establish, maintain, and operate with a governance structure and community advisory council (CAC) that is consistent with the requirements of ORS 414.625 and applicable health system transformation laws. (2) Consumer Representative means a person serving on a CAC who is currently or was within the previous six months a recipient of medical assistance and is at least 16 years of age, or a parent, guardian, or primary caregiver of an individual who is or was within the previous six months a recipient of medical assistance. (3) Each CCO’s governing body must include: (a) At least one member representing persons that share in the financial risk of the organization; (b) A representative of a dental subcontractor selected by the coordinated care organization; (c) The major components of the health care delivery system; (d) At least two health care providers in active practice, including: (A) A physician licensed under ORS chapter 677 or a nurse practitioner certified under ORS 678.375, whose area of practice is primary care; and (B) A mental health or chemical dependency treatment provider. (e) At least two members from the community at large, to ensure that the organization's decision-making is consistent with the values of the members and the community; and (f) At least two members of the CAC: (A) At least one of the CAC representatives on the CCO’s governing body must be a current CAC Consumer Representative; (B) CAC members of the governing body shall have full voting rights. (4) For purposes of the open meetings requirement in Section 2 of Enrolled 2018 HB 4018, 2018 Oregon Laws Chapter 49, “substantive decision” means a decision made by the governing board of a coordinated care organization (CCO) that relates to: (a) Spending of public funds; (b) The financial risk of the CCO; (c) Provider network development and capacity; or (d) The community advisory council, community health assessment, or community health improvement plan. (5) Substantive decision does not require or include: (a) Disclosure of trade secrets as defined in ORS 192.345; (b) Confidential communications with a lawyer that are privileged under ORS 40.225; (c) Information of a personal nature as described in ORS 192.355; (d) Protected health information as defined in ORS 192.556; (e) Names of Oregon Health Plan consumer members of a community advisory council who request to remain anonymous; (f) Confidential human resource matters; or (g) Provider credentialing, sanctioning, or termination. (6) The term “substantive decision” excludes immaterial technical decisions. Statutory/Other Authority: ORS 413.042 & 414.572 Statutes/Other Implemented: ORS 414.572 & 414.590 History: DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026 DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021 DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020 DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3725 CCO Contract Renewal Notification (1) No later than 134 days prior to the end of a benefit period, the Authority shall provide each CCO with notice of the proposed changes to the terms and conditions of the contract for the next benefit period that the Authority submits to the Centers for Medicare and Medicaid Services for approval. (2) If a CCO declines a contract renewal with the Authority, the CCO must notify the Authority of its intention not to enter into the contract renewal no later than 14 days after the Authority’s notice of proposed changes as described in section (1). (3) A CCO’s notice to the Authority of intent not to enter into a contract renewal terminates the contract at the end of the benefit period unless: (a) The Authority at its discretion requires the contract to remain in force into the next benefit period and be amended as proposed by the Authority until 90 days after the CCO has in accordance with criteria prescribed by the Authority: (A) Notified each of its members and contracted providers of the termination of the contract; (B) Provided to the Authority a plan to transition its members to other CCOs; and (C) Provided to the Authority a plan for closing out its CCO business. (b) The Authority may at its discretion waive compliance with the deadlines stated in sections (2) or (3) if the Authority determines such waiver to be consistent with the effective and efficient administration of the medical assistance program and the protection of medical assistance recipients. (4) A CCO that declines to renew its contract shall comply with the termination and close-out requirements in OAR 410-141-3710, except as otherwise provided in this rule. Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635, 414.651 & 414.652 Statutes/Other Implemented: ORS 414.610 - 414.685 History: DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3740 Traditional Health Workers (1) The Authority requires that all CCO members based on their health needs must have access to certified traditional health workers (THWs) who are part of the member’s care team in clinical and community-based settings to ensure members have improved access to appropriate services. The THWs, as a part of the member’s care team, must participate in processes affecting the member’s care and service needs. THW is defined in OAR 950-060-0010. (2) CCOs shall develop and implement a plan for integrating and utilizing THWs, in accordance with this rule and the CCO contract: (a) THW integration and utilization plans shall include: (A) Information on THW access and usage for CCO members; (B) Benchmarks and measurement of baseline data for integration and utilization of THWs; (C) Evaluations of the CCO’s progress in reaching those benchmarks. (b) THW integration and utilization plans shall be submitted to OHA as required under the contract. (3) CCOs shall establish, based on OHA’s and the Traditional Health Worker Commission guidelines, a THW payment grid that includes alternative and sustainable payment strategies. Each CCO shall provide its THW Payment Grid to OHA. OHA will then post each CCOs Payment Grid to make them publicly available. (4) CCOs shall designate a THW liaison, who shall serve as the central point of contact for THW integration. Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651 Statutes/Other Implemented: ORS 414.610 - 414.685 History: DMAP 102-2024, minor correction filed 06/11/2024, effective 06/11/2024 DMAP 56-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3826 Responsibility for Particular Covered Services Based on Plan Type (1) Coordinated Care Organization (CCO) responsibility for particular Covered Services, as that responsibility is described in the CCO contract, is determined by the member's plan type, as follows: (a) Universally Offered Newborn Nurse Home Visiting Program, commonly known as Family Connects Oregon (FCO): FCO is governed by ORS 433.301 and described in OAR Chapter 333, Division 6; (A) The CCO is responsible for care coordination for FCO services for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB); (B) The Oregon Health Authority's (Authority) fee-for-service (FFS) program is responsible for FCO services for all other plan types that include physical health services. (b) Out-of-Hospital Birth, commonly known as Planned Community Birth (PCB): PCB is described in OAR 410-141-3846; (A) The CCO is responsible for the components of PCB specified in the CCO contract for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB); (B) The Authority’s FFS program is responsible for PCB for all other plan types that include physical health services. The FFS program is also responsible for the components of PCB not specified as the CCO's responsibility in the contract for members for whom the CCO is responsible for physical health services. (c) Health-Related Social Needs (HRSN) Services: HRSN Services are authorized by the Oregon Health Plan 1115 Demonstration Project for 2022-2027, commonly known as the State 1115 Waiver, approved by the Centers for Medicare and Medicaid Services; (A) The CCO is responsible for all HRSN Services for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB), regardless of whether a particular HRSN Service is related to the member's physical health condition or needs; (B) OHA's FFS program is responsible for all HRSN Services for an eligible member if the FFS program is responsible for the member's physical health services, regardless of whether a particular HRSN Service is related to the member's physical health condition or needs. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.591 & 414.631 History: DMAP 36-2024, adopt filed 01/25/2024, effective 02/01/2024