justicedao/ipfs_state_laws huggingface dataset:
409-065-0000 Purpose Senate Bill 889 (2019 Legislature) established the Sustainable Health Care Cost Growth Target Program within the Oregon Health Authority and House Bill 2081 (2021 Legislature) authorized accountability mechanisms to achieve a sustainable rate of health care cost growth. These rules (OAR 409-065-0000 to 409-065-0055) define reporting and accountability requirements to the Oregon Health Authority. Submitted data will inform the work of the Sustainable Health Care Cost Growth Target Program as it reports on health care cost drivers and trends. Statutory/Other Authority: ORS 442.386 Statutes/Other Implemented: ORS 442.385 & 442.386 History: OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024 OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021 OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021
409-065-0010 General Reporting Requirements for Mandatory Reporters (1) Determination of a mandatory reporter. (a) For payers or licensed third-party administrators, the Authority must identify mandatory reporters using health insurance enrollment data from DCBS and Medicaid enrollment reports from the Authority. (A) The Authority must aggregate the most recent four (4) quarters of data. (B) The Authority must calculate the mean total lives for each payer and licensed third-party administrator for each reporting year. (b) All payers or licensed third-party administrators with calculated mean total lives of 1,000 or more across all lines of business must be mandatory reporters. (c) The Authority must make annual mandatory reporter determinations and provide written notification no later than April 30 of each year to all mandatory reporters subject to the reporting requirements of OAR 409-065-0010 to 409-065-0030 for the current year. (2) All Mandatory reporters must submit data files in a manner and form as prescribed by 409-065-0015. (3) The Authority must identify voluntary reporters that have calculated mean total lives of 1,000 or higher across all lines of business and invite them to participate in the annual data submission. (4) New mandatory reporters submitting for the first time, or mandatory reporters that did not submit data in the previous year, must attend a data submission training session prior to their first submission of data, as provided by the Authority. (5) A mandatory reporter may submit a waiver of reporting in compliance with OAR 409-065-0020. (6) An entity may appeal the Authority’s determination of mandatory reporter status pursuant to the procedure outlined in OAR 409-065-0050. Statutory/Other Authority: ORS 442.386 Statutes/Other Implemented: ORS 442.385 & 442.386 History: OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024 OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021 OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021
409-065-0015 Data Submission Requirements (1) Annual data submission dates are provided in the CGT-2; the data submission dates must not be before September 1st of each year. (2) Annual data submissions must be submitted on the CGT-1 in accordance with instructions published by the Authority in the CGT-2. (3) Mandatory reporters, and voluntary reporters who agree to participate, must submit data files for all required lines of business as defined in the CGT-2 and OAR 409-065-0015 (3)(a). Mandatory and voluntary reporters may submit data files for the voluntary lines of business and may not submit data files for any excluded lines of business as defined in the CGT-2 and OAR 409-065-0015 (3)(b). Mandatory and voluntary reporters must submit data files without subtracting or adjusting any costs including those listed as reasonable causes of cost growth in OAR 409-065-0035. (a) Required lines of business include: (A) Commercial; (B) Medicare; and (C) Medicaid. (b) Excluded lines of business include: (A) Accident policy; (B) Disability policy; (C) Hospital indemnity policy; (D) Long-term care insurance; (E) Medicare supplemental insurance; (F) Stand-alone prescription drug plans; (G) Specific disease policy; (H) Stop-loss plans; (I) Supplemental insurance that pays deductibles, copays or coinsurance; (J) Vision-only insurance; (K) Workers compensation; and (L) Dental-only insurance. (c) A mandatory reporter that contracts with another entity remains responsible for reporting all required lines of business. If the mandatory reporter elects to have the data reported by a contracted entity, the mandatory reporter must notify the Authority and provide contact information for the contracted entity. (4) The Authority must validate the submitted data on the CGT-1 in accordance with CGT-2. (5) The Authority must review a submitted CGT-1 within 90 calendar days after confirming receipt. If the Authority finds errors during its review through edit checks or validation, the Authority must issue a notice of the error(s) to the mandatory or voluntary reporter, as applicable. (a) Mandatory reporters must correct and resubmit data to the Authority within 30 calendar days after the date the Authority issues notice of the error(s). The Authority will consider the annual data submission complete after the mandatory reporter submits all necessary corrections and resubmissions, as determined by the Authority. (b) Voluntary reporters may correct and resubmit data to the Authority, as applicable. Statutory/Other Authority: ORS 442.386 Statutes/Other Implemented: ORS 442.385 & 442.386 History: OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024 OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021 OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021
409-065-0020 Data Submission Waivers (1) The Authority may grant a waiver or deadline extension to the data submission requirements in OAR 409-065-0015. (2) If a mandatory reporter believes they are eligible for a waiver of all or part of the data submission requirements they may request a waiver of reporting requirements by submitting a CGT-3 to the Authority. (a) Mandatory reporters must submit a CGT-3 form to request a waiver as follows: (A) To request a partial waiver to the data submission requirements, mandatory reporters must submit a completed CGT-3 form to the Authority no later than 14 calendar days before the annual reporting deadline. (B) To request a waiver of all data submission or validation requirements, mandatory reporters must submit a completed CGT-3 form to the Authority no later than 60 calendar days before the annual reporting deadline. (b) The Authority must approve or deny the waiver request and provide written notification to the requestor within 14 calendar days following receipt of the request. (3) If a mandatory reporter believes they need a deadline extension for the data submission requirements, they may request a deadline extension by submitting CGT-3 form to the Authority. (a) Mandatory reporters may submit a CGT-3 form to request a deadline extension as follows: (A) To request a deadline extension for data submission, mandatory reporters must submit a completed CGT-3 form to the Authority no later than 14 calendar days before the annual reporting deadline. (B) To request a deadline extension for data correction, resubmission, or validation requirements, mandatory reporters must submit a completed CGT-3 form to the Authority no later than seven calendar days after the date of the notice issued by the Authority requesting data correction, resubmission, or validation. (b) The Authority must issue its determination on a mandatory reporter’s CGT-3 deadline extension request within 14 calendar days after the date of the request. (4) If the Authority denies a CGT-3 request, the mandatory reporter may request a contested case hearing following the procedure outlined in OAR 409-065-0050. (5) The Authority will only grant CGT-3 requests for one data submission cycle at a time. Statutory/Other Authority: ORS 442.386 Statutes/Other Implemented: ORS 442.385 & 442.386 History: OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024 OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021 OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021
409-065-0025 Data Submission Compliance and Enforcement (1) Unless the Authority approves a waiver submitted pursuant to OAR 409-065-0020, a mandatory reporter fails to comply with general data submission requirements under OAR 409-065-0015 when a mandatory reporter: (a) Fails to submit data files by the specified submission date, or (b) Fails to submit data files for a required line of business. (2) Unless the Authority approves a waiver submitted pursuant to OAR 409-065-0020, a mandatory reporter fails to comply with data file requirements when a mandatory reporter: (a) Submits a data file in an unapproved layout; (b) Submits a data element in an unapproved format; (c) Submits a data element with unapproved coding; (d) Fails to submit a required data element; or (e) Fails to comply with validation and quality control efforts, including resubmitting or correcting data in a timely fashion as requested by the Authority. (3) The Authority must issue a notice of noncompliance to mandatory reporters before imposing a civil penalty in accordance with section (4) of this rule. Mandatory reporters must come into compliance within 30 calendar days from the date the Authority issues its notice of noncompliance. (4) The Authority may impose a civil penalty on a mandatory provider for a violation of this rule if the mandatory reporter does not come into compliance as required under section (3) of this rule. Pursuant to ORS 442.993, the Authority adopts the following schedule of civil penalties: (a) Up to $500 per day starting from the data of the notice in section (3) of this rule for each violation of OAR 409-065-0025(1)(a) through (b); (b) Up to $400 per day starting from the data of the notice in section (3) of this rule for each violation of OAR 409-065-0025(2)(a) through (e). (5) Civil penalties must be imposed in the manner provided in ORS 183.745. Statutory/Other Authority: ORS 442.386 & 442.993 Statutes/Other Implemented: ORS 442.385, 442.386 & 442.993 History: OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024 OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021 OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021
409-065-0029 Automatic Change in Monetary Limits for Frontline Workers Monetary limits for frontline workers will automatically change, without the necessity for amending such rules, by annual percentage increase (if any) in the Consumer Price Index for All Urban Consumers, West Region (All Items), as published by the Bureau of Labor Statistics of the United States Department of Labor, as determined by the Authority. The Authority must calculate the changes and post changes by June 1 of each year. Statutory/Other Authority: ORS 442.386 Statutes/Other Implemented: ORS 442.386 History: OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024
409-065-0030 Data Access and Disclosure (1) The Authority may use and disclose data submitted to it under these rules in accordance with ORS 442.386 and any applicable Authority policies and state and federal rules, regulations, and statutes. (2) The Authority may disclose data to payers or provider organizations in the administration of the program, excluding any information determined to be confidential pursuant to OAR 409-065-0042, regarding the determination of a reasonable cause of cost growth. (3) The Authority may provide a public use data set in compliance with applicable Authority policies and state and federal rules and regulations. Statutory/Other Authority: ORS 442.386 Statutes/Other Implemented: ORS 442.385 & 442.386 History: OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024 OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021 OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021
409-065-0042 Confidential Information (1) An entity that submits information to the Authority may claim portions of the information a trade secret and exempt from disclosure under ORS 192.311 to 192.478. (a) The entity must submit two versions of such materials to the Authority: (A) One must be marked as “CONFIDENTIAL” and must contain the full unredacted version of the document. (B) The second must be marked as “PUBLIC” and must contain a redacted version of the document (from which the confidential portions have been removed or obscured) and must be posted on the Program website. (b) An entity claiming confidentiality must include a redaction log that provides a reasonably detailed statement of the grounds on which confidentiality is claimed and the reasoning for such redaction. This redaction log must be posted on the Program website. Statutory/Other Authority: ORS 442.386 Statutes/Other Implemented: ORS 442.386 History: OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024
409-065-0055 Annual Public Hearings (1) The cost growth target program must hold an annual public hearing regarding the growth in total health care expenditures in relation to the health care cost growth in the previous calendar year. The director of the Authority may request any payer or provider organization that is found to be a significant contributor to health care cost growth in the state or exceeds the cost growth target with statistical confidence, as defined by the Authority, and without reasonable cause, as defined in OAR 409-065-0035, during the performance year, to participate in an annual public hearing. If the payer or provider organization does not commit to participating in the annual public hearing, the director of the Authority may require participation. The Authority must notify the payer or provider organization of the requirement to participate. Each such payer or provider organization that is required to participate in such hearing must provide testimony on issues identified by the director of the Authority and provide additional information on actions taken to reduce such payer's or provider organization’s contribution to state-wide and market-level health care costs. (2) The director of the Authority may request that any other entity, including but not limited to a drug manufacturer or pharmacy benefit manager, that is found to be a significant contributor to health care cost growth in this state during the performance year participate in such hearing. If the entity does not commit to participating in the annual public hearing, the director of the Authority may require participation. Any other entity that is required to participate in such hearing must provide testimony on issues identified by the director of the Authority and provide additional information on actions taken to reduce such other entity's contribution to state-wide health care costs. Statutory/Other Authority: ORS 413.037 & 442.386 Statutes/Other Implemented: ORS 442.386 History: OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024
409-070-0000 Scope and Purpose (1) OAR 409-070-0000 through OAR 409-070-0085 are adopted pursuant to authority in ORS 415.501. OAR 409-070-0000 through OAR 409-070-0085 govern the procedure for filing notices of material change transactions and the criteria and procedure for review of material change transactions. (2) Pursuant to ORS 415.501(1), the purpose of these rules is to promote the public interest and to advance the goals of the Authority and the Oregon Integrated and Coordinated Care Delivery System described in ORS 414.018 and ORS 414.570. (3) The Authority and the Department must aim to achieve the following goals when reviewing proposed material change transactions: (a) Improving health, increasing the quality, reliability, availability and continuity of care and reducing the cost of care for people living in Oregon. (b) Achieving health equity and equitable access to care. (c) A process that is transparent, robust and informed by the public, including the local community, through meaningful engagement. (d) Using resources wisely and in collaboration with the Department when applicable. Statutory/Other Authority: ORS 415.501 Statutes/Other Implemented: ORS 413.181 & 415.500 - 415.900 History: OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024 OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022
409-070-0015 Materiality Standard (1) Pursuant to ORS 415.500(6) and (9) and ORS 415.501(4), a covered transaction under OAR 409-070-0010 is a material change transaction and must be subject to review under these rules if: (a) At least one party to the transaction had average annual revenue of $25 million or more in the party's three most recent fiscal years; and (b) Another party to the transaction: (A) Had average annual revenue of $10 million or more in that party's three most recent three fiscal years; or (B) If such party is a newly organized legal entity, is projected to have at least $10 million in revenue over its first full year of operation at normal levels of utilization or operation. A party is a newly organized legal entity if the entity is an existing entity whose form of ownership is changed in connection with the transaction. Changes in the form of ownership include but are not limited to a change from physician-owned to private equity-owned and publicly-held to a privately-held form of ownership. (2) A covered transaction under OAR 409-070-0010 that qualifies as material under paragraph (1) of this rule must be subject to review under these rules notwithstanding that the transaction involves a health care entity in this state and an out-of-state entity if the transaction may increase the price of health care services or limit access to health care services in this state. (a) For the purpose of these rules, an entity is considered in-state if it: (A) is based or domiciled in Oregon; (B) owns or operates business locations in Oregon; (C) is registered with the Oregon Secretary of State to conduct business in Oregon; (D) is engaged in profit-seeking activity in Oregon; or (E) provides health care services to residents of Oregon. (b) An entity that is domiciled outside of Oregon and registered to conduct business in Oregon may be considered out-of-state under these rules if: (A) the entity served no more than 100 Oregon residents annually for each of the three previous fiscal years; or (B) the entity is a health care insurer, the proposed transaction involves only health care insurers, and the combined market share held by the health care insurer immediately after the completion of the proposed transaction does not exceed five percent of the total market share in any market. Statutory/Other Authority: ORS 415.501 Statutes/Other Implemented: ORS 415.500 - 415.900 History: OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024 OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022 OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022
409-070-0035 Material Change Transaction Involving a Domestic Health Insurer (1) The Authority must review a proposed material change transaction for an activity described in ORS 732.521 with respect to a domestic health insurer pursuant to the procedures set forth in OAR 409-070-0055 (preliminary review) and, if applicable, OAR 409-070-0060 (comprehensive review). (a) At the conclusion of the preliminary review period provided in OAR 409-070-0055, the Authority must report to the Department: (A) The results of the Authority's review under OAR 409-070-0055; or (B) That the Authority intends to review the proposed material change transaction under OAR 409-070-0060, including whether the Authority intends to appoint a community review board pursuant to OAR 409-070-0062. (b) If the Authority reviews the proposed material change transaction under OAR 409-070-0060, it must promptly provide to the Department the results of its review not later than the period specified in OAR 409-070-0060. (c) The periods for review under OAR 409-070-0055 and OAR 409-070-0060 must begin running upon the Authority's receipt from the Department of a complete notice of material change transaction as required under OAR 409-070-0030(1)(b) and subject to OAR 409-070-0045. (2) The Department must receive and consider the results of the Authority's review prior to entering its decision on the proposed material change transaction. The Department must coordinate with the Authority to incorporate the results of the Authority's review into the final determination issued by the Department pursuant to ORS 732.528 or ORS 732.542, as applicable. In the event the proposed material change transaction is deemed exempt from review or is otherwise not reviewed by the Department but remains subject to review by the Authority, the Authority must proceed with its review of the transaction pursuant to OAR 409-070-0045, OAR 409-070-0055, and OAR 409-070-0060 and must render the final determination. (3) The filing of a notice of material change transaction that is subject to review by each of the Authority and the Department under this rule shall be deemed to include an express consent to the sharing between the Authority and the Department of confidential material submitted in connection with such proposed material change transaction. Confidential material provided by any party in connection with such proposed material change transaction must be maintained as confidential material in accordance with ORS 705.137 and ORS 415.103, and OAR 409-070-0070, and may be shared between the Authority and the Department pursuant to ORS 705.137(3)(b) & (c) and (4), and ORS 192.355(1), (9), (10) and (31), as applicable. Such sharing shall not constitute a waiver of the confidential status of such materials. Statutory/Other Authority: ORS 415.501 Statutes/Other Implemented: ORS 415.500 - 415.900 History: OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024 OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022 OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022
409-070-0040 Material Change Transaction Involving a Charitable Organization or Hospital (1) The parties must provide a copy of any notice of a material change transaction involving a health care entity that is, controls, or is controlled by a charitable organization to the Charitable Activities Section of the Oregon Department of Justice in addition to the notice submitted to the Authority in accordance with OAR 409-070-0030(1)(a). (2) To the extent applicable, a health care entity involved in a material change transaction remains subject to the charitable registration and reporting requirements contained in ORS 128.610 et seq. and to the Attorney General notification and other provisions contained in ORS Chapter 65, the Nonprofit Corporations Act, including Attorney General review and approval of hospital transfers within the scope of ORS 65.803. (3) The filing of a notice of material change transaction that is subject to review by each of the Authority and the Charitable Activities Section of the Oregon Department of Justice under this rule must be deemed to include an express consent to the sharing between the Authority and the Department of Justice of confidential material submitted in connection with such proposed material change transaction. The Authority may consult with the Department of Justice regarding the potential effects of a proposed material change transaction on the charitable organization or its assets or charitable assets held by a health care entity. Confidential material provided by any party in connection with such proposed material change transaction shall be maintained as confidential material in accordance with OAR 409-070-0070. Such sharing shall not constitute a waiver of the confidential status of such materials. (4) The Authority may condition its approval of a material change transaction involving a health care entity that is, controls, or is controlled by a charitable organization on a required filing with, and approval by, the Charitable Activities Section of the Oregon Department of Justice. Statutory/Other Authority: ORS 415.501 Statutes/Other Implemented: ORS 415.500 - 415.900 History: OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024 OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022