ORS Chapter 414 — Medical Assistance

ORS 414.572. Coordinated care organizations; rules. (1) The Oregon Health Authority shall adopt by rule the qualification criteria and requirements for a coordinated care organization and shall integrate the criteria and requirements into each contract with a coordinated care organization. Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two. Coordinated care organizations may contract with counties or with other public or private entities to provide services to members. The authority may not contract with only one statewide organization. A coordinated care organization may be a single corporate structure or a network of providers organized through contractual relationships. The criteria and requirements adopted by the authority under this section must include, but are not limited to, a requirement that the coordinated care organization: (a) Have demonstrated experience and a capacity for managing financial risk and establishing financial reserves. (b) Meet the following minimum financial requirements: (A) Maintain restricted reserves of $250,000 plus an amount equal to 50 percent of the coordinated care organizations total actual or projected liabilities above $250,000. (B) Maintain capital or surplus of not less than $2,500,000 and any additional amounts necessary to ensure the solvency of the coordinated care organization, as specified by the authority by rules that are consistent with ORS 731.554 (6), 732.225, 732.230 and 750.045. (C) Expend a portion of the annual net income or reserves of the coordinated care organization that exceed the financial requirements specified in this paragraph on services designed to address health disparities and the social determinants of health consistent with the coordinated care organizations community health improvement plan and transformation plan and the terms and conditions of the Medicaid demonstration project under section 1115 of the Social Security Act (42 U.S.C. 1315). (c) Operate within a fixed global budget and other payment mechanisms described in subsection (6) of this section and spend on primary care, as defined by the authority by rule, at least 12 percent of the coordinated care organizations total expenditures for physical and mental health care provided to members, except for expenditures on prescription drugs, vision care and dental care. (d) Develop and implement alternative payment methodologies that are based on health care quality and improved health outcomes. (e) Coordinate the delivery of physical health care, behavioral health care, oral health care and covered long-term care services. (f) Engage community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the coordinated care organizations members and in the coordinated care organizations community. (2) In addition to the criteria and requirements specified in subsection (1) of this section, the authority must adopt by rule requirements for coordinated care organizations contracting with the authority so that: (a) Each member of the coordinated care organization receives integrated person centered care and services designed to provide choice, independence and dignity. (b) Each member has a consistent and stable relationship with a care team that is responsible for comprehensive care management and service delivery. (c) The supportive and therapeutic needs of each member are addressed in a holistic fashion, using patient centered primary care homes, behavioral health homes or other models that support patient centered primary care and behavioral health care and individualized care plans to the extent feasible. (d) Members receive comprehensive transitional care, including appropriate follow-up, when entering and leaving an acute care facility or a long term care setting. (e) Members are provided: (A) Assistance in navigating the health care delivery system; (B) Assistance in accessing community and social support services and statewide resources; (C) Meaningful language access as required by federal and state law including, but not limited to, 42 U.S.C. 18116, Title VI of the Civil Rights Act of 1964, Title VI Guidance issued by the United States Department of Justice and the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care as issued by the United States Department of Health and Human Services; and (D) Qualified health care interpreters or certified health care interpreters listed on the health care interpreter registry, as those terms are defined in ORS 413.550. (f) Services and supports are geographically located as close to where members reside as possible and are, if available, offered in nontraditional settings that are accessible to families, diverse communities and underserved populations. (g) Each coordinated care organization uses health information technology to link services and care providers across the continuum of care to the greatest extent practicable and if financially viable. (h) Each coordinated care organization complies with the safeguards for members described in ORS 414.605. (i) Each coordinated care organization convenes a community advisory council that meets the criteria specified in ORS 414.575. (j) Each coordinated care organization prioritizes working with members who have high health care needs, multiple chronic conditions or behavioral health conditions and involves those members in accessing and managing appropriate preventive, health, remedial and supportive care and services, including the services described in ORS 414.766, to reduce the use of avoidable emergency room visits and hospital admissions. (k) Members have a choice of providers within the coordinated care organizations network and that providers participating in a coordinated care organization: (A) Work together to develop best practices for care and service delivery to reduce waste and improve the health and well-being of members. (B) Are educated about the integrated approach and how to access and communicate within the integrated system about a patients treatment plan and health history. (C) Emphasize prevention, healthy lifestyle choices, evidence-based practices, shared decision-making and communication. (D) Are permitted to participate in the networks of multiple coordinated care organizations. (E) Include providers of specialty care. (F) Are selected by coordinated care organizations using universal application and credentialing procedures and objective quality information and are removed if the providers fail to meet objective quality standards. (G) Work together to develop best practices for culturally and linguistically appropriate care and service delivery to reduce waste, reduce health disparities and improve the health and well-being of members. (L) Each coordinated care organization reports on outcome and quality measures adopted under ORS 413.022 and participates in the health care data reporting system established in ORS 442.372 and 442.373. (m) Each coordinated care organization uses best practices in the management of finances, contracts, claims processing, payment functions and provider networks. (n) Each coordinated care organization participates in the learning collaborative described in ORS 413.259 (3). (o) Each coordinated care organization has a governing body that complies with ORS