ORS Chapter 414 — Medical Assistance

ORS 414.591. Coordinated care organization contracts; financial reporting; rules. (1) The Oregon Health Authority shall use, to the greatest extent possible, coordinated care organizations to provide fully integrated physical health services, chemical dependency and mental health services and oral health services. This section, and any contract entered into pursuant to this section, does not affect and may not alter the delivery of Medicaid-funded long term care services. (2) The authority shall execute contracts with coordinated care organizations that meet the criteria adopted by the authority under ORS 414.572. Contracts under this subsection are not subject to ORS chapters 279A and 279B, except ORS 279A.250 to 279A.290 and 279B.235. (3)(a) The authority shall establish financial reporting requirements for coordinated care organizations, consistent with ORS 415.115 and 731.574, no less than 90 days before the beginning of the reporting period. The authority shall prescribe requirements and procedures for financial reporting that: (A) Enable the authority to verify that the coordinated care organizations capital, surplus, reserves and other financial resources are adequate to ensure against the risk of insolvency; (B) Include information on the three highest executive salary and benefit packages of each coordinated care organization; (C) Require quarterly reports to be filed with the authority by May 31, August 31 and November 30; (D) In addition to the annual audited financial statement required by ORS 415.115, require an annual report to be filed with the authority by April 30 following the end of the period for which data is reported; and (E) Align, to the greatest extent practicable, with the National Association of Insurance Commissioners reporting forms to reduce the administrative costs of coordinated care organizations that are also regulated by the Department of Consumer and Business Services or have affiliates that are regulated by the department. (b) The authority shall provide information to coordinated care organizations about the reporting standards of the National Association of Insurance Commissioners and provide training on the reporting standards to the staff of coordinated care organizations who will be responsible for compiling the reports. (4) The authority shall hold coordinated care organizations, contractors and providers accountable for timely submission of outcome and quality data, including but not limited to data described in ORS 442.373, prescribed by the authority by rule. (5) The authority shall require compliance with the provisions of subsections (3) and (4) of this section as a condition of entering into a contract with a coordinated care organization. A coordinated care organization, contractor or provider that fails to comply with subsection (3) or (4) of this section may be subject to sanctions, including but not limited to civil penalties, barring any new enrollment in the coordinated care organization and termination of the contract. (6)(a) The authority shall adopt rules and procedures to ensure that if a rural health clinic provides a health service to a member of a coordinated care organization, and the rural health clinic is not participating in the members coordinated care organization, the rural health clinic receives total aggregate payments from the members coordinated care organization, other payers on the claim and the authority that are no less than the amount the rural health clinic would receive in the authoritys fee-for-service payment system. The authority shall issue a payment to the rural health clinic in accordance with this subsection within 45 days of receipt by the authority of a completed billing form. (b) Rural health clinic, as used in this subsection, shall be defined by the authority by rule and shall conform, as far as practicable or applicable in this state, to the definition of that term in 42 U.S.C. 1395x(aa)(2). (7) The authority may contract with providers other than coordinated care organizations to provide integrated and coordinated health care in areas that are not served by a coordinated care organization or where the organizations provider network is inadequate. Contracts authorized by this subsection are not subject to ORS chapters 279A and 279B, except ORS 279A.250 to 279A.290 and 279B.235. (8) The aggregate expenditures by the authority for health services provided pursuant to this chapter may not exceed the total dollars appropriated for health services under this chapter. (9) Actions taken by providers, potential providers, contractors and bidders in specific accordance with this chapter in forming consortiums or in otherwise entering into contracts to provide health care services shall be performed pursuant to state supervision and shall be considered to be conducted at the direction of this state, shall be considered to be lawful trade practices and may not be considered to be the transaction of insurance for purposes of the Insurance Code. (10) Health care providers contracting to provide services under this chapter shall advise a patient of any service, treatment or test that is medically necessary but not covered under the contract if an ordinarily careful practitioner in the same or similar community would do so under the same or similar circumstances. (11) A coordinated care organization shall provide information to a member as prescribed by the authority by rule, including but not limited to written information, within 30 days of enrollment with the coordinated care organization about available providers. (12) Each coordinated care organization shall work to provide assistance that is culturally and linguistically appropriate to the needs of the member to access appropriate services and participate in processes affecting the members care and services. (13) Each coordinated care organization shall provide upon the request of a member or prospective member annual summaries of the organizations aggregate data regarding: (a) Grievances and appeals; and (b) Availability and accessibility of services provided to members. (14) A coordinated care organization may not limit enrollment in a geographic area based on the zip code of a member or prospective member. [Formerly 414.651]