justicedao/ipfs_state_laws huggingface dataset:
ORS Chapter 414 — Medical Assistance

ORS 414.432. Reproductive health services for noncitizens. (1) The Oregon Health Authority shall administer a program to reimburse the cost of medically appropriate services, drugs, devices, products and procedures described in ORS 743A.067, for individuals who can become pregnant and who would be eligible for medical assistance if not for 8 U.S.C. 1611 or 1612. (2) The authority shall provide the medical assistance for pregnant women that is authorized by Title XXI, section 2112, of the Social Security Act (42 U.S.C. 1397ll) for 60 days immediately postpartum. (3) The authority shall collect data and analyze the cost-effectiveness of the services, drugs, devices, products and procedures paid for under this section. (4) The authority, in collaboration with the Department of Consumer and Business Services if necessary, shall explore any and all opportunities to obtain federal financial participation in the costs of implementing this section, including but not limited to waivers or demonstration projects under Title X of the Public Health Service Act or Title XIX or XXI of the Social Security Act. However, the implementation of this section is not contingent upon the authoritys receipt of a waiver or authorization to operate a demonstration project.
ORS Chapter 414 — Medical Assistance

ORS 414.440. [2011 c.207 1; 2013 c.640 1; renumbered 411.447 in 2013] MEDICAL ASSISTANCE BASED ON CONDITION (Hemophilia)
ORS Chapter 414 — Medical Assistance

ORS 414.500. Findings regarding medical assistance for persons with hemophilia. The Legislative Assembly finds that there are citizens of this state who have the disease of hemophilia and that hemophilia is generally excluded from any private medical insurance coverage except in an employment situation under group coverage which is usually ended upon termination of employment. The Legislative Assembly further finds that there is a need for a statewide program for the medical care of persons with hemophilia who are unable to pay for their necessary medical services, wholly or in part. [1975 c.513 1; 1989 c.224 81] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.510. Definitions. (1) Eligible individual means a resident of the State of Oregon over the age of 20 years. (2) Hemophilia services means a program for medical care, including the cost of blood transfusions and the use of blood derivatives. [1975 c.513 2] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.520. Hemophilia services. Within the limit of funds expressly appropriated and available for medical assistance to hemophiliacs, hemophilia services under ORS 414.500 to 414.530 shall be made available to eligible persons as recommended by the Medical Advisory Committee of the Oregon Chapter of the National Hemophilia Foundation. [1975 c.513 3] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.530. When payments not made for hemophilia services. Payments under ORS 414.500 to 414.530 shall not be made for any services which are available to the recipient under any other private, state or federal programs or under other contractual or legal entitlements. However, no provision of ORS 414.500 to 414.530 is intended to limit in any way state participation in any federal program for medical care of persons with hemophilia. [1975 c.513 4] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.532. Definitions for ORS 414.534 to 414.538. As used in ORS 414.534 to 414.538: (1) Medical assistance has the meaning given that term in ORS 414.025. (2) Provider has the meaning given that term in ORS 743B.001. [2001 c.902 1] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.534. Treatment for breast or cervical cancer; eligibility criteria for medical assistance; rules. (1) The Oregon Health Authority shall provide medical assistance, as defined in ORS 414.025, to a woman who: (a) Is found by a provider to be in need of treatment for breast or cervical cancer; (b) Meets the eligibility criteria for the Oregon Breast and Cervical Cancer Program prescribed by rule by the authority; (c) Does not otherwise have creditable coverage, as defined in 42 U.S.C. 300gg(c); and (d) Is 64 years of age or younger. (2) The period of time a woman can receive medical assistance based on the eligibility criteria of subsection (1) of this section: (a) Begins: (A) On the date the Department of Human Services or the Oregon Health Authority makes a formal determination that the woman is eligible for medical assistance in accordance with subsection (1) of this section; or (B) Up to three months prior to the month in which the woman applied for medical assistance if on the earlier date the woman met the eligibility criteria of subsection (1) of this section. (b) Ends when: (A) The woman is no longer in need of treatment; or (B) The department or the authority determines the woman no longer meets the eligibility criteria of subsection (1) of this section. [2001 c.902 2; 2009 c.595 313; 2011 c.555 1; 2013 c.688 75] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.536. Presumptive eligibility for medical assistance for treatment of breast or cervical cancer. (1) If the Department of Human Services or the Oregon Health Authority determines that a woman likely is eligible for medical assistance under ORS
ORS Chapter 414 — Medical Assistance

ORS 414.538. Prohibition on coverage limitations; priority to low-income women. (1) The Department of Human Services and the Oregon Health Authority may not impose income or resource limitations or a prior period of uninsurance on a woman who otherwise qualifies for medical assistance under ORS 414.534 or 414.536. (2) In establishing eligibility requirements for medical assistance under ORS
ORS Chapter 414 — Medical Assistance

ORS 414.540. Rules. The Oregon Health Authority shall adopt rules necessary for the implementation and administration of ORS 414.534 to 414.538. [2001 c.902 5; 2009 c.595 316] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.550. Definitions for ORS 414.550 to 414.565. As used in ORS 414.550 to 414.565: (1) Cystic fibrosis services means a program for medical care, including the cost of prescribed medications and equipment, respiratory therapy, physical therapy, counseling services that pertain directly to cystic fibrosis related health needs and outpatient services including physician, physician assistant, naturopathic physician or nurse practitioner fees, X-rays and necessary clinical tests to insure proper ongoing monitoring and maintenance of the patients health. (2) Eligible individual means a resident of the State of Oregon over 18 years of age. [1985 c.532 2; 2014 c.45 38; 2017 c.356 33] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.555. Findings regarding medical assistance for persons with cystic fibrosis. The Legislative Assembly finds that there are citizens of this state who have the disease of cystic fibrosis and that cystic fibrosis is generally excluded from any private medical insurance coverage except in an employment situation under group coverage which is usually ended upon termination of employment. The Legislative Assembly further finds that there is a need for a statewide program for the medical care of persons with cystic fibrosis who are unable to pay for their necessary medical services, wholly or in part. [1985 c.532 1; 1989 c.224 82] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.560. Cystic fibrosis services. (1) Within the limit of funds expressly appropriated and available for medical assistance to individuals who have cystic fibrosis, cystic fibrosis services under ORS 414.550 to 414.565 shall be made available by the Services for Children with Special Health Needs to eligible individuals as recommended by the review committee. The review committee shall consist of the Cystic Fibrosis Center Director, the Oregon Cystic Fibrosis Chapter Medical Advisory Committee and other recognized and knowledgeable community leaders in the area of health care delivery designated to serve on the review committee by the Director of the Services for Children with Special Health Needs. (2) No member of the review committee shall be held criminally or civilly liable for actions pursuant to this section provided the member acts in good faith, on probable cause and without malice. [1985 c.532 3; 1989 c.224 83] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.565. When payments not made for cystic fibrosis services. Payments under ORS 414.550 to 414.565 shall not be made for any services which are available to the recipient under any other private, state or federal programs or under other contractual or legal entitlements. However, no provision of ORS 414.550 to 414.565 is intended to limit in any way state participation in any federal program for medical care of persons with cystic fibrosis. [1985 c.532 4] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.570. System established. (1) There is established the Oregon Integrated and Coordinated Health Care Delivery System. The system shall consist of state policies and actions that make coordinated care organizations accountable for care management and provision of integrated and coordinated health care for each organizations members, primarily managed within fixed global budgets, by providing care so that efficiency and quality improvements reduce medical cost inflation while supporting the development of regional and community accountability for the health of the residents of each region and community, and while maintaining regulatory controls necessary to ensure quality and affordable health care for all Oregonians. (2) The Oregon Health Authority shall seek input from groups and individuals who are part of underserved communities, including ethnically diverse populations, geographically isolated groups, seniors, people with disabilities and people using mental health services, and shall also seek input from providers, coordinated care organizations and communities, in the development of strategies that promote person centered care and encourage healthy behaviors, healthy lifestyles and prevention and wellness activities and promote the development of patients skills in self-management and illness management. (3) The authority shall regularly report to the Oregon Health Policy Board, the Governor and the Legislative Assembly on the progress of payment reform and delivery system change including: (a) The achievement of benchmarks; (b) Progress toward eliminating health disparities; (c) Results of evaluations; (d) Rules adopted; (e) Customer satisfaction; (f) Use of patient centered primary care homes and behavioral health homes; (g) The involvement of local governments in governance and service delivery; and (h) Other developments with respect to coordinated care organizations. [Formerly
ORS Chapter 414 — Medical Assistance

ORS 414.577. Community health assessment and adoption of community health improvement plan; rules. (1) A coordinated care organization shall collaborate with local public health authorities and hospitals located in areas served by the coordinated care organization to conduct a community health assessment and adopt a community health improvement plan, shared with and endorsed by the coordinated care organization, local public health authorities and hospitals, to serve as a strategic population health and health care services plan for the residents of the areas served by the coordinated care organization, local public health authorities and hospitals. The health improvement plan must include strategies for achieving shared priorities. (2) The coordinated care organization shall post the health improvement plan to the coordinated care organizations website. (3) The Oregon Health Authority may prescribe by rule requirements for health improvement plans and provide guidance for aligning the timelines for the development of the community health assessments and health improvement plans by coordinated care organizations, local public health authorities and hospitals. [2019 c.529 1] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.581. Tribal Advisory Council established; membership; terms. (1) The Tribal Advisory Council is established. The duties of the council are to: (a) Serve as a channel of communication between the coordinated care organizations and Indian tribes in this state regarding the health of tribal communities; and (b) Oversee the tribal liaisons in each coordinated care organization, described in ORS 414.572 (2)(r), and work with coordinated care organizations. (2) The council consists of members who are appointed by each Indian tribe in this state and one member appointed by the members of the council to represent the urban Indian health programs in this state that are operated by urban Indian organizations pursuant to 25 U.S.C. 1651. (3) The term of office of each member of the council is four years, but a member serves at the pleasure of the Indian tribe that appointed the member. Before the expiration of the term of a member, the tribe that appointed the member shall appoint a successor whose term begins on January 1 next following. A member is eligible for reappointment. If there is a vacancy for any cause, the vacancy shall be filled by the appointing tribe to become immediately effective for the unexpired term. (4) Members of the council are not entitled to compensation or reimbursement of expenses and serve as volunteers on the council. (5) The council shall select one of its members as chairperson and another as vice chairperson, for terms and with duties and powers necessary for the performance of the functions of the offices as the council determines. The chairperson shall be responsible for the adoption of bylaws for the council. (6) A majority of the members of the council constitutes a quorum for the transaction of business. (7) The council shall meet at least once every three months at a time and place determined by the council. The council also may meet at other times and places specified by the call of the chairperson or of a majority of the members of the council. (8) The Oregon Health Authority shall provide staff support to the council. [2019 c.529 3] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.592. Requirements for contracts between authority and providers; alignment with behavioral quality health metrics and incentives. Notwithstanding ORS 414.590: (1) Contracts between the Oregon Health Authority and coordinated care organizations or individual providers for the provision of behavioral health services must align with the quality metrics and incentives developed by the Behavioral Health Committee under ORS 413.017 and contain provisions that ensure that: (a) Individuals have easy access to needed care; (b) Services are responsive to individual and community needs; and (c) Services will lead to meaningful improvement in individuals lives. (2) The authority must provide at least 90 days notice of changes needed to contracts that are necessary to comply with subsection (1) of this section.
ORS Chapter 414 — Medical Assistance

ORS 414.595. External quality reviews of coordinated care organizations; limits on documentation and reporting requirements. (1) As used in this section: (a) Coordinated care organization has the meaning given that term in ORS 414.025. (b) Subcontractor means an entity that contracts with a coordinated care organization to provide health care, dental care, behavioral health care or other services to medical assistance recipients enrolled in the coordinated care organization. (2) The Oregon Health Authority shall conduct one external quality review of each coordinated care organization annually. The authority may contract with an external quality review organization to conduct the review. (3) The authority shall compile a standard list of documents that the authority or contracted review organization collects from coordinated care organizations and subcontractors. When requesting information from a coordinated care organization about its subcontractors, the authority or contracted review organization shall inform the coordinated care organization of the documents on the standard list that have been collected from the coordinated care organizations subcontractors in the preceding 12-month period. (4) The authority or a contracted review organization may not request information from a coordinated care organization that is duplicative of or redundant with information previously provided by the coordinated care organization or a subcontractor if the information was provided within the preceding 12-month period and the relevant content of the information has not changed. (5) The authority shall provide a contracted review organization with all information about a coordinated care organization in the authoritys possession as necessary for the contracted review organization to conduct the external quality review. A contracted review organization may not seek information from a coordinated care organization before first requesting the information from the authority. (6) This section does not apply to documents requested, submitted or collected in connection with an audit for or an investigation of fraud, waste or abuse and does not: (a) Prohibit a coordinated care organization from requesting from a subcontractor information required by law or contract; (b) Require the authority or a contracted review organization to disclose to a coordinated care organization any information described in this section collected from a coordinated care organization or a subcontractor; or (c) Permit the authority or a contracted review organization to disclose to a coordinated care organization confidential or proprietary information reported to the authority or contracted review organization by another coordinated care organization or a subcontractor. [Formerly 414.661] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.607. Use and disclosure of member information; access by member to personal health information. (1) The Oregon Health Authority shall ensure the appropriate use of member information by coordinated care organizations, including the use of electronic health information and administrative data that is available when and where the data is needed to improve health and health care through a secure, confidential health information exchange. (2) A member of a coordinated care organization must have access to the members personal health information in the manner provided in 45 C.F.R. 164.524 so the member can share the information with others involved in the members care and make better health care and lifestyle choices. (3) Notwithstanding ORS 179.505, a coordinated care organization, its provider network and programs administered by the Department of Human Services for seniors and persons with disabilities shall use and disclose member information for purposes of service and care delivery, coordination, service planning, transitional services and reimbursement, in order to improve the safety and quality of care, lower the cost of care and improve the health and well-being of the organizations members. (4) A coordinated care organization and its provider network shall use and disclose sensitive diagnosis information including blood-borne infections and other health and mental health diagnoses, within the coordinated care organization for the purpose of providing whole-person care. Individually identifiable health information must be treated as confidential and privileged information subject to ORS 192.553 to 192.581 and applicable federal privacy requirements. Redisclosure of individually identifiable information outside of the coordinated care organization and the organizations providers for purposes unrelated to this section or the requirements of ORS 413.022, 413.032, 414.572,
ORS Chapter 414 — Medical Assistance

ORS 414.609. (3) The authority shall provide notice of a transfer under this section to members that will be affected by the transfer at least 90 days before the scheduled date of the transfer. (4)(a) The authority may not approve the transfer of members under this section if: (A) The transfer results from the termination of a providers contract with a coordinated care organization for just cause; and (B) The coordinated care organization has notified the authority that the providers contract was terminated for just cause. (b) A provider is entitled to a contested case hearing in accordance with ORS chapter 183, on an expedited basis, to dispute the denial of a transfer of members under this subsection. (c) As used in this subsection, just cause means that the contract was terminated for reasons related to quality of care, competency, fraud or other similar reasons prescribed by the authority by rule. (5) The provider and the organization shall be the parties to any contested case proceeding to determine whether the providers contract was terminated for just cause. The authority may award attorney fees and costs to the party prevailing in the proceeding, applying the factors in ORS 20.075. [Formerly 414.647]
ORS Chapter 414 — Medical Assistance

ORS 414.611. Transfer of 500 or more members of coordinated care organization. (1) The Oregon Health Authority may approve the transfer of 500 or more members from one coordinated care organization to another coordinated care organization if: (a) The members provider has contracted with the receiving organization and has stopped accepting patients from or has terminated providing services to members of the transferring organization; and (b) Members are offered the choice of remaining members of the transferring organization. (2) Members may not be transferred under this section until the authority has evaluated the receiving organization and determined that the organization meets criteria established by the authority by rule, including but not limited to criteria that ensure that the organization meets the requirements of ORS
ORS Chapter 414 — Medical Assistance

ORS 414.613. Discrimination based on scope of practice prohibited; appeals; rules. (1) A coordinated care organization may not discriminate with respect to participation in the organization or coverage against any health care provider who is acting within the scope of the providers license or certification under applicable state law. This section does not require that an organization contract with any health care provider willing to abide by the terms and conditions for participation established by the organization. This section does not prevent an organization from establishing varying reimbursement rates based on quality or performance measures. (2) An organization may establish an internal review process for a provider aggrieved under this section, including an alternative dispute resolution or peer review process. An aggrieved provider may appeal the determination of the internal review to the Oregon Health Authority. (3) The authority shall adopt by rule a process for resolving claims of discrimination under this section and, in making a determination of whether there has been discrimination, must consider the organizations: (a) Network adequacy; (b) Provider types and qualifications; (c) Provider disciplines; and (d) Provider reimbursement rates. (4) A prevailing party in an appeal under this section shall be awarded the costs of the appeal. [Formerly 414.646]
ORS Chapter 414 — Medical Assistance

ORS 414.615. [Formerly
ORS Chapter 414 — Medical Assistance

ORS 414.618. [Formerly
ORS Chapter 414 — Medical Assistance

ORS 414.619. Coordination between Oregon Health Authority and Department of Human Services. (1) The Oregon Health Authority and the Department of Human Services shall cooperate with each other by coordinating actions and responsibilities necessary to implement the Oregon Integrated and Coordinated Health Care Delivery System established in ORS 414.570. (2) The authority and the department may delegate to each other any duties, functions or powers that the authority or department are authorized to perform if necessary to carry out this section and ORS 413.022, 414.572, 414.598,
ORS Chapter 414 — Medical Assistance

ORS 414.627. Note: