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

ORS 414.772. Limits on use of step therapy. (1) As used in this section, step therapy means a drug protocol in which the cost of a prescribed drug is reimbursed only if the patient has first tried a specified drug or series of drugs. (2) A coordinated care organization that requires step therapy shall make easily accessible to any provider who is reimbursed by the organization, directly or through a risk-bearing entity, to provide health services to members of the organization, clear explanations of: (a) The clinical criteria for each step therapy protocol; (b) The procedure by which a provider may submit to the organization or risk-bearing entity, the providers medical rationale for determining that a particular step therapy protocol is not appropriate for a particular patient based on the patients medical condition and history; and (c) The documentation, if any, that a provider must submit to the organization or risk-bearing entity for the organization or entity to determine the appropriateness of step therapy for a specific patient. [Formerly 414.637]
ORS Chapter 414 — Medical Assistance

ORS 414.773. Certain conditions on reimbursement of claims for behavioral health services prohibited; assignment of CCO member to primary care provider. (1) A claim for reimbursement for a behavioral health service or a physical health service provided to a medical assistance recipient may not be denied by the Oregon Health Authority or a coordinated care organization on the basis that the behavioral health service and physical health service were provided on the same day or in the same facility, unless required by state or federal law. (2) A coordinated care organization may not require prior authorization for specialty behavioral health services provided to a medical assistance recipient at a behavioral health home or a patient centered primary care home unless permitted to do so by the authority. (3) A coordinated care organization must assign a member of the coordinated care organization to a primary care provider if the member has not selected a primary care provider by the 90th day after enrollment in medical assistance. The coordinated care organization shall provide notice of the assignment to the member and to the primary care provider. (4) A member may select a different primary care provider at any time. (5) Subsection (1) of this section does not apply to coordinated care organizations payments to providers using a value-based payment arrangement or other alternative payment methodology.
ORS Chapter 414 — Medical Assistance

ORS 414.774. Payment for private duty nursing services for medically fragile children; rules. (1) At least once each biennium, the Oregon Health Authority shall conduct a nursing market study for the purpose of determining the appropriate Medicaid reimbursement rates for providers of private duty nursing for medically fragile children. (2) No later than July 1 each year, the authority shall seek approval from the Centers for Medicare and Medicaid Services to adjust the Medicaid reimbursement rates for providers of private duty nursing for medically fragile children, taking into consideration the results of the most recent study described in subsection (1) of this section and applying a cost-of-living adjustment, as determined on an annual basis by the authority by rule. (3) As used in this section: (a) Medically fragile children means children who have a health impairment requiring intensive, specialized services on a daily basis and who meet hospital level of care and the clinical criteria as defined by the Department of Human Services and the authority by rule. (b) Private duty nursing has the meaning given that term by the authority by rule. [2022 c.11 2] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.781. Fee-for-service reimbursement of co-occurring mental health and substance use disorder treatment services. The Oregon Health Authority shall reimburse the cost of co-occurring mental health and substance use disorder treatment services paid for on a fee-for-service basis at an enhanced rate based on: (1) Existing reimbursement codes used for co-occurring disorder treatments; (2) Clinical complexity; and (3) The education level of the provider. [2021 c.667 2] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.782. Reimbursement to ensure access to addiction treatment statewide. The Oregon Health Authority, with the advice of stakeholders and the Alcohol and Drug Policy Commission, may establish minimum rates of reimbursement paid by the authority or coordinated care organizations to addiction treatment providers to ensure medical assistance recipients access, without delay, to all modalities of addiction treatment within each geographic region of this state. [2021 c.667 8] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.805. Liability of individual for medical services received while in custody of law enforcement officer. (1) An individual who receives medical services while in the custody of a law enforcement officer is liable: (a) To the provider of the medical services for the charges and expenses therefor; and (b) To the Oregon Health Authority for any charges or expenses paid by the authority out of the Law Enforcement Medical Liability Account for the medical services. (2) A person providing medical services to an individual described in subsection (1) of this section shall first make reasonable efforts to collect the charges and expenses thereof from the individual before seeking to collect them from the authority out of the Law Enforcement Medical Liability Account. (3)(a) If the provider has not been paid within 45 days of the date of the billing, the provider may bill the authority who shall pay the account out of the Law Enforcement Medical Liability Account. (b) A bill submitted to the authority under this subsection must be accompanied by evidence documenting that: (A) The provider has billed the individual or the individuals insurer or health care service contractor for the charges or expenses owed to the provider; and (B) The provider has made a reasonable effort to collect from the individual or the individuals insurer or health care service contractor the charges and expenses owed to the provider. (c) If the provider receives payment from the individual or the insurer or health care service contractor after receiving payment from the authority, the provider shall repay the authority the amount received from the public agency less any difference between payment received from the individual, insurer or contractor and the amount of the billing. (4) As used in this section: (a) Law enforcement officer means: (A) An officer who is commissioned and employed by a public agency as a peace officer to enforce the criminal laws of this state or laws or ordinances of a public agency; or (B) An authorized tribal police officer as defined in ORS 181A.940. (b) Public agency means the state, a city, university that has established a police department under ORS 352.121 or 353.125, port, school district, mass transit district or county. [1991 c.778 7; 2007 c.71 105; 2009 c.595 342; 2011 c.506 37; 2011 c.644 29,52; 2013 c.180 38,39; 2015 c.174 20] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.807. Oregon Health Authority to pay for medical services related to law enforcement activity; certification of injury. (1)(a) When charges and expenses are incurred for medical services provided to an individual for injuries related to law enforcement activity and subject to the availability of funds in the account, the cost of such services shall be paid by the Oregon Health Authority out of the Law Enforcement Medical Liability Account established in ORS 414.815 if the provider of the medical services has made all reasonable efforts to collect the amount, or any part thereof, from the individual who received the services. (b) When a law enforcement agency involved with an injury certifies that the injury is related to law enforcement activity, the Oregon Health Authority shall pay the provider: (A) If the provider is a hospital, in accordance with current fee schedules established by the Director of the Department of Consumer and Business Services for purposes of workers compensation under ORS 656.248; or (B) If the provider is other than a hospital, 75 percent of the customary and usual rates for the services. (2) After the injured person is incarcerated and throughout the period of incarceration, the Oregon Health Authority shall continue to pay, out of the Law Enforcement Medical Liability Account, charges and expenses for injuries related to law enforcement activities as provided in subsection (1) of this section. Upon release of the injured person from actual physical custody, the Law Enforcement Medical Liability Account is no longer liable for the payment of medical expenses of the injured person. (3) If the provider of medical services has filed a medical services lien as provided in ORS 87.555, the Oregon Health Authority shall be subrogated to the rights of the provider to the extent of payments made by the authority to the provider for the medical services. The authority may foreclose the lien as provided in ORS 87.585. (4) The authority shall deposit in the Law Enforcement Medical Liability Account all moneys received by the authority from: (a) Providers of medical services as repayment; (b) Individuals whose medical expenses were paid by the authority under this section; and (c) Foreclosure of a lien as provided in subsection (3) of this section. (5) As used in this section: (a) Injuries related to law enforcement activity means injuries sustained prior to booking, citation in lieu of arrest or release instead of booking that occur during and as a result of efforts by a law enforcement officer to restrain or detain, or to take or retain custody of, the individual. (b) Law enforcement officer has the meaning given that term in ORS 414.805. [1991 c.778 2; 1993 c.196 9; 2009 c.595 343] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.810. [Formerly
ORS Chapter 414 — Medical Assistance

ORS 414.815. Law Enforcement Medical Liability Account; limited liability; rules; report. (1) The Law Enforcement Medical Liability Account is established separate and distinct from the General Fund. Interest earned, if any, shall inure to the benefit of the account. The moneys in the Law Enforcement Medical Liability Account are appropriated continuously to the Oregon Health Authority to pay expenses in administering the account and paying claims out of the account as provided in ORS 414.807. (2) The liability of the Law Enforcement Medical Liability Account is limited to funds allocated to the account from the Criminal Fine Account, or collected from individuals under ORS 414.805. (3) The authority may contract with persons experienced in medical claims processing to provide claims processing for the account. (4) The authority shall adopt rules to implement administration of the Law Enforcement Medical Liability Account including, but not limited to, rules that establish reasonable deadlines for submission of claims. (5) Each biennium, the Oregon Health Authority shall submit a report to the Legislative Assembly regarding the status of the Law Enforcement Medical Liability Account. Within 30 days of the convening of each odd-numbered year regular session of the Legislative Assembly, the authority shall submit the report to the chair of the Senate Judiciary Committee and the chair of the House Judiciary Committee. The report shall include, but is not limited to, the number of claims submitted and paid during the biennium and the amount of money in the fund at the time of the report. [1991 c.778 1; 1993 c.196 10; 1999 c.1051 256; 2005 c.804 8; 2009 c.595 344; 2011 c.545 49; 2011 c.597 62] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.820. [Formerly
ORS Chapter 414 — Medical Assistance

ORS 414.830. [Formerly
ORS Chapter 414 — Medical Assistance

ORS 414.840. [Formerly
ORS Chapter 414 — Medical Assistance

ORS 414.846. [Formerly 735.726; repealed by 2013 c.681 65 and 2013 c.640 21]
ORS Chapter 414 — Medical Assistance

ORS 414.848. [Formerly 735.728; repealed by 2013 c.681 65 and 2013 c.640 21]
ORS Chapter 414 — Medical Assistance

ORS 414.850. [Formerly
ORS Chapter 414 — Medical Assistance

ORS 414.852. [Formerly 735.731; repealed by 2013 c.681 65 and 2013 c.640 21] HOSPITAL ASSESSMENT
ORS Chapter 414 — Medical Assistance

ORS 414.853. Definitions. As used in ORS 414.853 to 414.869 and 414.900: (1) Charity care means costs for providing inpatient or outpatient care services free of charge or at a reduced charge because of the indigence or lack of health insurance of the patient receiving the care services. (2) Contractual adjustments means the difference between the amounts charged based on the hospitals full established charges and the amount received or due from the payor. (3)(a) Hospital means a hospital licensed under ORS chapter 441. (b) Hospital does not include: (A) Special inpatient care facilities; (B) Hospitals that provide only psychiatric care; (C) Pediatric specialty hospitals providing care to children at no charge; and (D) Public hospitals other than hospitals created by health districts under ORS 440.315 to 440.410. (4) Net revenue: (a) Means the total amount of charges for inpatient or outpatient care provided by the hospital to patients, less charity care, bad debts and contractual adjustments; (b) Does not include revenue derived from sources other than inpatient or outpatient operations, including but not limited to interest and guest meals; and (c) Does not include any revenue that is taken into account in computing a long term care facility assessment under ORS 409.800 to 409.816 and 409.900. (5) Type A hospital has the meaning given that term in ORS 442.470. (6) Type B hospital has the meaning given that term in ORS 442.470. [2003 c.736 1; 2009 c.792 34; 2017 c.538 26] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.854. [Formerly 735.732; repealed by 2013 c.681 65 and 2013 c.640 21]
ORS Chapter 414 — Medical Assistance

ORS 414.855. Hospital assessment; rates; rules. (1) An assessment is imposed on the net revenue of each hospital in this state. The assessment shall be imposed at a rate determined by the Director of the Oregon Health Authority by rule that is the directors best estimate of the rate needed to fund the services and costs identified in ORS 414.869. The rate of assessment shall be imposed on the net revenue of each hospital subject to assessment. The director shall consult with representatives of hospitals before setting the assessment. (2) Each assessment shall be reported on a form prescribed by the Oregon Health Authority and shall contain the information required to be reported by the authority. The assessment form shall be filed with the authority on or before the 45th day following the end of the calendar quarter for which the assessment is being reported. Except as provided in subsection (5) of this section, the hospital shall pay the assessment at the time the hospital files the assessment report. The payment shall accompany the report. (3)(a) To the extent permitted by federal law, aggregate assessments imposed under this section may not exceed the total of the following amounts received by the hospitals that are reimbursed by Medicare based on diagnostic related groups: (A) 30 percent of payments made to the hospitals on a fee-for-service basis by the authority for inpatient hospital services; (B) 41 percent of payments made to the hospitals on a fee-for-service basis by the authority for outpatient hospital services; and (C) Payments made to the hospitals using a payment methodology established by the authority that advances the goals of the Oregon Integrated and Coordinated Health Care Delivery System described in ORS 414.570 (3). (b) Notwithstanding paragraph (a) of this subsection, aggregate assessments imposed under this section on or after July 1, 2015, may exceed the total of the amounts described in paragraph (a) of this subsection to the extent necessary to compensate for any reduction of funding in the legislatively adopted budget for hospital services under ORS 414.591, 414.631 and 414.688 to 414.745. (c) The director may impose a lower rate of assessment on type A hospitals and type B hospitals to take into account the hospitals financial position. (4) Notwithstanding subsection (3) of this section, a hospital is not guaranteed that any additional moneys paid to the hospital in the form of payments for services shall equal or exceed the amount of the assessment paid by the hospital. (5)(a) The authority shall develop a schedule for collection of the assessment for the calendar quarter ending September 30, 2021, that will result in the collection occurring between December 15, 2021, and the time all Medicaid cost settlements are finalized for that calendar quarter. (b) The authority shall prescribe by rule criteria for late payment of assessments. [2003 c.736 2; 2007 c.780 1; 2009 c.828 51; 2009 c.867 17; 2013 c.608 2; 2015 c.16 1; 2017 c.538 27,28,29] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.856. [Formerly 735.733; repealed by 2013 c.681 65 and 2013 c.640 21]
ORS Chapter 414 — Medical Assistance

ORS 414.857. Reduction in rate required by federal law. Notwithstanding ORS 414.855, the Director of the Oregon Health Authority shall reduce the rate of assessment imposed under ORS 414.855 (1) to the maximum rate allowed under federal law if the reduction is required to comply with federal law. [2003 c.736 3; 2013 c.608 3; 2017 c.538 30] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.858. [Formerly 735.734; repealed by 2013 c.681 65 and 2013 c.640 21]
ORS Chapter 414 — Medical Assistance

ORS 414.860. [Formerly 414.090; renumbered 566.360]
ORS Chapter 414 — Medical Assistance

ORS 414.861. [Formerly 735.736; repealed by 2013 c.681 65 and 2013 c.640 21]
ORS Chapter 414 — Medical Assistance

ORS 414.862. [Formerly 735.738; repealed by 2013 c.681 65 and 2013 c.640 21]
ORS Chapter 414 — Medical Assistance

ORS 414.863. repealed January 2, 2031, and applies to net revenues earned by hospitals during the period specified in 414.871. See section 12, chapter 736, Oregon Laws 2003, as amended (note following 414.871). Note: See second note under 414.853.
ORS Chapter 414 — Medical Assistance

ORS 414.865. Audits. The Oregon Health Authority may audit the records of any hospital in this state to determine compliance with ORS 414.853 to 414.869 and 414.900. The authority may audit records at any time for a period of five years following the date an assessment is due to be reported and paid under ORS 414.855. [2003 c.736 7; 2013 c.608 5; 2017 c.538 32] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.867. Deposit of assessments collected to Hospital Quality Assurance Fund. Amounts collected by the Oregon Health Authority from the assessments imposed under ORS 414.855 shall be deposited in the Hospital Quality Assurance Fund established under ORS
ORS Chapter 414 — Medical Assistance

ORS 414.869. Establishment of Hospital Quality Assurance Fund. (1) The Hospital Quality Assurance Fund is established in the State Treasury, separate and distinct from the General Fund. Interest earned by the Hospital Quality Assurance Fund shall be credited to the Hospital Quality Assurance Fund. (2) Amounts in the Hospital Quality Assurance Fund are continuously appropriated to the Oregon Health Authority for the purpose of: (a) Paying refunds due under ORS 414.863; (b) Funding services under ORS 414.591, 414.631 and 414.688 to 414.745, including but not limited to increasing reimbursement rates for inpatient and outpatient hospital services under ORS 414.591, 414.631 and 414.688 to 414.745; (c) Making payments described in ORS 414.855 (3)(a)(C); (d) Making payments to coordinated care organizations to be used to provide additional reimbursement to type A hospitals and type B hospitals to improve and expand access to services for medical assistance recipients, to the extent permitted by federal requirements; and (e) Paying administrative costs incurred by the authority to administer the assessments imposed under ORS 414.855. (3) Except for assessments imposed pursuant to ORS 414.855 (3)(b), the authority may not use moneys from the Hospital Quality Assurance Fund to supplant, directly or indirectly, other moneys made available to fund services described in subsection (2) of this section. [2003 c.736 9; 2005 c.757 2; 2007 c.780 2; 2009 c.828 53; 2009 c.867 19; 2011 c.602 59; 2013 c.608 7; 2017 c.538 33,34,35,36] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.870. [Formerly 735.754; repealed by 2013 c.681 65, 2013 c.640 21 and 2013 c.688 98]
ORS Chapter 414 — Medical Assistance

ORS 414.871. Applicability of hospital assessment. ORS 414.853 to 414.869 and 414.900 apply to net revenues earned by hospitals during a period beginning July 1, 2019, and ending the earlier of September 30, 2025, or the date on which the assessment no longer qualifies for federal financial participation under Title XIX or XXI of the Social Security Act. [2003 c.736 10; 2007 c.780 3; 2009 c.867 20; 2013 c.608 8; 2015 c.16 2; 2017 c.538 37a; 2019 c.2 13] Note: See second note under 414.853. Note: Sections 12 (1) to 14, chapter 736, Oregon Laws 2003, provide: Sec. 12. (1) Sections 1 to 9, chapter 736, Oregon Laws 2003 [414.853 to 414.869 and
ORS Chapter 414 — Medical Assistance

ORS 414.872. [Formerly 735.756; repealed by 2013 c.681 65, 2013 c.640 20,21, 2013 c.688 98 and 2013 c.698 42] MANAGED CARE ORGANIZATION ASSESSMENT
ORS Chapter 414 — Medical Assistance

ORS 414.880. Managed care organization assessment; rate. (1) As used in this section and ORS 414.882 and 414.902: (a) Managed care organization means: (A) A coordinated care organization as defined in ORS 414.025; and (B) A prepaid managed care health services organization as defined in ORS 414.025. (b) Premium equivalent means the payments made to the managed care organization by the Oregon Health Authority for providing health services under ORS chapter 414. (2) No later than 45 days following the end of a calendar quarter, a managed care organization shall pay an assessment at a rate of two percent of the gross amount of premium equivalents received during that calendar quarter. (3) The assessment shall be paid to the authority in a manner and form prescribed by the authority. (4) Assessments received by the authority under this section shall be paid into the State Treasury and credited to the Health System Fund established under section 2, chapter 538, Oregon Laws 2017. (5) The assessment imposed under this section is in addition to and not in lieu of any tax, surcharge or other assessment imposed on a managed care organization. [2017 c.538 9; 2019 c.2 9] Note:
ORS Chapter 414 — Medical Assistance

ORS 414.882. Refund of managed care organization assessment; right to contested case hearing. (1) A managed care organization that has paid an amount that is not required under ORS 414.880 may file a claim for refund with the Oregon Health Authority. (2) Any managed care organization that is aggrieved by an action of the authority taken pursuant to subsection (1) of this section shall be entitled to notice and an opportunity for a contested case hearing under ORS chapter 183. [2017 c.538 11] Note: See note under
ORS Chapter 414 — Medical Assistance

ORS 414.884. added to or made a part of ORS chapter 414 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.