reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 55 - PATIENT-CENTERED PRIMARY CARE HOME PROGRAM › Section 409-055-0070 - Compliance

Current through Register Vol. 63, No. 7, July 1, 2024
(1) If the
			 Authority finds that the practice is not in compliance with processes as
			 attested to, the Authority shall issue a written warning requiring the practice
			 to submit an improvement plan within 90 days of the date of the written
			 warning. The improvement plan must include a description of the practice's plan
			 and timeline to correct the deficiency and proposed documentation or other
			 demonstration that would verify the practice is in compliance.
(2) The Authority shall review the
			 improvement plan and any documentation the practice submits in accordance with
			 the deficiency, and if remedied, no further action shall be taken.
(3) If a practice fails to submit the
			 improvement plan or move into compliance within 90 days of the date of the
			 written warning, the Authority may issue a letter of non-compliance and amend
			 the practice's PCPCH recognition to reflect the appropriate Tier level or
			 revoke its PCPCH status.
(4) If the
			 Authority amends a practice's tier level or revokes PCPCH status this
			 information shall be made available to the Health Systems Division (Division),
			 the coordinated care or managed care plans, and insurance carriers.
(5) A practice that has had its PCPCH status
			 revoked may have it reissued after reapplying for recognition and when the
			 Authority determines that compliance with PCPCH Standards has been achieved
			 satisfactorily.
(6) The Authority
			 may revoke a practice's PCPCH recognition in the following circumstances:
(a) The practice submits false quantitative
			 data elements or falsely attests to meeting PCPCH recognition criteria;
(b) The practice misrepresents its
			 PCPCH status or tier level;
(c) The
			 practice is not compliant with a verification review as described in OAR
			 409-055-0060.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 55 - PATIENT-CENTERED PRIMARY CARE HOME PROGRAM › Section 409-055-0080 - Insurance Carrier, Managed Care Plan, and Public Stakeholder Communication

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The Authority shall develop a system for making recognized PCPCH Tier status
			 recognition information available to insurance carriers and managed care
			 organizations.
(2) The Authority
			 shall maintain and update monthly the recognized PCPCH Tier status lists.
(3) The Authority shall develop a
			 system for making recognized PCPCH practice names available to the general
			 public through the Program website.
(4) Practices that do not wish to have their
			 name listed on the publicly available list must send an e-mail to
			 PCPCH@state.or.us with the title "opt-out" in the subject line within 10
			 business days of receiving confirmation of Tier status pursuant to OAR
			 409-055-0040.
Stat. Auth: ORS
				  413.042, 413.259 &
				  414.655
Stats. Implemented: ORS 413.259,
				  413.260 &
				  414.655
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 55 - PATIENT-CENTERED PRIMARY CARE HOME PROGRAM › Section 409-055-0090 - Reimbursement Objectives

Current through Register Vol. 63, No. 7, July 1, 2024
(1) One
			 objective of these standards is to facilitate appropriate reimbursement for
			 PCPCHs consistent with their recognized Tier levels. The standards and Tier
			 recognition process established in this rule are consistent with statutory
			 objectives to align financial incentives to support utilization of PCPCHs, in
			 recognition of the standards that are required to be met at different Tiers.
(2) Managed care plans and
			 insurance carriers may obtain from the Authority the Tier level recognition of
			 any practice.
(3) Within
			 applicable programs, the Authority shall develop and implement reimbursement
			 methodologies that reimburse practices based on recognition of Tier level,
			 taking into consideration incurred practice costs for meeting the Tier
			 criteria.
Stat. Auth: ORS
				  413.042, 413.259 &
				  414.655
Stats. Implemented: ORS 413.259,
				  413.260 &
				  414.655
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 58 - HEALTH EVIDENCE REVIEW COMMISSION › Section 409-058-0100 - Scope

Current through Register Vol. 63, No. 7, July 1, 2024
These rules (OAR 409-058-0100  to 409-058-0110) require the
				Health Evidence Review Commission to adopt bylaws to govern, among other
				things, the management of potential conflicts of interest, actual conflicts of
				interest, and significant personal interests among Commissioners, subcommittee
				members, and appointed ad hoc experts. These rules apply to the Health Evidence
				Review Commission and its subcommittees as of October 16, 2021.
Statutory/Other Authority: ORS
				  413.042 &
				  414.689
Statutes/Other Implemented: ORS
				  414.688  & 414.689
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 58 - HEALTH EVIDENCE REVIEW COMMISSION › Section 409-058-0110 - Health Evidence Review Commission Bylaws

Current through Register Vol. 63, No. 7, July 1, 2024
The Health Evidence Review Commission shall adopt bylaws to
				govern its operations. The bylaws shall, among other things:
(1) Require Commission, subcommittee members,
			 and appointed ad hoc experts to disclose potential or actual conflicts of
			 interest as well as other significant personal interests.
(2) Specify how potential and actual
			 conflicts of interest will be disclosed and managed.
(3) Describe the qualifications for
			 subcommittee membership.
Statutory/Other Authority: ORS
				  413.042 &
				  414.689
Statutes/Other Implemented: ORS
				  414.688  & 414.689
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 60 - HEALTH EVIDENCE REVIEW COMMISSION › Section 409-060-0100 - Scope

Current through Register Vol. 63, No. 7, July 1, 2024
(1) These rules
			 (OAR 409-060-0100  to 409-060-0150) define criteria and processes that the
			 Health Evidence Review Commission shall use to develop evidence-based reports,
			 including medical technology assessments, evidence-based guidelines and
			 coverage guidances. These rules apply to evidence-based reports and revisions
			 to approved evidence-based reports whose development commences on or after
			 February 1, 2013.
(2) The
			 Commission may consider evidence relating to prescription drugs that is
			 relevant to an evidence-based report but may not conduct a drug class evidence
			 review or evidence-based report solely of a prescription drug.
Stat. Auth.: ORS
				  414.695 &
				  413.042
Stats. Implemented:
				  414.695 &
				  414.698
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 60 - HEALTH EVIDENCE REVIEW COMMISSION › Section 409-060-0110 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
The following definitions apply to OAR 409-060-0100  to
				409-060-0150:
(1) "Ad hoc expert"
			 means an individual identified by the Commission as having particular expertise
			 in a technology or its application.
(2) "Authority" means the Oregon Health
			 Authority.
(3) "Commission" means
			 the Health Evidence Review Commission.
(4) "Coverage guidance" means a report
			 approved by the Commission on a health service or technology which makes
			 coverage recommendations for insurers and health care purchasers in furthering
			 the use of evidence-based healthcare.
(5) "Evidence-based guideline" means an
			 evidence-based report on a health service or technology, for use by health care
			 providers in encouraging the use of the safest and most effective care
			 possible.
(6) "Evidence-based
			 report" means a medical technology assessment, evidence-based guideline or
			 coverage guidance which includes conclusions and recommendations based on the
			 information in the source documents, and which incorporates the clinical
			 context necessary for the information to be properly interpreted by
			 policymakers.
(7) "EbGS" means the
			 Evidence-based Guidelines Subcommittee.
(8) "HTAS" means the Health Technology
			 Assessment Subcommittee
(9)
			 "Medical technology" or "technology" means medical equipment and devices,
			 medical or surgical procedures and other techniques used or prescribed by
			 health care providers in delivering health care to individuals, and the
			 organizational or supportive systems within which health care is delivered.
(10) "Medical technology
			 assessment" means an evidence-based report on the use, clinical effectiveness
			 and risks, and cost of a technology in comparison with its alternatives.
(11) "Subcommittee" means a
			 subcommittee established by the Commission.
(12) "Scientific evidence" means scientific
			 studies found in peer-reviewed medical literature, printed in journals or other
			 publications that publish original manuscripts only after the manuscripts have
			 been critically reviewed by unbiased independent experts for scientific
			 accuracy, validity and reliability. Such evidence will be evaluated by the
			 Commission for evidence of bias based on the current principles of
			 evidence-based medicine.
Stat. Auth.: ORS
				  414.695 & 413.042
Stats. Implemented: 414.695 &
				  414.698
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 60 - HEALTH EVIDENCE REVIEW COMMISSION › Section 409-060-0130 - Medical Technology Assessments

Current through Register Vol. 63, No. 7, July 1, 2024
Medical technology assessments undertaken by the Commission
				shall be developed by HTAS and may include any technologies listed in the
				definition in ORS 414.695 and
				414.698(1).
				Medical technology assessments shall be performed in cases where technology
				assessments from trusted sources do not exist or require the consideration of
				additional evidence. Medical Technology Assessments shall include a new search
				of the current peer-reviewed research on the topic. Assessments shall be
				developed according to the process described in OAR 409-060-0120  except as
				described in this section.
Stat. Auth.: ORS
				  414.695 &
				  413.042
Stats. Implemented:
				  414.695 &
				  414.698
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 60 - HEALTH EVIDENCE REVIEW COMMISSION › Section 409-060-0140 - Evidence-based Guidelines

Current through Register Vol. 63, No. 7, July 1, 2024
The EbGS shall develop evidence-based guidelines based on one
				or more existing guidelines which may involve the consideration of additional
				research. Evidence-based guidelines shall be developed according to the process
				described in OAR 409-060-0120  except as described in this
				section.
Stat. Auth.: ORS
				  414.695 & 413.042
Stats. Implemented: 414.695 &
				  414.698
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 60 - HEALTH EVIDENCE REVIEW COMMISSION › Section 409-060-0150 - Coverage Guidances

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 Subcommittee shall develop coverage guidances based on evidence searches using
			 scope statements approved by the EbGS or HTAS after a seven-day public comment
			 period. These evidence searches may be supplemented as necessary to provide
			 additional contextual, economic, clinical or policy information based on
			 questions which arise during the development of the coverage guidance. Coverage
			 guidances shall be developed according to the process described in OAR
			 409-060-0120  except as described in this section.
(2) OAR 409-060-0120(3)  does not apply to
			 this section. Instead, if the Subcommittee responsible for development of the
			 report determines that it lacks sufficient expertise in the relevant field, or
			 a request is received from an interested outside party, the Subcommittee shall
			 solicit one or more ad hoc experts to provide additional information. Requests
			 from interested parties to appoint ad hoc experts must be submitted within
			 fourteen days after the public notice announcing the subcommittee's first
			 review of the initial draft coverage guidance. The subcommittee may solicit ad
			 hoc experts at any time thereafter if the committee determines such expertise
			 is necessary. Candidates wishing to serve as ad hoc experts shall disclose
			 conflicts of interest according to HERC bylaws. Ad hoc experts, if needed,
			 shall be appointed by the Authority. The Authority shall select experts that
			 best meet the needs of the state, considering any conflicts of interest, and
			 shall not be limited to those who have volunteered to serve. Ad hoc experts
			 shall answer technical questions and provide clinical context during the review
			 of the evidence.
Stat. Auth.: ORS
				  414.695 & 413.042
Stats. Implemented: 414.695 &
				  414.698
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0000 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0010 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0020 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0030 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0040 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0050 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0060 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth: ORS
				  413.042
Stats. Implemented: ORS
				  413.042
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0100 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
These rules establish a public notice for advance meeting
				materials, which must be posted for an advance comment period, before being
				considered by the Value-based Benefits Subcommittee (VbBS) of the Health
				Evidence Review Commission (HERC). Public comments help HERC learn about
				community needs and perspectives to inform its deliberations about coverage
				recommendations and prioritization of health services. An accessible public
				comment policy supports HERC's goals to eliminate health inequities and ensure
				that covered services are appropriate for the populations affected by its
				decisions.
Statutory/Other Authority: ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.688
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0110 - VbBS Meeting Material Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Advance meeting materials
include draft materials developed by Health Evidence Review Commission (HERC)
			 staff in preparation for a scheduled Value-based Benefits Subcommittee (VbBS)
			 meeting. Each item includes, but is not limited to, an issue summary document
			 which may include staff description of the issue, staff analysis, research,
			 draft recommendations, and/or supporting literature.
(2)
Advance comment period
means
			 a 14-calendar-day period of time for members of the public to review advance
			 meeting materials and to allow time to provide written feedback.
(3)
Final meeting materials
include materials that will be presented to the VbBS subcommittee members at
			 the public meeting.
(4)
Exempt topics.
The following topics are exempt from this advance
			 meeting material notice and comment process:
(a) Topics for which there is no
			 recommendation to change the Prioritized List or bylaws.
(b) Recommendations related to:
(A) Topics placed on a consent agenda related
			 to topics that do not require discussion.
(B) Placement or disposition of new medical
			 codes issued by federal authorities fewer than 60 days prior to the
			 meeting.
(C) A public health
			 emergency as declared by the state's Public Health Director or to align with
			 state or federal law.
(D) An
			 emergency use authorization by the United States Food and Drug
			 Administration.
(E) Coverage
			 changes that require immediate attention as determined by the HERC Director in
			 order to ensure timely access to health care services.
(c) Topics for which advance meeting
			 materials were previously posted but for which related recommendations were
			 considered but not approved by VbBS, either as recommended by staff or in
			 revised form.
(d) Topics for which
			 advance meeting materials were previously posted and approved by VbBS and which
			 HERC discussed but did not approve either as recommended by VbBS or in revised
			 form.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 62 - VALUE-BASED BENEFITS SUBCOMMITTEE › Section 409-062-0120 - Notice and Comment Process

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Prior to each Value-based Benefits Subcommittee (VbBS) meeting, Health Evidence
			 Review Commission (HERC) staff must develop advance meeting materials,
			 comprised of materials and draft recommendations related to all topics planned
			 for discussion, excluding exempt topics.
(2) HERC staff must post a list of topics
			 planned for VbBS discussion as well as advance meeting materials for a comment
			 period on the HERC website and provide notice by electronic means (including
			 but not limited to HERC's listserv).
(a) The
			 list of topics planned for VbBS discussion may include exempt topics for which
			 meeting materials are prepared.
(b)
			 HERC staff must post advance meeting materials by close of business 42 days in
			 advance of a public meeting of the VbBS, unless there is an unexpected state
			 office closure due to weather, infrastructure technology, or other emergency
			 situation, in which case materials must be posted no later than 38 days in
			 advance of a public VbBS meeting.
(c) The advance comment period for each
			 publication of advance meeting materials must be specified on the first page
			 and must end no sooner than 8 a.m., Pacific time, 15 calendar days after the
			 posting of advance meeting materials.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 65 - SUSTAINABLE HEALTH CARE COST GROWTH TARGET PROGRAM › Section 409-065-0000 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
Senate Bill 889 (2019 Legislature) established the Sustainable
				Health Care Cost Growth Target Program within the Oregon Health Authority.
				These rules (OAR 409-065-0000  to 409-065-0030) define reporting requirements to
				the Oregon Health Authority. The 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 442.386 & ORS
				  442.385
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 65 - SUSTAINABLE HEALTH CARE COST GROWTH TARGET PROGRAM › Section 409-065-0010 - General Reporting Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority shall make mandatory
			 reporter determinations on an annual basis and provide written notification no
			 later than April 30 to all reporters subject to the reporting requirements of
			 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
			 will 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) If
			 an entity believes a determination by the Authority of its mandatory reporter
			 status to be in error, the organization must contact the Authority to contest
			 the determination no later than 30 calendar days after receipt of
			 notification.
(5) 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.
Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.386 & ORS
				  442.385
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 65 - SUSTAINABLE HEALTH CARE COST GROWTH TARGET PROGRAM › Section 409-065-0015 - Data Submission Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Annual data submission dates are provided
			 in the Cost Growth Target Data Specification Manual (CGT-2); the data
			 submission dates must not be before September 1st of each year.
(2) CGT-1 must be submitted in accordance
			 with instructions published by the Authority in the Cost Growth Target Data
			 Specification Manual (CGT-2).
(3)
			 Mandatory and voluntary reporters must submit data files for all required lines
			 of business as defined in the Cost Growth Target Data Specification Manual
			 (CGT-2). They may submit data files for the voluntary lines of business and may
			 not submit data files for any excluded lines of business.
(a) Required lines of business include:
(A) Commercial;
(B) Medicare; and
(C) Medicaid.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 65 - SUSTAINABLE HEALTH CARE COST GROWTH TARGET PROGRAM › Section 409-065-0020 - Waivers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority
			 may grant a waiver or deadline extension to the data submission
			 requirements.
(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 Cost Growth Target Data Submission Waiver/Extension Request
			 (CGT-3).
(a) Mandatory reporters may submit a
			 CGT-3 form for the following reasons:
(A) To
			 request a partial waiver to the data submission requirements. The request must
			 be submitted no later than 14 calendar days prior to the annual reporting
			 deadline; or
(B) To request a
			 waiver of all data submission or validation requirements. The request must be
			 submitted no later than 60 calendar days prior to the applicable
			 deadline.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 65 - SUSTAINABLE HEALTH CARE COST GROWTH TARGET PROGRAM › Section 409-065-0025 - Compliance and Enforcement

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Unless approved by a waiver or exception, failure to comply with general data
			 submission requirements includes but is not limited to:
(a) Failure to submit data files by the
			 specified submission date;
(b)
			 Failure to submit data files for a required line of business.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 65 - SUSTAINABLE HEALTH CARE COST GROWTH TARGET PROGRAM › Section 409-065-0030 - Data Access and Disclosure

Current through Register Vol. 63, No. 7, July 1, 2024
(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 provide a public use
			 data set in compliance with applicable Authority policies and state and federal
			 rules, regulations, and statutes.
Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.386 & ORS
				  442.385
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0000 - Scope and Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
(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 shall
			 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.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0005 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
When used and not otherwise defined in OAR 409-070-0000  through
				OAR 409-070-0085, the following terms shall have the meaning given in this
				section:
(1) "Administrative services"
			 means support and administration services, outsourced and subcontracted
			 services and other equivalent services and servicing arrangements relating to,
			 supporting or facilitating the provision of patient care and
			 services.
(2) "Authority" means the
			 Oregon Health Authority.
(3) "AVP
			 methodologies" means the advanced value-based payment models (3A and higher)
			 described in the Oregon Value-Based Payment Compact (June 28, 2021).
(4) "Business entity" has the meaning given
			 in ORS 731.116.
(5) "Carrier" means:
(a) A carrier as defined in ORS
			 743B.005 (but excluding
			 subsection (d) thereof); or
(b) Any
			 person that offers Medicare Advantage plans in this state.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0010 - Covered Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Pursuant to ORS 415.500(6) and
			 (10) and subject to the materiality standards
			 under OAR 409-070-0015, transactions that are subject to review under these
			 rules are the following:
(a) A merger or
			 consolidation of a health care entity with another entity;
(b) An acquisition of a health care entity by
			 another entity;
(c) A transaction
			 to form a new contract, new clinical affiliation or new contracting affiliation
			 between or among health care entities that will eliminate or significantly
			 reduce essential services;
(d)
			 Formation of a corporate affiliation involving at least one health care entity;
			 or
(e) A transaction to form a new
			 partnership, joint venture, accountable care organization, parent organization
			 or management services organization between or among health care entities that
			 will:
(A) Eliminate or significantly reduce
			 essential services;
(B) Consolidate
			 or combine providers of essential services when contracting payment rates with
			 payers, insurers, or coordinated care organizations; or
(C) Consolidate or combine insurers when
			 establishing health benefit premiums.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0015 - Materiality Standard

Current through Register Vol. 63, No. 7, July 1, 2024
(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
			 shall 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:
(i) The entity is newly formed or capitalized
			 in connection with the transaction or in connection to a health care entity for
			 the purposes of a transaction including but not limited to a special purpose
			 entity; or
(ii) 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.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0020 - Excluded Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Pursuant to ORS 415.500(6)(b) and (7), the following transactions are not
			 material change transactions subject to review under these rules:
(a) A clinical affiliation of health care
			 entities formed to collaborate on clinical trials or graduate medical education
			 programs.
(b) A medical services
			 contract or an extension of a medical services contract as described in
			 paragraph (2) of this rule.
(c) An
			 affiliation that, pursuant to ORS 415.500(6)(b)(C):
(A) Does not impact the corporate leadership,
			 governance or control of a health care entity; and
(B) Is necessary to adopt AVP methodologies
			 to meet the health care cost growth targets under ORS
			 442.386.
(d) Contracts under which one
			 health care entity, for and on behalf of a second health care entity, provides
			 patient care and related services or provides administrative services relating
			 to, supporting or facilitating the provision of patient care and services, if
			 the second health care entity:
(A) Maintains
			 responsibility, oversight and control over the patient care and related
			 services;
(B) Bills and receives
			 reimbursement for the patient care and related services; and
(C) Does not provide comprehensive management
			 services.
(e)
			 Transactions in which a participant that is a health center as defined in
			 42 U.S.C. 254b,
			 while meeting all of the participant's obligations, acquires, affiliates with,
			 partners with or enters into any agreement with another entity unless the
			 transaction would result in the participant no longer qualifying as a health
			 center under
			 42 U.S.C.
			 254b.
(f) A transaction that consists solely of a
			 change in the immediate or intermediate ownership of a health care entity but
			 which (i) does not change the ultimate ownership or control of the health care
			 entity, and (ii) does not result in the acquisition of control of the health
			 care entity by any person not previously affiliated with the health care
			 entity.
(g) Agreements between an
			 affiliate and a health care entity that are subject to ORS
			 732.574(2)(d)(D).
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0022 - Emergency and Exempt Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Pursuant to ORS
			 415.501(8)(a),
			 the Authority, for good cause shown, may exempt an otherwise covered
			 transaction from review if the Authority finds that:
(a) There is an emergency situation,
			 including but not limited to a public health emergency, which immediately
			 threatens health care services; and
(b) The transaction is urgently needed to
			 protect the interest of consumers and to preserve the solvency of an entity
			 other than a domestic health insurer.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0025 - Acquisition of Control; Presumptions and Disclaimers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The following presumptions will apply in
			 determining whether a transaction involving a health care entity results in the
			 acquisition of direct or indirect control of that health care entity:
(a) A transaction shall be rebuttably
			 presumed to involve an acquisition of control of a health care entity that is a
			 domestic health insurer or a coordinated care organization if a person,
			 directly or indirectly, acquires voting control of ten percent (10%) or more of
			 any class of voting securities of the domestic health insurer or the
			 coordinated care organization.
(b)
			 For a health care entity other than a domestic health insurer or coordinated
			 care organization, a transaction shall be rebuttably presumed to involve an
			 acquisition of control of the health care entity if a person, directly or
			 indirectly, acquires voting control of twenty-five percent (25%) or more of any
			 class of voting securities of the health care entity.
(c) For any health care entity, a transaction
			 shall be irrebuttably presumed to involve an acquisition of control of the
			 health care entity if a person, directly or indirectly, acquires voting control
			 of more than fifty percent (50%) of any class of voting securities of the
			 health care entity.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0030 - Requirement to File a Notice of Material Change Transaction

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Any health care
			 entity shall:
(a) Submit to the Authority a
			 notice of material change transaction not involving an activity described in
			 ORS 732.521 with respect to a
			 domestic health insurer. The notice shall contain the information required
			 under OAR 409-070-0045.
(b) Submit
			 to the Department a notice of material change transaction for an activity
			 described in ORS 732.521 with respect to a
			 domestic health insurer. The notice shall be submitted as an addendum to
			 filings required by ORS
			 732.517 to ORS
			 732.546 or ORS
			 732.576. The Department shall
			 promptly provide to the Authority the notice submitted under this subsection to
			 enable to the Authority to conduct its review in accordance with OAR
			 409-070-0035.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0035 - Material Change Transaction Involving a Domestic Health Insurer

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority
			 shall 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
			 shall 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.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0040 - Material Change Transaction Involving a Charitable Organization or Hospital

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 parties shall 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 shall 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 to
				  415.900
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0042 - Optional Application for Determination of Covered Transaction Status

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Any party to a
			 proposed transaction may, but shall not be required to, submit a written
			 application to the Authority requesting a determination whether such
			 transaction is a covered transaction pursuant to these rules. The Authority
			 shall notify the applicant in writing of its determination within 30 calendar
			 days following receipt of the application and any additional information
			 requested by the Authority. If the Authority determines that the proposed
			 transaction is a covered transaction, and the parties desire to pursue the
			 transaction, the parties shall file a notice in accordance with these
			 rules.
(2) An application for
			 determination pursuant to paragraph (1) of this rule shall contain:
(a) A detailed explanation of the
			 transaction, including the parties to such transaction and all relevant terms,
			 conditions and agreements that comprise the transaction;
(b) A detailed explanation of the reasons the
			 parties to the proposed transaction believe such transaction is not a covered
			 transaction pursuant to these rules; and
(c) Such additional information, documents
			 and analyses as the Authority may require in order to evaluate the application
			 and the asserted grounds on which it should not be considered a covered
			 transaction pursuant to these rules.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0050 - Retention of Outside Advisors

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Pursuant to ORS 415.501(14), the Authority or the Department of Justice may
			 retain at the expense of the parties to a material change transaction any
			 actuaries, accountants, consultants, legal counsel and other advisors not
			 otherwise a part of the Authority's staff as the Authority may reasonably need
			 to assist the Authority in reviewing the proposed material change transaction.
			 The retention of such advisors shall not be subject to any otherwise applicable
			 procurement process, provided that the Authority or the Department of Justice,
			 as applicable, shall make a determination that such advisors have the requisite
			 qualifications and expertise to review the proposed transaction. The Authority
			 or the Department of Justice, as applicable, shall require that the retained
			 advisors certify in writing that:
(a) They are
			 not subject to any conflict of interest associated with reviewing a given
			 transaction, and:
(b) They will
			 protect any confidential information disclosed to them in the course of their
			 review of the transaction. Material that is privileged or confidential and
			 therefore exempt or determined by the Authority to be exempt from public
			 disclosure under ORS 415.501(13)(b) may be shared with the retained advisors,
			 and such disclosure shall not constitute a waiver of the privileged or
			 confidential status of the material.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0055 - Preliminary 30-Day Review of a Notice of Material Change Transaction

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Pursuant to ORS
			 415.501(5) and
			 after receipt of a complete notice of material change transaction in accordance
			 with OAR 409-070-0030(1)(a)  and OAR 409-070-0045(5), the Authority shall
			 complete a preliminary review to determine whether the proposed material change
			 transaction meets one or more of the criteria set forth in paragraph (2) of
			 this rule. The Authority shall, subject to OAR 409-070-0070, publish the notice
			 of material change transaction. For the duration of the preliminary review
			 period, the Authority shall accept and publish public comment pertaining to the
			 material change transaction.
(2) At
			 the conclusion of the preliminary review described in paragraph (1) of this
			 rule, the Authority shall approve, or approve with conditions as provided in
			 OAR 409-070-0065, a material change transaction, or, in the case of a material
			 change transaction involving a domestic health insurer, recommend to the
			 Department that the transaction be approved, if the Authority determines that
			 the transaction meets one or more of the following criteria:
(a) The material change transaction is in the
			 interest of consumers and is urgently necessary to maintain the solvency of an
			 entity involved in the transaction;
(b) The material change transaction is
			 unlikely to substantially reduce access to affordable health care in
			 Oregon;
(c) The material change
			 transaction is likely to meet the criteria set forth in OAR
			 409-070-0060;
(d) The material
			 change transaction is not likely to substantially alter the delivery of health
			 care in Oregon; or
(e)
			 Comprehensive review of the material change transaction is not warranted given
			 the size and effects of the transaction.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0062 - Community Review Board

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Authority may appoint and convene a community review board to participate in
			 the comprehensive review of a material change transaction, pursuant to ORS
			 425.501(11). A
			 community review board shall:
(a) Advise the
			 Authority on the impact of the transaction to the community; and
(b) Make recommendations to the Authority on
			 the approval or disapproval of a transaction, or the approval of a transaction
			 subject to certain conditions.
Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 70 - HEALTH CARE MARKET OVERSIGHT PROGRAM › Section 409-070-0065 - Conditional Approval; Suspension of Proposed Material Change Transaction

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Following
			 completion of a preliminary review pursuant to OAR 409-070-0055  or a
			 comprehensive review pursuant to OAR 409-070-0060, which may include the
			 appointment of a community review board pursuant to OAR 409-070-0062, the
			 Authority may approve, or recommend for approval in the case of transaction
			 involving a domestic insurer, a material change transaction with conditions
			 designed to further the purposes and goals described in OAR
			 409-070-0000.
(2) If the Authority
			 approves a material change transaction with conditions as set forth in
			 paragraph (1) of this rule, the Authority may suspend, or in the case of
			 transaction involving a domestic insurer recommend that the Department suspend,
			 the effective date of the transaction for such reasonable time as necessary to
			 conduct an examination and complete an analysis of whether the conditions have
			 been satisfied.
Statutory/Other Authority: ORS
				  415.501
Statutes/Other Implemented: ORS
				  415.500 to
				  415.900