reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3890 - Grievances And Appeals: Appeal Process

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A member, member representative, or
			 provider with the member's written consent, may file an oral or written appeal
			 with the Managed Care Entity (MCE) to:
(a)
			 Express disagreement with an adverse benefit determination; or
(b) Oral appeals timeframes shall begin when
			 there is established contact made between the member and an MCE representative.
			 If the member leaves a voice mail message with the MCE indicating that they
			 wish to appeal a denial the MCE shall make reasonable efforts (multiple calls
			 at different times of day) to reach the member by phone to get the details of
			 the service they wish to appeal. The MCE shall document each attempt to reach
			 the member (date(s) and time(s)) by phone and make note of the date they
			 establish contact with the member and are able to attain the appeal information
			 needed to process the appeal.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3895 - Grievances & Appeals: Expedited Appeal

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Each MCE shall establish and maintain an
			 expedited review process for all oral and written appeals when the member or
			 the provider indicates that taking the time for a standard resolution could
			 seriously jeopardize the member's life, health, or ability to attain, maintain,
			 or regain maximum function as set forth in OAR 410-120-1860. Oral appeals
			 timeframes shall begin when there is established contact made between the
			 member and an MCE representative.
(2) The MCE shall ensure that punitive action
			 is not taken against a provider who requests an expedited resolution.
(3) A request for an expedited appeal for a
			 service that has already been provided (post-service) to the member will not be
			 granted. The MCE shall transfer the appeal to the timeframe for standard
			 resolution as set forth in 410-141-3890 (4).
(4) For expedited resolution of an appeal and
			 notice to affected parties, the MCE shall complete the review of the expedited
			 appeal in a timeframe that is no longer than 72 hours after the MCE receives
			 the appeal. The MCE shall:
(a) Inform the
			 member of the limited time available for receipt of materials or documentation
			 for the review;
(b) Make reasonable
			 efforts to call the member and the provider to tell them of the resolution
			 within 72 hours after receiving the request;
(c) Mail written confirmation of the
			 resolution to the member within three days;
(d) Extend the timeframes by up to 14 days
			 if:
(A) The member requests the extension;
			 or
(B) The MCE shows (to the
			 satisfaction of the Authority upon its request) that there is need for
			 additional information and how the delay is in the member's interest.
(e) If the MCE extends the
			 timeframes not at the request of the member, the MCE shall:
(A) Make reasonable efforts (including as
			 necessary multiple calls at different times of day) to give the member prompt
			 oral notice of the delay;
(B)
			 Within two days, give the member written notice of the reason for the decision
			 to extend the timeframe and inform the member of the right to file a grievance
			 if he or she disagrees with that decision.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3900 - Grievances And Appeals: Contested Case Hearings

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A Managed Care Entity (MCE) shall have a
			 system in place to ensure its members and providers have access to appeal for
			 MCE's action by requesting a contested case hearing:
(a) Contested case hearings are conducted
			 pursuant to ORS 183.411 to
			 183.497 and the Attorney
			 General's Uniform and Model Rules of Procedure for the Office of Administrative
			 Hearings, OAR 137-003-0501  to 137-003-0700. Processes for contested case
			 hearings are provided in OAR 410-120-1860  Contested Case Hearing
			 Procedures;
(b) If a provider filed
			 an appeal on behalf of a member, as permitted in OAR 410-141-3890, the provider
			 may subsequently request a contested case hearing on behalf of the member in
			 accordance with the procedures in this rule;
(c) Appeals brought on the provider's own
			 behalf are not subject to this rule, which governs appeals brought by member or
			 by a provider on the member's behalf but are governed by OAR
			 410-120-1560.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3905 - Grievances & Appeals: Expedited Contested Case Hearings

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An MCE shall
			 have a system in place to ensure its members and providers have access to
			 expedited review for MCE's action by requesting an expedited contested case
			 hearing. Contested case hearings are conducted pursuant to ORS
			 183.411 to
			 183.497 and the Attorney General's Uniform and Model Rules of Procedure for the Office
			 of Administrative Hearings, OAR 137-003-0501  to 137-003-0700. Processes for
			 expedited contested case hearings are provided in OAR 410-120-1860  Contested
			 Case Hearing Procedures.
(2) A
			 member or provider who believes that taking the time for a standard resolution
			 of a request for a contested case hearing could seriously jeopardize the
			 member's life or health or ability to attain, maintain, or regain maximum
			 function may request an expedited contested case hearing.
(3) A request for an expedited hearing for a
			 service that has already been provided (post-service) to the member will not be
			 granted.
(4) The member may not
			 request an expedited contested case hearing without first completing an appeal
			 or expedited appeal with the MCE, subject to the exception in OAR
			 410-141-3900(3). When a member files a hearing request prior to completion of
			 an MCE appeal or expedited appeal, the Authority shall follow procedures set
			 forth in OAR 410-141-3900.
(5)
			 Expedited hearings are requested using Authority form MSC 443 or other
			 Authority-approved appeal or hearing request forms.
(6) The MCE shall submit relevant
			 documentation to the Authority within two working days. The Authority shall
			 decide within two working days from the date of receiving the relevant
			 documentation whether the member is entitled to an expedited contested case
			 hearing.
(7) If the Authority
			 denies a request for an expedited contested case hearing, the Authority shall:
(a) Handle the request for a contested case
			 hearing in accordance with OAR 410-120-1860; and
(b) Make reasonable efforts to give the
			 member prompt oral notice of the denial and follow up within two days with a
			 written notice.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3910 - Grievances And Appeals: Continuation of Benefits

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A member who may be entitled to
			 continuing benefits may request and receive continuing benefits in the same
			 manner and same amount while an appeal or contested case hearing is pending:
(a) A member can request continuation of
			 benefits by phone, letter, fax or by using the Review of Health Care Decision
			 form and check the box requesting continuing benefits by:
(A) The tenth day following the date of the
			 notice of adverse benefit determination or the notice of appeal resolution;
			 or
(B) The effective date of the
			 action proposed in the notice, if applicable.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3915 - Grievances & Appeals: System Recordkeeping

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Each MCE shall maintain records of
			 grievances and appeals and shall review the information as part of its ongoing
			 monitoring procedures, as well as for updates and revisions to the state
			 quality strategy as stated in
			 42 CFR
			 438.416 and in alignment with contractual
			 requirements.
(2) Consistent with
			 record retention requirements in OAR 410-141-3520, MCE's must maintain yearly
			 logs of all appeals and grievances for 10 years, which must include information
			 about the reasons for each grievance or appeal, as well as the resolution and
			 supporting reasoning.
(3) The MCE
			 must review the log monthly for completeness, accuracy, and compliance with
			 required procedures.
(4) MCE's
			 shall submit for the Authority's review the Grievance and Appeals Log, samples
			 of Notices of Adverse Benefit Determination, and other reports as required
			 under the MCE contract.
(5) The
			 Grievance System Report and Grievance and Appeals Log shall be forwarded to the
			 MCE's Quality Improvement committee to comply with the Quality Improvement
			 standards as follows:
(a) Review of
			 completeness, accuracy, and timeliness of documentation;
(b) Compliance with written procedures for
			 receipt, disposition, and documentation; and
(c) Compliance with applicable OHP
			 rules.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3920 - Transportation: NEMT General Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A Coordinated Care Organization (CCO)
			 shall provide all non-emergency medical transportation (NEMT) services for its
			 members. For purposes of OAR 410-141-3920  to 410-141-3965, references to a
			 "member" include any individual eligible for NEMT services under section (1) of
			 this rule unless context dictates otherwise:
(a) The CCO is responsible for NEMT services
			 for all of its members' health care services consistent with the covered
			 services described in OAR 410-141-3820  and the excluded services and
			 limitations described in 410-141-3825  and (1)(b) and (1)(c) of this
			 rule;
(b) NEMT services for those
			 health care services that, based on the member's plan type, are paid by the
			 Authority's fee-for-service program and that, based on rule or contract, are
			 carved-out from or otherwise not covered by the CCO and provided by the
			 Authority;
(c) For members enrolled
			 in the Compact of Free Association (COFA) Dental Program or the Veteran Dental
			 Program, both of which are defined in OAR chapter 410, division 200, the CCO is
			 responsible only for NEMT services related to the member's dental
			 services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3925 - Transportation: Vehicle Equipment and Driver Standards

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule does not apply to ambulance
			 providers, ambulance vehicles, or ambulance personnel that are licensed and
			 regulated by ORS Chapter 682 and OAR chapter 333, divisions 250, 255, 260 and
			 265, whether providing ambulance or stretcher transports.
(2) The CCO shall require all vehicles used
			 for NEMT services to meet the following requirements for the comfort and safety
			 of the members:
(a) The interior of the
			 vehicle shall be clean and free from any debris impeding a member's ability to
			 ride comfortably;
(b) Smoking,
			 aerosolizing or vaporizing of inhalants is prohibited in the vehicle at all
			 times in accordance with ORS
			 433.835 to
			 433.990 and OAR
			 333-015-0025  to 333-015-0090; and
(c) Compliance with all applicable local,
			 state, and federal transportation laws regarding vehicle and passenger safety
			 standards and comfort. All vehicles shall include, without limitation, the
			 following safety equipment:
(A) Safety belts
			 for all passengers if the vehicle is legally required to provide safety
			 belts;
(B) First aid kit;
(C) Fire extinguisher;
(D) Roadside reflective or warning
			 devices;
(E) Flashlight;
(F) Tire traction devices when
			 appropriate;
(G) Disposable gloves;
			 and
(H) All equipment necessary to
			 securely transport members using wheelchairs or stretchers in accordance with
			 the Americans with Disabilities Act of 1990 (as amended) (ADA), Section 504 of
			 the Rehabilitation Act of 1973, and Oregon Revised Statute 659A.103.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3930 - Transportation: Out-of-Service Area and Out-of-State Transportation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A CCO shall
			 provide NEMT services outside the CCO's service area under any and all of the
			 following circumstances:
(a) The member is
			 receiving covered services that are not available, in accordance with OAR
			 410-141-3515, in the CCO's service area;
(b) The member is receiving covered services
			 outside of Oregon, but the location is contiguous to the CCO's service area and
			 no more than 75 miles from the Oregon border;
(c) The member is receiving in-patient
			 services at a facility outside the CCO's service area due to unavailability
			 within the CCO's service area and the member requires additional covered
			 services within the service area where the inpatient service facility is
			 located; and
(d) The member is
			 receiving covered services outside the State of Oregon because the required
			 covered service is not available within Oregon.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3935 - Transportation: Attendants for Child and Special Needs Transports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 applies to NEMT for children 12 years of age and under who are eligible for
			 NEMT services to and from OHP-covered medical services. The rule also applies
			 to members with special physical or developmental needs regardless of
			 age.
(2) Parents or guardians must
			 provide an attendant to accompany these members while traveling to and from
			 covered services and other purposes authorized by the CCO in accordance with
			 OAR 410-141-3930(2)  except when:
(a) The
			 driver is a Department of Human Services (Department) volunteer or employee or
			 an Authority employee;
(b) The
			 member requires secured transport pursuant to OAR 410-141-3940  (Secured
			 Transports); or
(c) An ambulance
			 provider transports the member for non-emergent services, and the CCO
			 reimburses the ambulance provider at the ambulance transport rate, per CCO
			 contract or non-contracted rate policy.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3940 - Transportation: Secured Transports

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 "Secured transport" means NEMT services for the involuntary transport of
			 members who are in danger of harming themselves or others. Secured transports
			 may be used when:
(a) The CCO verified that
			 the secured transporter has met the requirements of the secured transport
			 protocol pursuant to OAR 309-033-0200  through 309-033-0970, and the secured
			 transporter is able to transport the member who is in crisis or at immediate
			 risk of harming themselves or others due to mental or emotional problems or
			 substance abuse; and
(b) The
			 transport is to a Medicaid enrolled facility that the Authority recognizes as
			 being able to treat the immediate medical or behavioral health care needs of
			 the member in crisis.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3945 - Transportation: Ground and Air Ambulance Transports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Transporting a member via ambulance is
			 required when a medical facility or provider states the member's medical
			 condition requires the presence of a health care professional during the
			 emergency or non-emergency transport. This includes neonatal
			 transports.
(2) For NEMT services,
			 the CCOs shall authorize the transport.
(3) CCOs shall provide ambulance transports
			 with a medical technician when:
(a) A
			 member's medical condition requires a stretcher and the length of transport
			 requires a personal care attendant, but the member does not have one;
			 or
(b) Necessitated by the member's
			 medical condition consistent with section (1) above of this rule.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3955 - Transportation: Member Service Modifications and Rights

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For the purposes of this rule, "direct
			 threat" means a significant risk to the health or safety of others and which:
(a) Cannot be eliminated or reduced to an
			 acceptable level through the provision of auxiliary aids and services or
			 through reasonably modifying policies, practices, or processes; and
(b) Is identified through an individual
			 assessment that relies on current medical evidence or the best available
			 objective evidence which shows:
(A) The
			 nature, duration, and severity of the risk;
(B) The probability that a potential injury
			 will actually occur; and
(C)
			 Whether reasonable modification of policies, practices, or processes will lower
			 or eliminate the risk.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3960 - Transportation: Member Reimbursed Mileage, Meals, and Lodging

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A Coordinated Care Organization (CCO) may
			 prior authorize a member's mileage, meals, and lodging to covered medical
			 service in order for the member to qualify for reimbursement.
(2) A CCO may disallow a client reimbursement
			 request received more than 45 days after the travel.
(3) A CCO shall reimburse a member for
			 mileage, meals, and lodging at rates not less than the Authority's allowable
			 rates. The Oregon Health Plan (OHP) fee schedule is available on the Oregon
			 Health Authorities (Authority's) website.
(4) The member must return any documentation
			 a CCO requires before receiving reimbursement.
(5) A member must be reimbursed within
			 fourteen (14) days after verifying the member's attendance of the appointment
			 after the CCO receiving the reimbursement request.
(a) A CCO may hold reimbursements under the
			 amount of $10 until the member's reimbursement reaches $10; or
(b) A CCO must issue the member a Notice of
			 Adverse Benefit Determination, in accordance with requirements in OAR
			 410-141-3885, within fourteen (14) days if the member reimbursement is denied
			 for any reason. If the member reimbursement request is incomplete the CCO shall
			 take an additional fourteen (14) days to assist the member in completing the
			 submission.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3965 - Reports and Documentation

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 CCOs shall maintain documentation of rides denied and rides provided to
			 members.
(2) The CCO shall retain
			 the documentation on NEMT service denials for 10 calendar years, even if the
			 CCO, its brokerage, or subcontractor that denied the service is no longer a
			 Medicaid enrolled provider before the end of the 10 years. The Authority may
			 request this information at any time during the 10-year retention
			 period.
(3) The Authority may
			 request and the CCO shall provide other reports or information not specified in
			 this rule.
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.625
Statutes/Other Implemented: ORS
				  414.625
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4000

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.025
Statutes/Other Implemented: ORS
				  414.065  & 2017 HB 2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4005

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.025
Statutes/Other Implemented: ORS
				  414.065  & 2017 HB 2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4010

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.025
Statutes/Other Implemented: ORS
				  414.065  & 2017 HB 2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4020

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.025
Statutes/Other Implemented: ORS
				  414.065  & 2017 HB 2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4030

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented: 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4040

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented:
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4050

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.025
Statutes/Other Implemented: ORS
				  414.065  & 2017 HB 2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4060

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented: 414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4070

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented: 414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4080

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented: 414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4090

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented: 414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4100

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented: 414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4110

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented: 414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-4120

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: 413.042 & 414.025
Statutes/Other Implemented: 414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5000 - FINANCIAL SOLVENCY REGULATION: Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
When used and not otherwise defined in OAR 410-141-5005  through
				OAR-141-5380, the following terms shall have the meaning given in this
				section:
(1) "AICPA" means the
			 American Institute of Certified Public Accountants.
(2) "Applicable Law" means,
(a) S.B. 1041;
(b) OAR 410-141-5000  to OAR-141-5380
			 and;
(c) Any other state or federal
			 laws, rules, regulations or regulatory guidance applicable to the operations of
			 CCOs in this state.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5005 - FINANCIAL SOLVENCY REGULATION: CCO Financial Solvency Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A CCO shall
			 assume the risk for providing capitated services under its agreements with the
			 Authority.
(2) Each CCO must
			 demonstrate that it is able to provide coordinated care services efficiently,
			 effectively, and economically. CCOs shall maintain sound financial management
			 procedures, maintain protections against insolvency, and generate periodic
			 financial reports as provided in these rules.
(3) A CCO shall comply with the applicable
			 solvency requirements of Division 141 of Chapter 410 and as specified in the
			 CCO's agreements with the Authority. Solvency requirements shall include the
			 following components:
(a) Maintenance of
			 Restricted Reserve Funds as required by OAR 410-141-5285  and by the CCO's
			 agreements with the Authority;
(b)
			 Protection against catastrophic and unexpected loss or expenses related to
			 capitated services for CCOs Loss Protection Program. A CCO's Loss Protection
			 Program:
(A) May include stop loss insurance
			 coverage, reinsurance or such other alternative protection(s) as may be
			 approved by the Authority, and
(B)
			 Shall be subject to the Authority's review and approval.
(c) Any material change to a CCO's Loss
			 Protection Program shall be submitted to the Authority in writing and shall be
			 subject to the Authority's review and approval;
(d) Maintenance of professional liability
			 coverage of not less than $1,000,000 per person per incident and not less than
			 $1,000,000 in the aggregate either through binder issued by an insurance
			 carrier or by self-insurance with proof of same acceptable to the Authority;
			 and
(e) Management systems,
			 practices and procedures that capture, compile, and evaluate information and
			 data concerning financial operations. Such systems shall include, without
			 limitation, the following features and functionalities:
(A) Determination of future budget
			 requirements for the next three quarters.
(B) Determination of incurred but not
			 reported expenses.
(C) Tracking
			 additions and deletions of Members and accounting for capitation
			 payments.
(D) Tracking claims
			 payment.
(E) Tracking all monies
			 collected from third party resources on behalf of Members.
(F) Documentation of, and reports on the use
			 of, incentive payment mechanisms, risk-sharing, and risk-pooling, as
			 applicable.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5015 - FINANCIAL SOLVENCY REGULATION: Financial Statement Reporting

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Financial
			 reports to the Authority. A CCO shall submit the following:
(a) On or before April 30 of each year, an
			 unaudited financial statement for the year ending December 31 immediately
			 preceding;
(b) On or before May 31,
			 August 31, and November 30 of each year, an unaudited financial statement for
			 the quarter ending March 31, June 30 and September 30, respectively;
(c) On or before June 30 of each year, an
			 audited financial statement for the year ending December 31 immediately
			 preceding.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5020 - FINANCIAL SOLVENCY REGULATION: Annual Audited Financial Statements and Auditor's Report

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Annual
			 audited financial statements shall report the financial position of the CCO as
			 of the end of the most recent calendar year and the results of its operations,
			 cash flows and changes in capital and surplus for the year then ended in
			 accordance with the form and content requirements of OAR
			 410-141-5015.
(2) The audit of the
			 CCO's annual financial statements shall be performed by an independent
			 accounting firm and shall include, but not limited to:
(a) A report of the independent accounting
			 firm that meets the requirements of this section.
(b) A written statement of opinion by the
			 independent accounting firm based on the firm's audit regarding the CCO's
			 annual financial statements.
(c) A
			 written statement of opinion by an independent actuarial firm with respect to
			 the assumptions and methods used in determining the CCO's loss reserves,
			 actuarial liabilities and related items, and the consistency of those
			 assumptions and methods with generally accepted actuarial standards and
			 practices for such matters.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5025 - FINANCIAL SOLVENCY REGULATION: Qualifications of Independent Certified Public Accountant

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Authority shall not recognize any person as a qualified independent certified
			 public accountant for the purposes of OAR 410-141-5020  if the person:
(a) Is not in good standing with the AICPA
			 and in all states in which the person is licensed to practice as a certified
			 public accountant; or
(b) Has
			 either directly or indirectly entered into an agreement of indemnity or a
			 release from liability (collectively referred to as indemnification) with
			 respect to the audit of the CCO.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5030 - FINANCIAL SOLVENCY REGULATION: Notification of Adverse Financial Condition

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A CCO
			 required to furnish an annual audited financial report shall require the
			 independent certified public accountant to report in writing to the CCO's
			 Board, or to the audit committee of the CCO, any determination by the
			 independent certified public accountant that the CCO has materially misstated
			 its financial condition as reported to the Authority as of the date of the
			 balance sheet currently under audit or that the CCO does not meet the minimum
			 capital and surplus requirements under these rules or if the CCO's risk based
			 capital, as determined in accordance with OAR 410-141-5195  to 5220 is below the
			 Company Action Level threshold for the CCO. The CCO shall require the
			 independent certified public accountant to submit the report not later than the
			 fifth business day after the independent certified public accountant makes such
			 a determination. A CCO that has received a report under this section shall
			 forward a copy of the report to the Authority not later than the fifth business
			 day after receiving the report and shall provide the independent certified
			 public accountant with evidence that the report was furnished to the Authority.
			 If the independent certified public accountant does not receive such evidence
			 within the required period, the independent certified public accountant shall
			 furnish to the Authority a copy of its report not later than the fifth business
			 day after the end of the period within which the CCO was required to submit the
			 report.
(2) An independent
			 certified public accountant shall not be liable to any person for any statement
			 made in connection with the requirements of subsection (1) if the statement is
			 made in good faith and in compliance with subsection (1).
(3) If the accountant, after the date of the
			 audited financial report filed pursuant to OAR 410-141-5020, becomes aware of
			 facts that might have affected the report, the Authority notes the obligation
			 of the accountant to act as prescribed in Volume 1, Section AU 561 of the
			 Professional Standards of the AICPA.
Statutory/Other Authority: ORS
				  413.042,
				  414.615,
				  414.625,
				  414.635 & 414.651
Statutes/Other Implemented: ORS
				  414.610-414.685
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5035 - FINANCIAL SOLVENCY REGULATION: Accountant's Letter of Qualifications

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An accountant
			 shall furnish the CCO, in connection with and for inclusion in the filing of
			 the annual audited financial report, a letter stating the following:
(a) That the accountant is independent with
			 respect to the CCO and conforms to the standards of the accounting profession
			 as contained in the Code of Professional Ethics and pronouncements of the AICPA
			 and the Rules of Professional Conduct of the Oregon State Board of Accountancy,
			 or a similar code of conduct of the state board regulating the practice of
			 accountancy in the state in which the accountant is licensed to
			 practice.
(b) The background and
			 experience in general, and the experience in audits of CCOs, of the staff
			 assigned to the engagement and whether each is an independent certified public
			 accountant.
(c) That the accountant
			 understands that the annual audited financial report and the opinion of the
			 accountant thereon must be filed in compliance with OAR 410-141-5020  and that
			 the Authority will rely on the information contained in the report and opinion
			 in the monitoring and regulation of the financial position of CCOs.
(d) That the accountant consents to the
			 requirements of OAR 410-141-5020  and that the accountant agrees to make the
			 workpapers described in OAR 410-141-5040  available for review by the Authority,
			 or the Authority's designee or appointed agent.
(e) A representation that the accountant is
			 currently licensed by an appropriate state licensing authority and is a member
			 in good standing in the American Institute of Certified Public
			 Accountants.
(f) A representation
			 that the accountant is in compliance with OAR 410-141-5025.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5040 - FINANCIAL SOLVENCY REGULATION: Independent Certified Public Accountants Workpapers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For the
			 purpose of this section, workpapers are the records kept by an independent
			 certified public accountant of the procedures followed, the tests performed,
			 the information obtained and the conclusions reached pertinent to the
			 accountant's audit of the financial statements of a CCO. Accordingly,
			 workpapers may include audit planning documentation, work programs, analyses,
			 memoranda, letters of confirmation and representation, abstracts of company
			 documents and schedules or commentaries prepared or obtained by the independent
			 certified public accountant in the course of the accountant's audit of the
			 financial statements of a CCO and which support the accountant's
			 opinion.
(2) A CCO that is required
			 to file an audited financial report pursuant to OAR 410-141-5020  shall require
			 the accountant to make available for review by the Authority, all workpapers
			 prepared in the conduct of the accountant's audit and any communications
			 related to the audit between the accountant and the CCO, at the offices of the
			 CCO, at the Authority's offices or at any other reasonable place designated by
			 the Authority. The CCO shall require that the accountant retain the audit
			 workpapers and communications until the Authority has filed a report on
			 examination covering the period of the audit but no longer than seven years
			 from the date of the audit report.
(3) In the conduct of a periodic review by
			 the Authority's examiners, the Authority may make and retain photocopies of
			 pertinent audit workpapers. Any such review by the Authority's examiners is an
			 investigation and all working papers and communications obtained during the
			 course of such an investigation must be given the same confidentiality as other
			 examination workpapers generated by the Authority.
Statutory/Other Authority: ORS
				  413.042,
				  414.615,
				  414.625,
				  414.635 & 414.651
Statutes/Other Implemented: ORS
				  414.610 -
				  414.685
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5045 - FINANCIAL SOLVENCY REGULATION: Corporate Governance Annual Disclosure Filing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A CCO shall
			 file a corporate governance annual disclosure report with the Authority, as
			 described in this section, no later than June 1 of each calendar year. A CCO
			 that is not subject to the requirement under this section to submit a CGAD
			 Report shall nevertheless submit a CGAD Report at the Authority's
			 request.
(2) A CGAD Report shall
			 contain the following information:
(a) The
			 CGAD Report shall describe the CCO's corporate governance framework and
			 structure including consideration of the following:
(A) The CCO's Board and the various
			 committees thereof that are ultimately responsible for overseeing the CCO and
			 the level(s) at which that oversight occurs (e.g. ultimate control level,
			 intermediate holding company, legal entity, etc.). The CGAD Report shall
			 describe and discuss the rationale for the current CCO Board size and
			 structure.
(B) The duties of the
			 CCO Board and each of its significant committees and how they are governed
			 (e.g. bylaws, charters, informal mandates, etc.), as well as how the CCO
			 Board's leadership is structured, including a discussion of the roles of Chief
			 Executive Officer and Chairman of CCO Board, as applicable, within the
			 organization.
(C) The membership,
			 structure and authority of the CCO's governing body, if the CCO is a
			 coordinated care organization whose governing body as required by ORS
			 414.625(2)(o)
			 is not the CCO Board.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5060 - FINANCIAL SOLVENCY REGULATION: Qualified Trust Agreements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As used in this
			 section:
(a) "Beneficiary" includes any
			 successor by operation of law of the named beneficiary, including without
			 limitation any liquidator, rehabilitator, receiver or conservator.
(b) "Grantor" means the entity that has
			 established a trust for the sole benefit of the beneficiary. When established
			 in conjunction with a reinsurance agreement, the grantor is the unauthorized or
			 unlicensed unaccredited reinsurer.
(c) "Obligations" as used in subsection (2)
			 means:
(A) Reinsured losses and allocated loss
			 expenses paid by the cedent CCO, but not recovered from the
			 reinsurer;
(B) Reserves for
			 reinsured losses reported and outstanding;
(C) Reserves for reinsured losses incurred
			 but not reported; and
(D) Reserves
			 for allocated reinsured loss expenses and unearned capitated revenue.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5070 - FINANCIAL SOLVENCY REGULATION: Assets, Liabilities, Reserves

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In any
			 determination of the financial condition of a CCO, there shall be allowed as
			 assets only such assets as are owned by the CCO and which consist of:
(a) Cash in the possession or control of the
			 CCO, including the true balance of any deposit in a solvent bank or trust
			 company.
(b) Investments held in
			 accordance with these rules, and due or accrued income items in connection
			 therewith to the extent considered by the Authority to be
			 collectible.
(c) Receivables for
			 capitated revenue payments due the CCO, to the extent allowed by the
			 Authority.
(d) Amounts recoverable
			 from reinsurers if credit for reinsurance may be allowed to the CCO pursuant to
			 OAR 410-141-5050  to 5070.
(e) Other
			 assets considered by the Authority to be available for the payment of losses
			 and claims, at values determined by the Authority.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5075 - FINANCIAL SOLVENCY REGULATION: Disallowance of Certain Reinsurance Transactions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Authority shall disallow as an asset or as a credit against liabilities any
			 reinsurance found by the Authority after a hearing thereon to have been
			 arranged for the purpose principally of deception as to the ceding CCO's
			 financial condition as of the date of any financial statement of the CCO.
			 Without limiting the general purport of the foregoing provision, reinsurance of
			 any substantial part of the CCO's outstanding risks placed within four months
			 prior to the date of any such financial statement and canceled in fact within
			 eight months after the date of such statement, or reinsurance under which the
			 reinsurer bears no substantial insurance risk or substantial risk of net loss
			 to itself, shall prima facie be deemed to have been arranged for the principal
			 purpose of deception.
(2) The
			 Authority shall disallow as an asset any deposit, funds or other assets of the
			 CCO found by the Authority after a hearing thereon:
(a) Not to be the property of the
			 CCO;
(b) Not freely subject to
			 withdrawal or liquidation by the CCO at any time for the payment or discharge
			 of claims or other obligations arising under its Member Contracts; or
(c) To result from arrangements made
			 principally for the purpose of deception as to the CCO's financial condition as
			 of the date of any financial statement of the CCO.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-5055 - FINANCIAL SOLVENCY REGULATION: Requirements for Obtaining Credit for Reinsurance

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Authority shall not allow financial statement credit for reinsurance to a
			 cedent CCO as either an asset or a reduction from liability on account of
			 reinsurance ceded unless the reinsurance meets the requirements of subsection
			 (2) or (3) of this section.
(2)
			 Credit shall be allowed when the reinsurance is ceded to an authorized assuming
			 CCO or an authorized health insurer that has been approved and accepted by the
			 Authority to act as a reinsurer of the cedent CCO in accordance with OAR
			 410-141-5050. The Authority shall not allow credit to a cedent CCO if the
			 approval or acceptance of the reinsurer has been revoked by the Authority after
			 notice and opportunity for hearing.
(3) The Authority shall allow a reduction
			 from liability for reinsurance ceded by a CCO to an assuming reinsurer not
			 meeting the requirements of subsection (2) in an amount not exceeding the
			 liabilities carried by the cedent CCO. The reduction shall be in the amount of
			 funds held by or on behalf of the cedent CCO, including funds held in trust for
			 the exclusive benefit of the cedent CCO, under a reinsurance contract with such
			 reinsurer as security for the payment of obligations under the reinsurance
			 contract. The security must be held in the United States subject to withdrawal
			 solely by and under the exclusive control of the cedent CCO insurer or, in the
			 case of a trust, held in a Qualified United States Financial Institution. The
			 security may be in the form of any of the following:
(a) Cash.
(b) Securities listed by the SVO.
(c) Clean, irrevocable, unconditional and
			 "evergreen" letters of credit issued or confirmed by a Qualified United States
			 Financial Institution effective no later than December 31 of the year for which
			 filing is being made, and in the possession of, or in trust for, the cedent CCO
			 on or before the filing date of its annual statement. Letters of credit meeting
			 applicable standards of issuer acceptability as of the dates of their issuance
			 or confirmation shall, notwithstanding the issuing or confirming institution's
			 subsequent failure to meet applicable standards of issuer acceptability,
			 continue to be acceptable as security until their expiration, extension,
			 renewal, modification or amendment, whichever first occurs.
(d) Any other form of security acceptable to
			 the Authority.