Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1380 - Compliance with Federal and State Statutes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When a Provider submits a claim for
			 medical services or supplies provided to a Division of Medical Assistance
			 Programs (Division) client, Division will deem the submission as a
			 representation by the medical Provider to the Medical Assistance Program of the
			 medical Provider's compliance with the applicable sections of the federal and
			 state statutes referenced in this rule:
(a)
			  45 CFR Part 84  which implements Title V, Section 504 of the Rehabilitation Act
			 of 1973;
(b)  42 CFR Part 493
			  Laboratory Requirements and ORS 438 (Clinical Laboratories).
(c) Unless exempt under  45CFR Part 87  for
			 Faith-Based Organizations (Federal Register, July 16, 2004, Volume 69, #136),
			 or other federal provisions, the Provider must comply and, as indicated, cause
			 all sub-contractors to comply with the following federal requirements to the
			 extent that they are applicable to the goods and services governed by these
			 rules. For purposes of these rules, all references to federal and state laws
			 are references to federal and state laws as they may be amended from time to
			 time:
(A) The Provider must comply and cause
			 all subcontractors to comply with all federal laws, regulations, executive
			 orders applicable to the goods and services provided under these rules. Without
			 limiting the generality of the foregoing, the Provider expressly agrees to
			 comply and cause all subcontractors to comply with the following laws,
			 regulations and executive orders to the extent they are applicable to the goods
			 and services provided under these rules:
(i)
			 Title VI and VII of the Civil Rights Act of 1964, as amended;
(ii) Sections 503 and 504 of the
			 Rehabilitation Act of 1973, as amended;
(iii) The Americans with Disabilities Act of
			 1990, as amended;
(iv) Executive
			 Order 11246, as amended;
(v) The
			 Health Insurance Portability and Accountability Act of 1996;
(vi) The Age Discrimination in Employment Act
			 of 1967, as amended, and the Age Discrimination Act of 1975, as
			 amended;
(vii) The Vietnam Era
			 Veterans' Readjustment Assistance Act of 1974, as amended,
(viii) all regulations and administrative
			 rules established pursuant to the foregoing laws;
(viii) All other applicable requirements of
			 federal civil rights and rehabilitation statutes, rules and
			 regulations;
(ix) All federal law
			 governing operation of Community Mental Health Programs, including without
			 limitation, all federal laws requiring reporting of client abuse. These laws,
			 regulations and executive orders are incorporated by reference herein to the
			 extent that they are applicable to the goods and services governed by these
			 rules and required by law to be so incorporated. No federal funds may be used
			 to provide services in violation of
			 42 USC
			 14402.
(B) Any Provider that receives or makes
			 annual payments under the Title XIX State Plan of at least $5,000,000, as a
			 condition of receiving such payments, shall:
(i) Establish written policies for all
			 employees of the entity (including management), and of any contractor,
			 subcontractor, or agent of the entity, that provide detailed information about
			 the False Claims Act established under sections 3729 through 3733 of title 31,
			 United States Code, administrative remedies for false claims and statements
			 established under chapter 38 of title 31, United States Code, any Oregon State
			 laws pertaining to civil or criminal penalties for false claims and statements,
			 and whistleblowing protections under such laws, with respect to the role of
			 such laws in preventing and detecting fraud, waste, and abuse in Federal health
			 care programs (as defined in section 1128B(f));
(ii) Include as part of written policies,
			 detailed provisions regarding the entity's policies and procedures for
			 detecting and preventing fraud, waste and abuse; and
(iii) Include in any employee handbook for
			 the entity, a specific discussion of the laws described in (i), the rights of
			 the employees to be protected as whistleblowers, and the entity's policies and
			 procedures for detecting and preventing fraud, waste, and abuse.
(C) If the goods and services
			 governed under these rules exceed $10,000, the Provider must comply and cause
			 all subcontractors to comply with Executive Order 11246, entitled "Equal
			 Employment Opportunity," as amended by Executive Order 11375, and as
			 supplemented in Department of Labor regulations ( 41 CFR Part 60);
(D) If the goods and services governed under
			 these rules exceed $100,000, the Provider must comply and cause all
			 subcontractors to comply with all applicable standards, orders, or requirements
			 issued under Section 306 of the Clean Air Act (42 U.S.C. 7606), the
			 Federal Water Pollution Control Act as amended (commonly known as the Clean
			 Water Act- 33 U.S.C.
			 1251 to
			 1387), specifically including, but
			 not limited to, Section 508 (33 U.S.C. 1368). Executive Order
			 11738, and Environmental Protection Agency regulations ( 40 CFR Part 32), which
			 prohibit the use under non-exempt Federal contracts, grants or loans of
			 facilities included on the EPA List of Violating Facilities. Violations must be
			 reported to the Authority, the federal Department of Health and Human Services
			 (DHHS) and the appropriate Regional Office of the Environmental Protection
			 Agency. The Provider must include and cause all subcontractors to include in
			 all contracts with subcontractors receiving more than $100,000, language
			 requiring the subcontractor to comply with the federal laws identified in this
			 section;
(E) The Provider must
			 comply and cause all subcontractors to comply with applicable mandatory
			 standards and policies relating to energy efficiency that are contained in the
			 Oregon energy conservation plan issued in compliance with the Energy Policy and
			 Conservation Act, 42 U.S.C.
			 6201 et seq. (Pub. L.
			 94-163);
(F) The Provider certifies, to the best of
			 the Provider's knowledge and belief, that:
(i)
			 No federal appropriated funds have been paid or will be paid, by or on behalf
			 of the Provider, to any person for influencing or attempting to influence an
			 officer or employee of an agency, a Member of Congress, an officer or employee
			 of Congress, or an employee of a Member of Congress in connection with the
			 awarding of any federal contract, the making of any federal grant, the making
			 of any federal loan, the entering into of any cooperative agreement, and the
			 extension, continuation, renewal, amendment or modification of any federal
			 contract, grant, loan or cooperative agreement;
(ii) If any funds other than federal
			 appropriated funds have been paid or will be paid to any person for influencing
			 or attempting to influence an officer or employee of any agency, a Member of
			 Congress, an officer or employee of Congress, or an employee of a Member of
			 Congress in connection with this federal contract, grant, loan or cooperative
			 agreement, the Provider must complete and submit Standard Form LLL, "Disclosure
			 Form to Report Lobbying" in accordance with its instructions;
(iii) The Provider must require that the
			 language of this certification be included in the award documents for all
			 sub-awards at all tiers (including subcontracts, sub-grants, and contracts
			 under grants, loans, and cooperative agreements) and that all sub-recipients
			 and subcontractors must certify and disclose accordingly;
(iv) This certification is a material
			 representation of fact upon which reliance was placed when this Provider
			 agreement was made or entered into. Submission of this certification is a
			 prerequisite for making or entering into this Provider agreement imposed by
			 section 1352, Title 31, U.S. Code. Any person who fails to file the required
			 certification will be subject to a civil penalty of not less than $10,000 and
			 not more than $100,000 for each such failure.
(G) If the goods and services funded in whole
			 or in part with financial assistance provided under these rules are covered by
			 the Health Insurance Portability and Accountability Act or the federal
			 regulations implementing the Act (collectively referred to as HIPAA), the
			 Provider agrees to deliver the goods and services in compliance with HIPAA.
			 Without limiting the generality of the foregoing, goods and services funded in
			 whole or in part with financial assistance provided under these rules are
			 covered by HIPAA. The Provider must comply and cause all subcontractors to
			 comply with the following:
(i) Individually
			 Identifiable Health Information about specific individuals is confidential.
			 Individually Identifiable Health Information relating to specific individuals
			 may be exchanged between the Provider and the Authority for purposes directly
			 related to the provision to clients of services that are funded in whole or in
			 part under these rules. However, the Provider must not use or disclose any
			 Individually Identifiable Health Information about specific individuals in a
			 manner that would violate Authority Privacy Rules, or Authority Notice of
			 Privacy Practices, if done by the Authority. A copy of the most recent
			 Authority Notice of Privacy Practices is posted on the Authority Web site or
			 may be obtained from the Authority;
(ii) If the Provider intends to engage in
			 Electronic Data Interchange (EDI) transactions with the Authority in connection
			 with claims or encounter data, eligibility or enrollment information,
			 authorizations or other electronic transactions, the Provider must execute an
			 EDI Trading Partner Agreement with the Authority and must comply with the
			 Authority EDI rules;
(iii) If a
			 Provider reasonably believes that the Provider's or the Authority's data
			 transactions system or other application of HIPAA privacy or security
			 compliance policy may result in a violation of HIPAA requirements, the Provider
			 must promptly consult the Authority Privacy Officer. The Provider or Authority
			 may initiate a request to test HIPAA transactions, subject to available
			 resources and the Authority testing schedule.
(H) The Provider must comply and cause all
			 subcontractors to comply with all mandatory standards and policies that relate
			 to resource conservation and recovery pursuant to the Resource Conservation and
			 Recovery Act (codified at 42
			 USC 6901 et. seq.). Section 6002 of that Act
			 (codified at 42 USC
			 6962) requires that preference be given in
			 procurement programs to the purchase of specific products containing recycled
			 materials identified in guidelines developed by the Environmental Protection
			 Agency. Current guidelines are set forth in 40 CFR Parts 247;
(I) The Provider must comply and, if
			 applicable, cause a subcontractor to comply, with the applicable audit
			 requirements and responsibilities set forth in the Office of Management and
			 Budget Circular A-133 entitled "Audits of States, Local Governments and
			 Non-Profit Organizations;"
(J) The
			 Provider must not permit any person or entity to be a subcontractor if the
			 person or entity is listed on the non-procurement portion of the General
			 Service Administration's "List of Parties Excluded from Federal Procurement or
			 Nonprocurement Programs" in accordance with Executive Orders No. 12,549 and No.
			 12,689, "Debarment and Suspension". (See  45 CFR part 76). This list contains
			 the names of parties debarred, suspended, or otherwise excluded by agencies,
			 and Providers and subcontractors declared ineligible under statutory authority
			 other than Executive Order No. 12549. Subcontractors with awards that exceed
			 the simplified acquisition threshold must provide the required certification
			 regarding their exclusion status and that of their principals prior to
			 award;
(K) The Provider must comply
			 and cause all subcontractors to comply with the following provisions to
			 maintain a drug-free workplace:
(i) The
			 Provider certifies that it will provide a drug-free workplace by publishing a
			 statement notifying its employees that the unlawful manufacture, distribution,
			 dispensation, possession or use of a controlled substance, except as may be
			 present in lawfully prescribed or over-the-counter medications, is prohibited
			 in the Provider's workplace or while providing services to Authority clients.
			 The Provider's notice must specify the actions that will be taken by the
			 Provider against its employees for violation of such prohibitions;
(ii) Establish a drug-free awareness program
			 to inform its employees about the dangers of drug abuse in the workplace, the
			 Provider's policy of maintaining a drug-free workplace, any available drug
			 counseling, rehabilitation, and employee assistance programs, and the penalties
			 that may be imposed upon employees for drug abuse violations;
(iii) Provide each employee to be engaged in
			 the performance of services under these rules a copy of the statement mentioned
			 in paragraph (J)(i) above in this section;
(iv) Notify each employee in the statement
			 required by paragraph (J)(i) of this section that, as a condition of employment
			 to provide services under these rules, the employee will abide by the terms of
			 the statement and notify the employer of any criminal drug statute conviction
			 for a violation occurring in the workplace no later than five (5) days after
			 such conviction;
(v) Notify the
			 Authority within ten (10) days after receiving notice under subparagraph
			 (J)(iv) of this section from an employee or otherwise receiving actual notice
			 of such conviction;
(vi) Impose a
			 sanction on, or require the satisfactory participation in a drug abuse
			 assistance or rehabilitation program by any employee who is so convicted as
			 required by Section 5154 of the Drug-Free Workplace Act of 1988;
(vii) Make a good-faith effort to continue a
			 drug-free workplace through implementation of subparagraphs (J)(i) through
			 (J)(vi) of this section;
(viii)
			 Require any subcontractor to comply with subparagraphs (J)(i) through (J)(vii)
			 of this section;
(ix) Neither the
			 Provider, nor any of the Provider's employees, officers, agents or
			 subcontractors may provide any service required under these rules while under
			 the influence of drugs. For purposes of this provision, "under the influence"
			 means observed abnormal behavior or impairments in mental or physical
			 performance leading a reasonable person to believe the Provider or Provider's
			 employee, officer, agent or subcontractor has used a controlled substance,
			 prescription or non-prescription medication that impairs the Provider or
			 Provider's employee, officer, agent or subcontractor's performance of essential
			 job function or creates a direct threat to Authority clients or others.
			 Examples of abnormal behavior include, but are not limited to hallucinations,
			 paranoia or violent outbursts. Examples of impairments in physical or mental
			 performance include, but are not limited to slurred speech, difficulty walking
			 or performing job activities;
(x)
			 Violation of any provision of this subsection may result in termination of the
			 Provider agreement under these rules.
(L) The Provider must comply and cause all
			 sub-contractors to comply with the Pro-Children Act of 1994 (codified at
			 20 USC section
			 6081 et. seq.);
(M) The Provider must comply with all
			 applicable federal and state laws and regulations pertaining to the provision
			 of Medicaid Services under the Medicaid Act, Title XIX,
			 42 USC Section
			 1396 et. Seq., and CHIP benefits established
			 by Title XXI of the Social Security Act, including without limitation:
(i) Keep such records as are necessary to
			 fully disclose the extent of the services provided to individuals receiving
			 Medicaid assistance and must furnish such information to any state or federal
			 agency responsible for administering the Medicaid program regarding any
			 payments claimed by such person or institution for providing Medicaid Services
			 as the state or federal agency may from time to time request.
			 42 USC Section
			 1396a(a)(27);
			  42 CFR 431.107(b)(1)  & (2);
			 42 CFR
			 457.950(a)(3);
(ii) Comply with all disclosure requirements
			 of 42 CFR
			 1002.3(a) and
			  42 CFR 455  Subpart (B);
			 42 CFR
			 457.950(a)(3);
(iii) Maintain written notices and procedures
			 respecting advance directives in compliance with
			 42 USC Section
			 1396a(a)(57) and (w),
			  42 CFR 431.107(b)(4), and
			  42 CFR
			 489  subpart I;
(iv) Certify when submitting any claim for
			 the provision of Medicaid Services that the information submitted is true,
			 accurate and complete. The Provider must acknowledge Provider's understanding
			 that payment of the claim will be from federal and state funds and that any
			 falsification or concealment of a material fact may be prosecuted under federal
			 and state laws.