ORS 414.572
Coordinated care organizations

  • rules

(1)

The Oregon Health Authority shall adopt by rule the qualification criteria and requirements for a coordinated care organization and shall integrate the criteria and requirements into each contract with a coordinated care organization. Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two. Coordinated care organizations may contract with counties or with other public or private entities to provide services to members. The authority may not contract with only one statewide organization. A coordinated care organization may be a single corporate structure or a network of providers organized through contractual relationships. The criteria and requirements adopted by the authority under this section must include, but are not limited to, a requirement that the coordinated care organization:

(a)

Have demonstrated experience and a capacity for managing financial risk and establishing financial reserves.

(b)

Meet the following minimum financial requirements:

(A)

Maintain restricted reserves of $250,000 plus an amount equal to 50 percent of the coordinated care organization’s total actual or projected liabilities above $250,000.

(B)

Maintain capital or surplus of not less than $2,500,000 and any additional amounts necessary to ensure the solvency of the coordinated care organization, as specified by the authority by rules that are consistent with ORS 731.554 (Capital and surplus requirements) (6), 732.225 (Impairment of required capitalization prohibited), 732.230 (Order to cure impairment) and 750.045 (Required capitalization).

(C)

Expend a portion of the annual net income or reserves of the coordinated care organization that exceed the financial requirements specified in this paragraph on services designed to address health disparities and the social determinants of health consistent with the coordinated care organization’s community health improvement plan and transformation plan and the terms and conditions of the Medicaid demonstration project under section 1115 of the Social Security Act (42 U.S.C. 1315).

(c)

Operate within a fixed global budget and, by January 1, 2023, spend on primary care, as defined in section 2, chapter 575, Oregon Laws 2015, at least 12 percent of the coordinated care organization’s total expenditures for physical and mental health care provided to members, except for expenditures on prescription drugs, vision care and dental care.

(d)

Develop and implement alternative payment methodologies that are based on health care quality and improved health outcomes.

(e)

Coordinate the delivery of physical health care, behavioral health care, oral health care and covered long-term care services.

(f)

Engage community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the coordinated care organization’s members and in the coordinated care organization’s community.

(2)

In addition to the criteria and requirements specified in subsection (1) of this section, the authority must adopt by rule requirements for coordinated care organizations contracting with the authority so that:

(a)

Each member of the coordinated care organization receives integrated person centered care and services designed to provide choice, independence and dignity.

(b)

Each member has a consistent and stable relationship with a care team that is responsible for comprehensive care management and service delivery.

(c)

The supportive and therapeutic needs of each member are addressed in a holistic fashion, using patient centered primary care homes, behavioral health homes or other models that support patient centered primary care and behavioral health care and individualized care plans to the extent feasible.

(d)

Members receive comprehensive transitional care, including appropriate follow-up, when entering and leaving an acute care facility or a long term care setting.

(e)

Members are provided:

(A)

Assistance in navigating the health care delivery system;

(B)

Assistance in accessing community and social support services and statewide resources;

(C)

Meaningful language access as required by federal and state law including, but not limited to, 42 U.S.C. 18116, Title VI of the Civil Rights Act of 1964, Title VI Guidance issued by the United States Department of Justice and the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care as issued by the United States Department of Health and Human Services; and

(D)

Qualified health care interpreters or certified health care interpreters listed on the health care interpreter registry, as those terms are defined in ORS 413.550 (Definitions for ORS 413.550 to 413.559).

(f)

Services and supports are geographically located as close to where members reside as possible and are, if available, offered in nontraditional settings that are accessible to families, diverse communities and underserved populations.

(g)

Each coordinated care organization uses health information technology to link services and care providers across the continuum of care to the greatest extent practicable and if financially viable.

(h)

Each coordinated care organization complies with the safeguards for members described in ORS 414.605 (Consumer and provider protections).

(i)

Each coordinated care organization convenes a community advisory council that meets the criteria specified in ORS 414.575 (Community advisory councils).

(j)

Each coordinated care organization prioritizes working with members who have high health care needs, multiple chronic conditions or behavioral health conditions and involves those members in accessing and managing appropriate preventive, health, remedial and supportive care and services, including the services described in ORS 414.766 (Behavioral health treatment), to reduce the use of avoidable emergency room visits and hospital admissions.

(k)

Members have a choice of providers within the coordinated care organization’s network and that providers participating in a coordinated care organization:

(A)

Work together to develop best practices for care and service delivery to reduce waste and improve the health and well-being of members.

(B)

Are educated about the integrated approach and how to access and communicate within the integrated system about a patient’s treatment plan and health history.

(C)

Emphasize prevention, healthy lifestyle choices, evidence-based practices, shared decision-making and communication.

(D)

Are permitted to participate in the networks of multiple coordinated care organizations.

(E)

Include providers of specialty care.

(F)

Are selected by coordinated care organizations using universal application and credentialing procedures and objective quality information and are removed if the providers fail to meet objective quality standards.

(G)

Work together to develop best practices for culturally and linguistically appropriate care and service delivery to reduce waste, reduce health disparities and improve the health and well-being of members.

(L)

Each coordinated care organization reports on outcome and quality measures adopted under ORS 414.638 (Metrics and scoring subcommittee) and participates in the health care data reporting system established in ORS 442.372 (Definitions for ORS 442.372 and 442.373) and 442.373 (Health care data reporting by health insurers).

(m)

Each coordinated care organization uses best practices in the management of finances, contracts, claims processing, payment functions and provider networks.

(n)

Each coordinated care organization participates in the learning collaborative described in ORS 413.259 (Patient centered primary care home program and behavioral health home program) (3).

(o)

Each coordinated care organization has a governing body that complies with ORS 414.584 (Meetings of coordinated care organization governing body to be open to public) and that includes:

(A)

At least one member representing persons that share in the financial risk of the organization;

(B)

A representative of a dental care organization selected by the coordinated care organization;

(C)

The major components of the health care delivery system;

(D)

At least two health care providers in active practice, including:
(i)
A physician licensed under ORS chapter 677 or a nurse practitioner licensed under ORS 678.375 (Nurse practitioners), whose area of practice is primary care; and
(ii)
A behavioral health provider;

(E)

At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and

(F)

At least two members of the community advisory council, one of whom is or was within the previous six months a recipient of medical assistance and is at least 16 years of age, or a parent, guardian or primary caregiver of an individual who is or was within the previous six months a recipient of medical assistance.

(p)

Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.

(q)

Each coordinated care organization publishes on a website maintained by or on behalf of the coordinated care organization, in a manner determined by the authority, a document designed to educate members about best practices, care quality expectations, screening practices, treatment options and other support resources available for members who have mental illnesses or substance use disorders.

(r)

Each coordinated care organization works with the Tribal Advisory Council established in ORS 414.581 (Tribal Advisory Council established) and has a dedicated tribal liaison, selected by the council, to:

(A)

Facilitate a resolution of any issues that arise between the coordinated care organization and a provider of Indian health services within the area served by the coordinated care organization;

(B)

Participate in the community health assessment and the development of the health improvement plan;

(C)

Communicate regularly with the Tribal Advisory Council; and

(D)

Be available for training by the office within the authority that is responsible for tribal affairs, any federally recognized tribe in Oregon and the urban Indian health program that is located within the area served by the coordinated care organization and operated by an urban Indian organization pursuant to 25 U.S.C. 1651.

(3)

The authority shall consider the participation of area agencies and other nonprofit agencies in the configuration of coordinated care organizations.

(4)

In selecting one or more coordinated care organizations to serve a geographic area, the authority shall:

(a)

For members and potential members, optimize access to care and choice of providers;

(b)

For providers, optimize choice in contracting with coordinated care organizations; and

(c)

Allow more than one coordinated care organization to serve the geographic area if necessary to optimize access and choice under this subsection.

(5)

On or before July 1, 2014, each coordinated care organization must have a formal contractual relationship with any dental care organization that serves members of the coordinated care organization in the area where they reside. [Formerly 414.625; 2021 c.453 §13]
Note 1: The amendments to 414.572 (Coordinated care organizations) by section 13, chapter 453, Oregon Laws 2021, become operative July 1, 2022. See section 18, chapter 453, Oregon Laws 2021. The text that is operative until July 1, 2022, is set forth for the user’s convenience.
414.572 (Coordinated care organizations). (1) The Oregon Health Authority shall adopt by rule the qualification criteria and requirements for a coordinated care organization and shall integrate the criteria and requirements into each contract with a coordinated care organization. Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two. Coordinated care organizations may contract with counties or with other public or private entities to provide services to members. The authority may not contract with only one statewide organization. A coordinated care organization may be a single corporate structure or a network of providers organized through contractual relationships. The criteria and requirements adopted by the authority under this section must include, but are not limited to, a requirement that the coordinated care organization:

(a)

Have demonstrated experience and a capacity for managing financial risk and establishing financial reserves.

(b)

Meet the following minimum financial requirements:

(A)

Maintain restricted reserves of $250,000 plus an amount equal to 50 percent of the coordinated care organization’s total actual or projected liabilities above $250,000.

(B)

Maintain capital or surplus of not less than $2,500,000 and any additional amounts necessary to ensure the solvency of the coordinated care organization, as specified by the authority by rules that are consistent with ORS 731.554 (Capital and surplus requirements) (6), 732.225 (Impairment of required capitalization prohibited), 732.230 (Order to cure impairment) and 750.045 (Required capitalization).

(C)

Expend a portion of the annual net income or reserves of the coordinated care organization that exceed the financial requirements specified in this paragraph on services designed to address health disparities and the social determinants of health consistent with the coordinated care organization’s community health improvement plan and transformation plan and the terms and conditions of the Medicaid demonstration project under section 1115 of the Social Security Act (42 U.S.C. 1315).

(c)

Operate within a fixed global budget and, by January 1, 2023, spend on primary care, as defined in section 2, chapter 575, Oregon Laws 2015, at least 12 percent of the coordinated care organization’s total expenditures for physical and mental health care provided to members, except for expenditures on prescription drugs, vision care and dental care.

(d)

Develop and implement alternative payment methodologies that are based on health care quality and improved health outcomes.

(e)

Coordinate the delivery of physical health care, mental health and chemical dependency services, oral health care and covered long-term care services.

(f)

Engage community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the coordinated care organization’s members and in the coordinated care organization’s community.

(2)

In addition to the criteria and requirements specified in subsection (1) of this section, the authority must adopt by rule requirements for coordinated care organizations contracting with the authority so that:

(a)

Each member of the coordinated care organization receives integrated person centered care and services designed to provide choice, independence and dignity.

(b)

Each member has a consistent and stable relationship with a care team that is responsible for comprehensive care management and service delivery.

(c)

The supportive and therapeutic needs of each member are addressed in a holistic fashion, using patient centered primary care homes, behavioral health homes or other models that support patient centered primary care and behavioral health care and individualized care plans to the extent feasible.

(d)

Members receive comprehensive transitional care, including appropriate follow-up, when entering and leaving an acute care facility or a long term care setting.

(e)

Members receive assistance in navigating the health care delivery system and in accessing community and social support services and statewide resources, including through the use of certified health care interpreters and qualified health care interpreters, as those terms are defined in ORS 413.550 (Definitions for ORS 413.550 to 413.559).

(f)

Services and supports are geographically located as close to where members reside as possible and are, if available, offered in nontraditional settings that are accessible to families, diverse communities and underserved populations.

(g)

Each coordinated care organization uses health information technology to link services and care providers across the continuum of care to the greatest extent practicable and if financially viable.

(h)

Each coordinated care organization complies with the safeguards for members described in ORS 414.605 (Consumer and provider protections).

(i)

Each coordinated care organization convenes a community advisory council that meets the criteria specified in ORS 414.575 (Community advisory councils).

(j)

Each coordinated care organization prioritizes working with members who have high health care needs, multiple chronic conditions, mental illness or chemical dependency and involves those members in accessing and managing appropriate preventive, health, remedial and supportive care and services, including the services described in ORS 414.766 (Behavioral health treatment), to reduce the use of avoidable emergency room visits and hospital admissions.

(k)

Members have a choice of providers within the coordinated care organization’s network and that providers participating in a coordinated care organization:

(A)

Work together to develop best practices for care and service delivery to reduce waste and improve the health and well-being of members.

(B)

Are educated about the integrated approach and how to access and communicate within the integrated system about a patient’s treatment plan and health history.

(C)

Emphasize prevention, healthy lifestyle choices, evidence-based practices, shared decision-making and communication.

(D)

Are permitted to participate in the networks of multiple coordinated care organizations.

(E)

Include providers of specialty care.

(F)

Are selected by coordinated care organizations using universal application and credentialing procedures and objective quality information and are removed if the providers fail to meet objective quality standards.

(G)

Work together to develop best practices for culturally appropriate care and service delivery to reduce waste, reduce health disparities and improve the health and well-being of members.

(L)

Each coordinated care organization reports on outcome and quality measures adopted under ORS 414.638 (Metrics and scoring subcommittee) and participates in the health care data reporting system established in ORS 442.372 (Definitions for ORS 442.372 and 442.373) and 442.373 (Health care data reporting by health insurers).

(m)

Each coordinated care organization uses best practices in the management of finances, contracts, claims processing, payment functions and provider networks.

(n)

Each coordinated care organization participates in the learning collaborative described in ORS 413.259 (Patient centered primary care home program and behavioral health home program) (3).

(o)

Each coordinated care organization has a governing body that complies with ORS 414.584 (Meetings of coordinated care organization governing body to be open to public) and that includes:

(A)

At least one member representing persons that share in the financial risk of the organization;

(B)

A representative of a dental care organization selected by the coordinated care organization;

(C)

The major components of the health care delivery system;

(D)

At least two health care providers in active practice, including:
(i)
A physician licensed under ORS chapter 677 or a nurse practitioner licensed under ORS 678.375 (Nurse practitioners), whose area of practice is primary care; and
(ii)
A mental health or chemical dependency treatment provider;

(E)

At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and

(F)

At least two members of the community advisory council, one of whom is or was within the previous six months a recipient of medical assistance and is at least 16 years of age, or a parent, guardian or primary caregiver of an individual who is or was within the previous six months a recipient of medical assistance.

(p)

Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.

(q)

Each coordinated care organization publishes on a website maintained by or on behalf of the coordinated care organization, in a manner determined by the authority, a document designed to educate members about best practices, care quality expectations, screening practices, treatment options and other support resources available for members who have mental illnesses or substance use disorders.

(r)

Each coordinated care organization works with the Tribal Advisory Council established in ORS 414.581 (Tribal Advisory Council established) and has a dedicated tribal liaison, selected by the council, to:

(A)

Facilitate a resolution of any issues that arise between the coordinated care organization and a provider of Indian health services within the area served by the coordinated care organization;

(B)

Participate in the community health assessment and the development of the health improvement plan;

(C)

Communicate regularly with the Tribal Advisory Council; and

(D)

Be available for training by the office within the authority that is responsible for tribal affairs, any federally recognized tribe in Oregon and the urban Indian health program that is located within the area served by the coordinated care organization and operated by an urban Indian organization pursuant to 25 U.S.C. 1651.

(3)

The authority shall consider the participation of area agencies and other nonprofit agencies in the configuration of coordinated care organizations.

(4)

In selecting one or more coordinated care organizations to serve a geographic area, the authority shall:

(a)

For members and potential members, optimize access to care and choice of providers;

(b)

For providers, optimize choice in contracting with coordinated care organizations; and

(c)

Allow more than one coordinated care organization to serve the geographic area if necessary to optimize access and choice under this subsection.

(5)

On or before July 1, 2014, each coordinated care organization must have a formal contractual relationship with any dental care organization that serves members of the coordinated care organization in the area where they reside.
Note 2: The amendments to 414.572 (Coordinated care organizations) (formerly 414.625) by section 14, chapter 489, Oregon Laws 2017, become operative January 1, 2023. See section 20, chapter 489, Oregon Laws 2017. The text that is operative on and after January 1, 2023, including amendments by section 4, chapter 49, Oregon Laws 2018, section 8, chapter 358, Oregon Laws 2019, section 2, chapter 364, Oregon Laws 2019, section 58, chapter 478, Oregon Laws 2019, section 7, chapter 529, Oregon Laws 2019, and section 14, chapter 453, Oregon Laws 2021, is set forth for the user’s convenience.
414.572 (Coordinated care organizations). (1) The Oregon Health Authority shall adopt by rule the qualification criteria and requirements for a coordinated care organization and shall integrate the criteria and requirements into each contract with a coordinated care organization. Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two. Coordinated care organizations may contract with counties or with other public or private entities to provide services to members. The authority may not contract with only one statewide organization. A coordinated care organization may be a single corporate structure or a network of providers organized through contractual relationships. The criteria and requirements adopted by the authority under this section must include, but are not limited to, a requirement that the coordinated care organization:

(a)

Have demonstrated experience and a capacity for managing financial risk and establishing financial reserves.

(b)

Meet the following minimum financial requirements:

(A)

Maintain restricted reserves of $250,000 plus an amount equal to 50 percent of the coordinated care organization’s total actual or projected liabilities above $250,000.

(B)

Maintain capital or surplus of not less than $2,500,000 and any additional amounts necessary to ensure the solvency of the coordinated care organization, as specified by the authority by rules that are consistent with ORS 731.554 (Capital and surplus requirements) (6), 732.225 (Impairment of required capitalization prohibited), 732.230 (Order to cure impairment) and 750.045 (Required capitalization).

(C)

Expend a portion of the annual net income or reserves of the coordinated care organization that exceed the financial requirements specified in this paragraph on services designed to address health disparities and the social determinants of health consistent with the coordinated care organization’s community health improvement plan and transformation plan and the terms and conditions of the Medicaid demonstration project under section 1115 of the Social Security Act (42 U.S.C. 1315).

(c)

Operate within a fixed global budget and spend on primary care, as defined by the authority by rule, at least 12 percent of the coordinated care organization’s total expenditures for physical and mental health care provided to members, except for expenditures on prescription drugs, vision care and dental care.

(d)

Develop and implement alternative payment methodologies that are based on health care quality and improved health outcomes.

(e)

Coordinate the delivery of physical health care, behavioral health care, oral health care and covered long-term care services.

(f)

Engage community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the coordinated care organization’s members and in the coordinated care organization’s community.

(2)

In addition to the criteria and requirements specified in subsection (1) of this section, the authority must adopt by rule requirements for coordinated care organizations contracting with the authority so that:

(a)

Each member of the coordinated care organization receives integrated person centered care and services designed to provide choice, independence and dignity.

(b)

Each member has a consistent and stable relationship with a care team that is responsible for comprehensive care management and service delivery.

(c)

The supportive and therapeutic needs of each member are addressed in a holistic fashion, using patient centered primary care homes, behavioral health homes or other models that support patient centered primary care and behavioral health care and individualized care plans to the extent feasible.

(d)

Members receive comprehensive transitional care, including appropriate follow-up, when entering and leaving an acute care facility or a long term care setting.

(e)

Members are provided:

(A)

Assistance in navigating the health care delivery system;

(B)

Assistance in accessing community and social support services and statewide resources;

(C)

Meaningful language access as required by federal and state law including, but not limited to, 42 U.S.C. 18116, Title VI of the Civil Rights Act of 1964, Title VI Guidance issued by the United States Department of Justice and the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care as issued by the United States Department of Health and Human Services; and

(D)

Qualified health care interpreters or certified health care interpreters listed on the health care interpreter registry, as those terms are defined in ORS 413.550 (Definitions for ORS 413.550 to 413.559).

(f)

Services and supports are geographically located as close to where members reside as possible and are, if available, offered in nontraditional settings that are accessible to families, diverse communities and underserved populations.

(g)

Each coordinated care organization uses health information technology to link services and care providers across the continuum of care to the greatest extent practicable and if financially viable.

(h)

Each coordinated care organization complies with the safeguards for members described in ORS 414.605 (Consumer and provider protections).

(i)

Each coordinated care organization convenes a community advisory council that meets the criteria specified in ORS 414.575 (Community advisory councils).

(j)

Each coordinated care organization prioritizes working with members who have high health care needs, multiple chronic conditions or behavioral health conditions and involves those members in accessing and managing appropriate preventive, health, remedial and supportive care and services, including the services described in ORS 414.766 (Behavioral health treatment), to reduce the use of avoidable emergency room visits and hospital admissions.

(k)

Members have a choice of providers within the coordinated care organization’s network and that providers participating in a coordinated care organization:

(A)

Work together to develop best practices for care and service delivery to reduce waste and improve the health and well-being of members.

(B)

Are educated about the integrated approach and how to access and communicate within the integrated system about a patient’s treatment plan and health history.

(C)

Emphasize prevention, healthy lifestyle choices, evidence-based practices, shared decision-making and communication.

(D)

Are permitted to participate in the networks of multiple coordinated care organizations.

(E)

Include providers of specialty care.

(F)

Are selected by coordinated care organizations using universal application and credentialing procedures and objective quality information and are removed if the providers fail to meet objective quality standards.

(G)

Work together to develop best practices for culturally and linguistically appropriate care and service delivery to reduce waste, reduce health disparities and improve the health and well-being of members.

(L)

Each coordinated care organization reports on outcome and quality measures adopted under ORS 414.638 (Metrics and scoring subcommittee) and participates in the health care data reporting system established in ORS 442.372 (Definitions for ORS 442.372 and 442.373) and 442.373 (Health care data reporting by health insurers).

(m)

Each coordinated care organization uses best practices in the management of finances, contracts, claims processing, payment functions and provider networks.

(n)

Each coordinated care organization participates in the learning collaborative described in ORS 413.259 (Patient centered primary care home program and behavioral health home program) (3).

(o)

Each coordinated care organization has a governing body that complies with ORS 414.584 (Meetings of coordinated care organization governing body to be open to public) and that includes:

(A)

At least one member representing persons that share in the financial risk of the organization;

(B)

A representative of a dental care organization selected by the coordinated care organization;

(C)

The major components of the health care delivery system;

(D)

At least two health care providers in active practice, including:
(i)
A physician licensed under ORS chapter 677 or a nurse practitioner licensed under ORS 678.375 (Nurse practitioners), whose area of practice is primary care; and
(ii)
A behavioral health provider;

(E)

At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and

(F)

At least two members of the community advisory council, one of whom is or was within the previous six months a recipient of medical assistance and is at least 16 years of age or a parent, guardian or primary caregiver of an individual who is or was within the previous six months a recipient of medical assistance.

(p)

Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.

(q)

Each coordinated care organization publishes on a website maintained by or on behalf of the coordinated care organization, in a manner determined by the authority, a document designed to educate members about best practices, care quality expectations, screening practices, treatment options and other support resources available for members who have mental illnesses or substance use disorders.

(r)

Each coordinated care organization works with the Tribal Advisory Council established in ORS 414.581 (Tribal Advisory Council established) and has a dedicated tribal liaison, selected by the council, to:

(A)

Facilitate a resolution of any issues that arise between the coordinated care organization and a provider of Indian health services within the area served by the coordinated care organization;

(B)

Participate in the community health assessment and the development of the health improvement plan;

(C)

Communicate regularly with the Tribal Advisory Council; and

(D)

Be available for training by the office within the authority that is responsible for tribal affairs, any federally recognized tribe in Oregon and the urban Indian health program that is located within the area served by the coordinated care organization and operated by an urban Indian organization pursuant to 25 U.S.C. 1651.

(3)

The authority shall consider the participation of area agencies and other nonprofit agencies in the configuration of coordinated care organizations.

(4)

In selecting one or more coordinated care organizations to serve a geographic area, the authority shall:

(a)

For members and potential members, optimize access to care and choice of providers;

(b)

For providers, optimize choice in contracting with coordinated care organizations; and

(c)

Allow more than one coordinated care organization to serve the geographic area if necessary to optimize access and choice under this subsection.

(5)

On or before July 1, 2014, each coordinated care organization must have a formal contractual relationship with any dental care organization that serves members of the coordinated care organization in the area where they reside.

Source: Section 414.572 — Coordinated care organizations; rules, https://www.­oregonlegislature.­gov/bills_laws/ors/ors414.­html.

414.018
Legislative intent
414.025
Definitions for ORS chapters 411, 413 and 414
414.033
Expenditures for medical assistance authorized
414.034
Acceptance of federal billing, reimbursement and reporting forms
414.041
Simplified application process
414.044
Notice to Department of Veterans’ Affairs of information regarding applications for health care coverage by uniformed service members and veterans
414.065
Determination of health care and services covered
414.066
Billing patient for services covered by medical assistance prohibited
414.067
Coordinated care organization assumption of costs
414.071
Timely payment for dental services
414.072
Prior authorization data and reports
414.075
Payment of deductibles imposed under federal law
414.095
Exemptions applicable to payments
414.109
Oregon Health Plan Fund
414.115
Medical assistance by insurance or service contracts
414.117
Premium assistance for health insurance coverage
414.125
Rates on insurance or service contracts
414.135
Contracts relating to direct providers of care and services
414.145
Implementation of ORS 414.115, 414.125 or 414.135
414.150
Purpose of ORS 414.150 to 414.153
414.152
Duty of state agencies to work with local health departments
414.153
Services provided by local health departments
414.211
Medicaid Advisory Committee
414.221
Duties of committee
414.225
Oregon Health Authority to consult with committee
414.227
Application of public meetings law to advisory committees
414.231
Eligibility for Cover All People program
414.312
Oregon Prescription Drug Program
414.314
Application and participation in Oregon Prescription Drug Program
414.318
Prescription Drug Purchasing Fund
414.320
Rules
414.325
Prescription drugs
414.326
Supplemental rebates from pharmaceutical manufacturers
414.327
Electronically transmitted prescriptions
414.328
Synchronization of prescription drug refills
414.329
Prescription drug benefits for certain persons who are eligible for Medicare Part D prescription drug coverage
414.330
Legislative findings on prescription drugs
414.332
Policy for Practitioner-Managed Prescription Drug Plan
414.334
Practitioner-Managed Prescription Drug Plan for medical assistance program
414.337
Limitation on rules regarding Practitioner-Managed Prescription Drug Plan
414.351
Definitions for ORS 414.351 to 414.414
414.353
Committee established
414.354
Meetings
414.356
Executive session
414.359
Mental Health Clinical Advisory Group
414.361
Committee to advise and make recommendations on drug utilization review standards and interventions
414.364
Intervention approaches
414.369
Prospective drug use review program
414.371
Retrospective drug use review program
414.372
Pharmacy lock-in program
414.381
Annual reports
414.382
Requirements for annual report
414.414
Use and disclosure of confidential information
414.426
Payment of cost of medical care for institutionalized persons
414.428
Coverage for American Indian and Alaska Native beneficiaries
414.430
Access to dental care for pregnant women
414.432
Reproductive health services for noncitizens
414.500
Findings regarding medical assistance for persons with hemophilia
414.510
Definitions
414.520
Hemophilia services
414.530
When payments not made for hemophilia services
414.532
Definitions for ORS 414.534 to 414.538
414.534
Treatment for breast or cervical cancer
414.536
Presumptive eligibility for medical assistance for treatment of breast or cervical cancer
414.538
Prohibition on coverage limitations
414.540
Rules
414.550
Definitions for ORS 414.550 to 414.565
414.555
Findings regarding medical assistance for persons with cystic fibrosis
414.560
Cystic fibrosis services
414.565
When payments not made for cystic fibrosis services
414.570
System established
414.572
Coordinated care organizations
414.575
Community advisory councils
414.577
Community health assessment and adoption of community health improvement plan
414.578
Community health improvement plan
414.581
Tribal Advisory Council established
414.584
Meetings of coordinated care organization governing body to be open to public
414.590
Coordinated care organization contracts
414.591
Coordinated care organization contracts
414.592
Requirements for contracts between authority and providers
414.593
Reporting and public disclosure of expenditures by coordinated care organizations
414.595
External quality reviews of coordinated care organizations
414.598
Alternative payment methodologies
414.605
Consumer and provider protections
414.607
Use and disclosure of member information
414.609
Network adequacy
414.611
Transfer of 500 or more members of coordinated care organization
414.613
Discrimination based on scope of practice prohibited
414.619
Coordination between Oregon Health Authority and Department of Human Services
414.628
Innovator agents
414.631
Mandatory enrollment in coordinated care organization
414.632
Services to individuals who are dually eligible for Medicare and Medicaid
414.638
Metrics and scoring subcommittee
414.654
Persons served by prepaid managed care health services organizations
414.655
Utilization of patient centered primary care homes and behavioral health homes by coordinated care organizations
414.665
Traditional health workers utilized by coordinated care organizations
414.667
Definition for ORS 414.667 to 414.669
414.668
Access to doula services
414.669
Payment for doula services
414.672
Tribal-based practices for mental health and substance abuse prevention, counseling and treatment
414.686
Health assessments for foster children
414.688
Commission established
414.689
Members
414.690
Prioritized list of health services
414.694
Commission review of covered reproductive health services
414.695
Medical technology assessment
414.698
Comparative effectiveness of medical technologies
414.701
Commission may not rely solely on comparative effectiveness research
414.704
Advisory committee
414.706
Persons eligible for medical assistance
414.709
Adjustment of population of eligible persons in event of insufficient resources prohibited
414.710
Services not subject to prioritized list
414.712
Health services for certain eligible persons
414.717
Palliative care program
414.719
Housing navigation services and social determinants of health
414.723
Telemedicine services
414.726
Requirement to use certified or qualified health care interpreters
414.728
Reimbursement of rural hospitals on fee-for-service basis
414.735
Reduction in scope of health services in event of insufficient resources
414.742
Payment for mental health drugs
414.743
Payment to noncontracting hospital by coordinated care organization
414.745
Liability of health care providers and plans
414.755
Payment for hospital services
414.756
Payments to Oregon Health and Science University
414.760
Payment for patient centered primary care home and behavioral health home services
414.762
Payment for child abuse assessment
414.764
Payment for services provided by pharmacy or pharmacist
414.766
Behavioral health treatment
414.767
Survey of medical assistance recipients regarding experience with behavioral health care and services
414.770
Participants in clinical trials
414.772
Limits on use of step therapy
414.780
Coordinated care organization reporting of data to assess compliance with mental health parity requirements
414.781
Fee-for-service reimbursement of co-occurring mental health and substance use disorder treatment services
414.782
Reimbursement to ensure access to addiction treatment statewide
414.805
Liability of individual for medical services received while in custody of law enforcement officer
414.807
Oregon Health Authority to pay for medical services related to law enforcement activity
414.815
Law Enforcement Medical Liability Account
414.853
Definitions
414.855
Hospital assessment
414.857
Reduction in rate required by federal law
414.863
Refund of hospital assessment
414.865
Audits
414.867
Deposit of assessments collected to Hospital Quality Assurance Fund
414.869
Establishment of Hospital Quality Assurance Fund
414.871
Applicability of hospital assessment
414.880
Managed care organization assessment
414.882
Refund of managed care organization assessment
414.884
Applicability of managed care organization assessment
414.900
Hospital assessment
414.902
Managed care organization assessment
Green check means up to date. Up to date