2017 ORS 414.651¹
Coordinated care organization contracts
  • financial reporting
  • rules

(1)(a) The Oregon Health Authority shall use, to the greatest extent possible, coordinated care organizations to provide fully integrated physical health services, chemical dependency and mental health services and oral health services. This section, and any contract entered into pursuant to this section, does not affect and may not alter the delivery of Medicaid-funded long term care services.

(b) The authority shall execute contracts with coordinated care organizations that meet the criteria adopted by the authority under ORS 414.625 (Coordinated care organizations). Contracts under this subsection are not subject to ORS chapters 279A and 279B, except ORS 279A.250 (Definitions for ORS 279A.250 to 279A.290) to 279A.290 (Miscellaneous receipts accounts) and 279B.235 (Condition concerning hours of labor).

(c) The authority shall establish financial reporting requirements for coordinated care organizations. The authority shall prescribe a reporting procedure that elicits sufficiently detailed information for the authority to assess the financial condition of each coordinated care organization and that:

(A) Enables the authority to verify that the coordinated care organization’s reserves and other financial resources are adequate to ensure against the risk of insolvency; and

(B) Includes information on the three highest executive salary and benefit packages of each coordinated care organization.

(d) The authority shall hold coordinated care organizations, contractors and providers accountable for timely submission of outcome and quality data, including but not limited to data described in ORS 442.466 (Health care data reporting by health insurers), prescribed by the authority by rule.

(e) The authority shall require compliance with the provisions of paragraphs (c) and (d) of this subsection as a condition of entering into a contract with a coordinated care organization. A coordinated care organization, contractor or provider that fails to comply with paragraph (c) or (d) of this subsection may be subject to sanctions, including but not limited to civil penalties, barring any new enrollment in the coordinated care organization and termination of the contract.

(f)(A) The authority shall adopt rules and procedures to ensure that if a rural health clinic provides a health service to a member of a coordinated care organization, and the rural health clinic is not participating in the member’s coordinated care organization, the rural health clinic receives total aggregate payments from the member’s coordinated care organization, other payers on the claim and the authority that are no less than the amount the rural health clinic would receive in the authority’s fee-for-service payment system. The authority shall issue a payment to the rural health clinic in accordance with this subsection within 45 days of receipt by the authority of a completed billing form.

(B) “Rural health clinic,” as used in this paragraph, shall be defined by the authority by rule and shall conform, as far as practicable or applicable in this state, to the definition of that term in 42 U.S.C. 1395x(aa)(2).

(2) The authority may contract with providers other than coordinated care organizations to provide integrated and coordinated health care in areas that are not served by a coordinated care organization or where the organization’s provider network is inadequate. Contracts authorized by this subsection are not subject to ORS chapters 279A and 279B, except ORS 279A.250 (Definitions for ORS 279A.250 to 279A.290) to 279A.290 (Miscellaneous receipts accounts) and 279B.235 (Condition concerning hours of labor).

(3) As provided in subsections (1) and (2) of this section, the aggregate expenditures by the authority for health services provided pursuant to ORS 414.631 (Mandatory enrollment in coordinated care organization), 414.651 (Coordinated care organization contracts) and 414.688 (Commission established) to 414.745 (Liability of health care providers and plans) may not exceed the total dollars appropriated for health services under ORS 414.631 (Mandatory enrollment in coordinated care organization), 414.651 (Coordinated care organization contracts) and 414.688 (Commission established) to 414.745 (Liability of health care providers and plans).

(4) Actions taken by providers, potential providers, contractors and bidders in specific accordance with ORS 414.631 (Mandatory enrollment in coordinated care organization), 414.651 (Coordinated care organization contracts), 414.654 (Persons served by prepaid managed care health services organizations) and 414.688 (Commission established) to 414.745 (Liability of health care providers and plans) in forming consortiums or in otherwise entering into contracts to provide health care services shall be performed pursuant to state supervision and shall be considered to be conducted at the direction of this state, shall be considered to be lawful trade practices and may not be considered to be the transaction of insurance for purposes of the Insurance Code.

(5) Health care providers contracting to provide services under ORS 414.631 (Mandatory enrollment in coordinated care organization), 414.651 (Coordinated care organization contracts) and 414.688 (Commission established) to 414.745 (Liability of health care providers and plans) shall advise a patient of any service, treatment or test that is medically necessary but not covered under the contract if an ordinarily careful practitioner in the same or similar community would do so under the same or similar circumstances.

(6) A coordinated care organization shall provide information to a member as prescribed by the authority by rule, including but not limited to written information, within 30 days of enrollment with the coordinated care organization about available providers.

(7) Each coordinated care organization shall work to provide assistance that is culturally and linguistically appropriate to the needs of the member to access appropriate services and participate in processes affecting the member’s care and services.

(8) Each coordinated care organization shall provide upon the request of a member or prospective member annual summaries of the organization’s aggregate data regarding:

(a) Grievances and appeals; and

(b) Availability and accessibility of services provided to members.

(9) A coordinated care organization may not limit enrollment in a geographic area based on the zip code of a member or prospective member. [Formerly 414.725; 2015 c.792 §6]

1 Legislative Counsel Committee, CHAPTER 414—Medical Assistance, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ors414.­html (2017) (last ac­cessed Mar. 30, 2018).
 
2 OregonLaws.org contains the con­tents of Volume 21 of the ORS, inserted along­side the per­tin­ent statutes. See the preface to the ORS An­no­ta­tions for more information.
 
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.