Bill Text: OR HB2522 | 2013 | Regular Session | Introduced
Bill Title: Relating to ensuring access to a full range of health care providers; declaring an emergency.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Failed) 2013-07-08 - In committee upon adjournment. [HB2522 Detail]
Download: Oregon-2013-HB2522-Introduced.html
77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 1463
House Bill 2522
Sponsored by Representative THOMPSON (Presession filed.)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Requires coordinated care organization to provide members with
access to chiropractic, naturopathic and nurse practitioner
services for primary care and access to licensed acupuncturists,
licensed massage therapists and licensed optometrists for
specialty care and to pay same reimbursement rate for service to
all providers of service, regardless of license or certification
of provider. Requires coordinated care organizations and prepaid
managed care health services organizations to ensure adequacy of
provider network. Modifies description of network adequacy.
Declares emergency, effective on passage.
A BILL FOR AN ACT
Relating to ensuring access to a full range of health care
providers; creating new provisions; amending ORS 414.625 and
414.645 and section 4, chapter 80, Oregon Laws 2012; repealing
section 6, chapter 80, Oregon Laws 2012; and declaring an
emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 414.625, as amended by section 20, chapter 8,
Oregon Laws 2012, is amended to read:
414.625. (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 adopted
by the authority under this section must include, but are not
limited to, the coordinated care organization's demonstrated
experience and capacity for:
(a) Managing financial risk and establishing financial
reserves.
(b) Meeting the following minimum financial requirements:
(A) Maintaining 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) Maintaining a net worth in an amount equal to at least five
percent of the average combined revenue in the prior two quarters
of the participating health care entities.
(c) Operating within a fixed global budget.
(d) Developing and implementing alternative payment
methodologies that are based on health care quality and improved
health outcomes.
(e) Coordinating the delivery of physical health care, mental
health and chemical dependency services, oral health care and
covered long-term care services.
(f) Engaging 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 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 or other models that support patient centered primary
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, as defined in ORS 413.550,
community health workers and personal health navigators who meet
competency standards established by the authority under ORS
414.665 or who are certified by the Home Care Commission under
ORS 410.604.
(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 414.635.
(i) Each coordinated care organization convenes a community
advisory council that meets the criteria specified in section 13,
chapter 8, Oregon Laws 2012.
(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 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 { + licensed acupuncturists, licensed massage
therapists, licensed optometrists and other + } providers of
specialty care.
(F) Are selected by coordinated care organizations using
universal application and credentialing procedures, 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 and participates in
the health care data reporting system established in ORS 442.464
and 442.466.
(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 442.210 (3).
(o) Each coordinated care organization has a governance
structure that includes:
(A) Persons that share in the financial risk of the
organization who must constitute a majority of the governance
structure;
(B) The major components of the health care delivery system;
(C) At least two health care providers in active practice,
including:
(i) A physician licensed under ORS chapter 677 or a nurse
practitioner certified under ORS 678.375, whose area of practice
is primary care; and
(ii) A mental health or chemical dependency treatment provider;
(D) 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
(E) At least one member of the community advisory council.
(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.
SECTION 2. ORS 414.645 is amended to read:
414.645. (1) A prepaid managed care health services
organization { + or a coordinated care organization + } that
contracts with the Oregon Health Authority must maintain a
network of providers { + from each health care profession
requiring a license or certification in this state,
+ }sufficient in numbers and { - areas of practice and - }
geographically distributed { - in a manner - } to ensure that
{ - the health services provided under the contract are
reasonably accessible to - } enrollees { + and members have
reasonable access, without significant waiting periods or other
restrictions, to all types of providers and all services under
the contract, including reasonable access to chiropractic
physicians, naturopathic physicians and certified nurse
practitioners for all primary care services that are within the
scope of the provider's license or certification + }.
{ + (2) An organization shall pay the same reimbursement rate
for a service to all providers who are acting within the scope of
their license or certification. An organization may not vary
reimbursement rates solely on the basis of a provider's license
or certification. + }
{ - (2) - } { + (3) + } An enrollee { + or member + } may
transfer from one organization to another organization no more
than once during each enrollment period.
SECTION 3. Section 4, chapter 80, Oregon Laws 2012, as amended
by section 5, chapter 80, Oregon Laws 2012, is amended to read:
{ + Sec. 4. + } (1) A coordinated care organization { + ,
fully capitated health plan or physician care organization + }
may not discriminate with respect to participation in the
organization { + or plan + } or coverage against any health care
provider who is acting within the scope of the provider's license
or certification under applicable state law. This section does
not require that an organization { + or plan + } contract with
any health care provider willing to abide by the terms and
conditions for participation established by the organization { +
or plan + }. This section does not prevent an organization
{ + or plan + } from establishing varying reimbursement rates
based on quality or performance measures.
(2) An organization { + or plan + } may establish an internal
review process for a provider aggrieved under this section,
including an alternative dispute resolution or peer review
process. An aggrieved provider may appeal the determination of
the internal review to the Oregon Health Authority.
(3) The authority shall adopt by rule a process for resolving
claims of discrimination under this section and, in making a
determination of whether there has been discrimination, must
consider the organization's { + or plan's + }:
(a) Network adequacy { + , as described in ORS 414.645 (1) + };
(b) Provider types and qualifications;
(c) Provider disciplines; and
(d) Provider reimbursement rates.
(4) A prevailing party in an appeal under this section shall be
awarded the costs of the appeal.
SECTION 4. Section 4, chapter 80, Oregon Laws 2012, as amended
by section 5, chapter 80, Oregon Laws 2012, and section 3 of this
2013 Act is amended to read:
{ + Sec. 4. + } (1) A coordinated care organization { - ,
fully capitated health plan or physician care organization - }
may not discriminate with respect to participation in the
organization { - or plan - } or coverage against any health
care provider who is acting within the scope of the provider's
license or certification under applicable state law. This section
does not require that an organization { - or plan - } contract
with any health care provider willing to abide by the terms and
conditions for participation established by the organization
{ - or plan - } . This section does not prevent an organization
{ - or plan - } from establishing varying reimbursement rates
based on quality or performance measures.
(2) An organization { - or plan - } may establish an
internal review process for a provider aggrieved under this
section, including an alternative dispute resolution or peer
review process. An aggrieved provider may appeal the
determination of the internal review to the Oregon Health
Authority.
(3) The authority shall adopt by rule a process for resolving
claims of discrimination under this section and, in making a
determination of whether there has been discrimination, must
consider the organization's { - or plan's - } :
(a) Network adequacy, as described in ORS 414.645 (1);
(b) Provider types and qualifications;
(c) Provider disciplines; and
(d) Provider reimbursement rates.
(4) A prevailing party in an appeal under this section shall be
awarded the costs of the appeal.
SECTION 5. { + The amendments to section 4, chapter 80, Oregon
Laws 2012, by section 4 of this 2013 Act become operative July 1,
2017. + }
SECTION 6. { + Section 6, chapter 80, Oregon Laws 2012, is
repealed. + }
SECTION 7. { + The qualification criteria and requirements
specified under ORS 414.625 and 414.645 must be incorporated into
any contract between the Oregon Health Authority and a
coordinated care organization that is entered into, renewed or
extended on or after the effective date of this 2013 Act. + }
SECTION 8. { + This 2013 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2013 Act takes effect on its
passage. + }
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