Bill Text: OR HB3309 | 2013 | Regular Session | Engrossed

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Bill Title: Relating to coordinated care organizations; declaring an emergency.

Spectrum: Bipartisan Bill

Status: (Failed) 2013-07-08 - In committee upon adjournment. [HB3309 Detail]

Download: Oregon-2013-HB3309-Engrossed.html

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     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 2931

                           A-Engrossed

                         House Bill 3309
                   Ordered by the House June 4
             Including House Amendments dated June 4

Sponsored by Representatives CAMERON, CLEM

                             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.

    { - Authorizes - }   { + Establishes pilot project in Marion
and Polk Counties in which + } board of directors of coordinated
care organization   { - to - }   { + may + } petition Director of
Oregon Health Authority to remove board member by vote of
two-thirds of membership under specified conditions. Requires
reduction in reimbursement paid for services provided by health
care entity represented by removed board member. Requires Oregon
Health Authority to decertify coordinated care organization that
fails to meet qualification criteria and requirements, fails to
ensure member safeguards or fails to reduce reimbursement paid to
health care entity represented by removed board member. { +
Requires authority to report to Legislative Assembly on pilot
project 12 months after effective date. + }
   { +  Sunsets January 2, 2018. + }
  Declares emergency, effective on passage.

                        A BILL FOR AN ACT
Relating to coordinated care organizations; creating new
  provisions; amending ORS 414.025, 414.625, 414.632, 414.635 and
  416.510; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
  SECTION 1.  { + The Oregon Health Authority shall conduct a
pilot project in Marion and Polk Counties. In the pilot project:
  (1) The board of directors of a coordinated care organization
that serves members residing in Marion County or Polk County may
petition the Director of the Oregon Health Authority to remove a
board member by a vote of two-thirds of the membership of the
board if the board member or the health care entity represented
by the board member:
  (a) Refuses to deliver contracted services; or
  (b) By an act or refusal to act, puts the organization at risk
of decertification under ORS 414.635.
  (2) The director shall use the dispute resolution process
described in ORS 414.635 to determine if the board member should
be removed.
  (3) If a board member removed under this section is an
individual described in ORS 414.625 (2)(o)(A) or (B), the health
care entity represented by the board member shall continue to
provide services to members of the coordinated care organization
but the organization may not reimburse the entity for those
services at a rate greater than 58 percent of the Medicare
reimbursement rate for the services.
  (4) A board member removed under this section and the health
care entity represented by the board member may not contract with
a coordinated care organization for a period of five years after
the removal or upon the termination of the pilot project,
whichever occurs first.
  (5) A board member who represents a county government may not
be removed under the pilot project. + }
  SECTION 2.  { + No later than 12 months after the effective
date of this 2013 Act, the Oregon Health Authority shall report
to the House Interim Committee on Health Care in the manner
prescribed by ORS 192.245:
  (1) The results of the pilot project;
  (2) Recommendations for legislative changes to the pilot
project; and
  (3) Recommendations for expanding the pilot project
statewide. + }
  SECTION 3. 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  { + the
certification of + } 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
 { + certification + } 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 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)  { + Except as provided in section 1 of this 2013 Act, + }
each coordinated care organization has a   { - governance
structure - }  { +  governing body + } that includes:
  (A)   { - Persons - }  { +  Individuals representing the health
care entities + } that share in the financial risk of the
organization who must constitute a majority of the
 { - governance structure - }  { +  governing body + };
  (B)  { + Individuals representing + } 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 4. ORS 414.635, as amended by section 9, chapter 602,
Oregon Laws 2011, and section 5, chapter 8, Oregon Laws 2012, is
amended to read:
  414.635. (1) The Oregon Health Authority shall adopt by rule
safeguards for members enrolled in coordinated care organizations
that protect against underutilization of services and
inappropriate denials of services. In addition to any other
consumer rights and responsibilities established by law, each
member:
  (a) Must be encouraged to be an active partner in directing the
member's health care and services and not a passive recipient of
care.
  (b) Must be educated about the coordinated care approach being
used in the community and how to navigate the coordinated health
care system.
  (c) Must have access to advocates, including qualified peer
wellness specialists where appropriate, personal health
navigators, and qualified community health workers who are part
of the member's care team to provide assistance that is
culturally and linguistically appropriate to the member's need to
access appropriate services and participate in processes
affecting the member's care and services.
  (d) Shall be encouraged within all aspects of the integrated
and coordinated health care delivery system to use wellness and
prevention resources and to make healthy lifestyle choices.

  (e) Shall be encouraged to work with the member's care team,
including providers and community resources appropriate to the
member's needs as a whole person.
  (2) The authority shall establish and maintain an enrollment
process for individuals who are dually eligible for Medicare and
Medicaid that promotes continuity of care and that allows the
member to disenroll from a coordinated care organization that
fails to promptly provide adequate services and:
  (a) To enroll in another coordinated care organization of the
member's choice; or
  (b) If another organization is not available, to receive
Medicare-covered services on a fee-for-service basis.
  (3) Members and their providers and coordinated care
organizations have the right to appeal decisions about care and
services through the authority in an expedited manner and in
accordance with the contested case procedures in ORS chapter 183.
  (4) A health care entity may not unreasonably refuse to
contract with an organization seeking to form a coordinated care
organization if the participation of the entity is necessary for
the organization to qualify as a coordinated care organization.
  (5) A health care entity may refuse to contract with a
coordinated care organization if the reimbursement established
for a service provided by the entity under the contract is below
the reasonable cost to the entity for providing the service.
  (6) A health care entity that unreasonably refuses to contract
with a coordinated care organization may not receive
fee-for-service reimbursement from the authority for services
that are available through a coordinated care organization either
directly or by contract.
  (7) The authority shall adopt by rule a process for resolving
disputes involving an entity's refusal to contract with a
coordinated care organization under subsections (4) and (5) of
this section. The process must include the use of an independent
third party arbitrator.
  (8) A coordinated care organization may not unreasonably refuse
to contract with a licensed health care provider.
  (9) The authority shall:
  (a) Monitor and enforce consumer rights and protections within
the Oregon Integrated and Coordinated Health Care Delivery System
and ensure a consistent response to complaints of violations of
consumer rights or protections.
  (b) Monitor and report on the statewide health care
expenditures and recommend actions appropriate and necessary to
contain the growth in health care costs incurred by all sectors
of the system.
   { +  (c) Decertify a coordinated care organization that:
  (A) Substantially fails to comply with rules adopted pursuant
to ORS 414.625 or this section; or
  (B) Fails to comply with section 1 (3) of this 2013 Act. + }
  SECTION 5. ORS 414.025 is amended to read:
  414.025. As used in this chapter and ORS chapters 411 and 413,
unless the context or a specially applicable statutory definition
requires otherwise:
  (1)(a) 'Alternative payment methodology' means a payment other
than a fee-for-services payment, used by coordinated care
organizations as compensation for the provision of integrated and
coordinated health care and services.
  (b) 'Alternative payment methodology' includes, but is not
limited to:
  (A) Shared savings arrangements;
  (B) Bundled payments; and
  (C) Payments based on episodes.
  (2) 'Category of aid' means assistance provided by the Oregon
Supplemental Income Program, aid granted under ORS 412.001 to
412.069 and 418.647 or federal Supplemental Security Income
payments.
  (3) 'Categorically needy' means, insofar as funds are available
for the category, a person who is a resident of this state and
who:
  (a) Is receiving a category of aid.
  (b) Would be eligible for a category of aid but is not
receiving a category of aid.
  (c) Is in a medical facility and, if the person left such
facility, would be eligible for a category of aid.
  (d) Is under the age of 21 years and would be a dependent child
as defined in ORS 412.001 except for age and regular attendance
in school or in a course of professional or technical training.
  (e)(A) Is a caretaker relative, as defined in ORS 412.001, who
cares for a child who would be a dependent child except for age
and regular attendance in school or in a course of professional
or technical training; or
  (B) Is the spouse of the caretaker relative.
  (f) Is under the age of 21 years and:
  (A) Is in a foster family home or licensed child-caring agency
or institution and is one for whom a public agency of this state
is assuming financial responsibility, in whole or in part; or
  (B) Is 18 years of age or older, is one for whom federal
financial participation is available under Title XIX or XXI of
the federal Social Security Act and who met the criteria in
subparagraph (A) of this paragraph immediately prior to the
person's 18th birthday.
  (g) Is a spouse of an individual receiving a category of aid
and who is living with the recipient of a category of aid, whose
needs and income are taken into account in determining the cash
needs of the recipient of a category of aid, and who is
determined by the Department of Human Services to be essential to
the well-being of the recipient of a category of aid.
  (h) Is a caretaker relative as defined in ORS 412.001 who cares
for a dependent child receiving aid granted under ORS 412.001 to
412.069 and 418.647 or is the spouse of the caretaker relative.
  (i) Is under the age of 21 years, is in a youth care center and
is one for whom a public agency of this state is assuming
financial responsibility, in whole or in part.
  (j) Is under the age of 21 years and is in an intermediate care
facility which includes institutions for persons with
developmental disabilities.
  (k) Is under the age of 22 years and is in a psychiatric
hospital.
  (L) Is under the age of 21 years and is in an independent
living situation with all or part of the maintenance cost paid by
the Department of Human Services.
  (m) Is a member of a family that received aid in the preceding
month under ORS 412.006 or 412.014 and became ineligible for aid
due to increased hours of or increased income from employment. As
long as the member of the family is employed, such families will
continue to be eligible for medical assistance for a period of at
least six calendar months beginning with the month in which such
family became ineligible for assistance due to increased hours of
employment or increased earnings.
  (n) Is an adopted person under 21 years of age for whom a
public agency is assuming financial responsibility in whole or in
part.
  (o) Is an individual or is a member of a group who is required
by federal law to be included in the state's medical assistance
program in order for that program to qualify for federal funds.
  (p) Is an individual or member of a group who, subject to the
rules of the department or the Oregon Health Authority, may
optionally be included in the state's medical assistance program
under federal law and regulations concerning the availability of
federal funds for the expenses of that individual or group.

  (q) Is a pregnant woman who would be eligible for aid granted
under ORS 412.001 to 412.069 and 418.647, whether or not the
woman is eligible for cash assistance.
  (r) Except as otherwise provided in this section, is a pregnant
woman or child for whom federal financial participation is
available under Title XIX or XXI of the federal Social Security
Act.
  (s) Is not otherwise categorically needy and is not eligible
for care under Title XVIII of the federal Social Security Act or
is not a full-time student in a post-secondary education program
as defined by the department or the authority by rule, but whose
family income is at or below the federal poverty level and whose
family investments and savings equal less than the investments
and savings limit established by the department or the authority
by rule.
  (t) Would be eligible for a category of aid but for the receipt
of qualified long term care insurance benefits under a policy or
certificate issued on or after January 1, 2008. As used in this
paragraph, 'qualified long term care insurance' means a policy or
certificate of insurance as defined in ORS 743.652 (7).
  (u) Is eligible for the Health Care for All Oregon Children
program established in ORS 414.231.
  (v) Is dually eligible for Medicare and Medicaid and receiving
care through a coordinated care organization.
  (4) 'Community health worker' means an individual who:
  (a) Has expertise or experience in public health;
  (b) Works in an urban or rural community, either for pay or as
a volunteer in association with a local health care system;
  (c) To the extent practicable, shares ethnicity, language,
socioeconomic status and life experiences with the residents of
the community where the worker serves;
  (d) Assists members of the community to improve their health
and increases the capacity of the community to meet the health
care needs of its residents and achieve wellness;
  (e) Provides health education and information that is
culturally appropriate to the individuals being served;
  (f) Assists community residents in receiving the care they
need;
  (g) May give peer counseling and guidance on health behaviors;
and
  (h) May provide direct services such as first aid or blood
pressure screening.
  (5) 'Coordinated care organization' means an organization  { +
certified by the Oregon Health Authority as + } meeting
 { + the + } criteria  { +  and requirements + } adopted by the
 { - Oregon Health - }  authority under ORS 414.625.
  (6) 'Dually eligible for Medicare and Medicaid' means, with
respect to eligibility for enrollment in a coordinated care
organization, that an individual is eligible for health services
funded by Title XIX of the Social Security Act and is:
  (a) Eligible for or enrolled in Part A of Title XVIII of the
Social Security Act; or
  (b) Enrolled in Part B of Title XVIII of the Social Security
Act.
  (7) 'Global budget' means a total amount established
prospectively by the Oregon Health Authority to be paid to a
coordinated care organization for the delivery of, management of,
access to and quality of the health care delivered to members of
the coordinated care organization.
  (8) 'Health services' means at least so much of each of the
following as are funded by the Legislative Assembly based upon
the prioritized list of health services compiled by the Health
Evidence Review Commission under ORS 414.690:
  (a) Services required by federal law to be included in the
state's medical assistance program in order for the program to
qualify for federal funds;
  (b) Services provided by a physician as defined in ORS 677.010,
a nurse practitioner certified under ORS 678.375 or other
licensed practitioner within the scope of the practitioner's
practice as defined by state law, and ambulance services;
  (c) Prescription drugs;
  (d) Laboratory and X-ray services;
  (e) Medical equipment and supplies;
  (f) Mental health services;
  (g) Chemical dependency services;
  (h) Emergency dental services;
  (i) Nonemergency dental services;
  (j) Provider services, other than services described in
paragraphs (a) to (i), (k), (L) and (m) of this subsection,
defined by federal law that may be included in the state's
medical assistance program;
  (k) Emergency hospital services;
  (L) Outpatient hospital services; and
  (m) Inpatient hospital services.
  (9) 'Income' has the meaning given that term in ORS 411.704.
  (10) 'Investments and savings' means cash, securities as
defined in ORS 59.015, negotiable instruments as defined in ORS
73.0104 and such similar investments or savings as the department
or the authority may establish by rule that are available to the
applicant or recipient to contribute toward meeting the needs of
the applicant or recipient.
  (11) 'Medical assistance' means so much of the medical, mental
health, preventive, supportive, palliative and remedial care and
services as may be prescribed by the authority according to the
standards established pursuant to ORS 414.065, including premium
assistance and payments made for services provided under an
insurance or other contractual arrangement and money paid
directly to the recipient for the purchase of health services and
for services described in ORS 414.710.
  (12) 'Medical assistance' includes any care or services for any
individual who is a patient in a medical institution or any care
or services for any individual who has attained 65 years of age
or is under 22 years of age, and who is a patient in a private or
public institution for mental diseases. 'Medical assistance '
does not include care or services for an inmate in a nonmedical
public institution.
  (13) 'Patient centered primary care home' means a health care
team or clinic that is organized in accordance with the standards
established by the Oregon Health Authority under ORS 414.655 and
that incorporates the following core attributes:
  (a) Access to care;
  (b) Accountability to consumers and to the community;
  (c) Comprehensive whole person care;
  (d) Continuity of care;
  (e) Coordination and integration of care; and
  (f) Person and family centered care.
  (14) 'Peer wellness specialist' means an individual who is
responsible for assessing mental health service and support needs
of the individual's peers through community outreach, assisting
individuals with access to available services and resources,
addressing barriers to services and providing education and
information about available resources and mental health issues in
order to reduce stigmas and discrimination toward consumers of
mental health services and to provide direct services to assist
individuals in creating and maintaining recovery, health and
wellness.
  (15) 'Person centered care' means care that:
  (a) Reflects the individual patient's strengths and
preferences;
  (b) Reflects the clinical needs of the patient as identified
through an individualized assessment; and

  (c) Is based upon the patient's goals and will assist the
patient in achieving the goals.
  (16) 'Personal health navigator' means an individual who
provides information, assistance, tools and support to enable a
patient to make the best health care decisions in the patient's
particular circumstances and in light of the patient's needs,
lifestyle, combination of conditions and desired outcomes.
  (17) 'Quality measure' means the measures and benchmarks
identified by the authority in accordance with ORS 414.638.
  (18) 'Resources' has the meaning given that term in ORS
411.704. For eligibility purposes, 'resources' does not include
charitable contributions raised by a community to assist with
medical expenses.
  SECTION 6. ORS 414.632, as amended by section 25, chapter 8,
Oregon Laws 2012, is amended to read:
  414.632. (1) Subject to the Oregon Health Authority obtaining
any necessary authorization from the Centers for Medicare and
Medicaid Services, coordinated care organizations   { - that meet
the criteria - }  { +  certified by the authority as meeting the
criteria and requirements + } adopted under ORS 414.625 are
responsible for providing covered Medicare and Medicaid services,
other than Medicaid-funded long term care services, to members
who are dually eligible for Medicare and Medicaid in addition to
medical assistance recipients.
  (2) An individual who is dually eligible for Medicare and
Medicaid shall be permitted to enroll in and remain enrolled in
a:
  (a) Program of all-inclusive care for the elderly, as defined
in 42 C.F.R. 460.6; and
  (b) Medicare Advantage plan, as defined in 42 C.F.R. 422.2,
until the plan is fully integrated into a coordinated care
organization.
  (3) Except for the enrollment in coordinated care organizations
of individuals who are dually eligible for Medicare and Medicaid,
the rights and benefits of Medicare beneficiaries under Title
XVIII of the Social Security Act shall be preserved.
  SECTION 7. ORS 416.510 is amended to read:
  416.510. As used in ORS 416.510 to 416.610, unless the context
requires otherwise:
  (1) 'Action' means an action, suit or proceeding.
  (2) 'Alternative payment methodology' has the meaning given
that term in ORS 414.025.
  (3) 'Applicant' means an applicant for assistance.
  (4) 'Assistance' means moneys paid by the Department of Human
Services to persons directly and moneys paid by the Oregon Health
Authority or by a prepaid managed care health services
organization or a coordinated care organization for services
provided under contract pursuant to ORS 414.651 to others for the
benefit of such persons.
  (5) 'Authority' means the Oregon Health Authority.
  (6) 'Claim' means a claim of a recipient of assistance for
damages for personal injuries against any person or public body,
agency or commission other than the State Accident Insurance Fund
Corporation or Workers' Compensation Board.
  (7) 'Compromise' means a compromise between a recipient and any
person or public body, agency or commission against whom the
recipient has a claim.
  (8) 'Coordinated care organization' means an organization
  { - that meets the criteria - }  { +  certified by the
authority as meeting the criteria and requirements + } adopted by
the authority under ORS 414.625.
  (9) 'Judgment' means a judgment in any action or proceeding
brought by a recipient to enforce the claim of the recipient.
  (10) 'Prepaid managed care health services organization ' means
a managed health, dental or mental health care organization that
contracted with the authority on a prepaid capitated basis.
Prepaid managed care health services organizations may be dental
care organizations, fully capitated health plans, mental health
organizations or chemical dependency organizations.
  (11) 'Recipient' means a recipient of assistance.
  (12) 'Settlement' means a settlement between a recipient and
any person or public body, agency or commission against whom the
recipient has a claim.
  SECTION 8. ORS 414.625, as amended by section 3 of this 2013
Act, is amended to read:
  414.625. (1) The Oregon Health Authority shall adopt by rule
the qualification criteria and requirements for the certification
of 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 certification
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 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)   { - Except as provided in section 1 of this 2013 Act, - }
Each coordinated care organization has a governing body that
includes:
  (A) Individuals representing the health care entities that
share in the financial risk of the organization who must
constitute a majority of the governing body;
  (B) Individuals representing 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 9. ORS 414.635, as amended by section 9, chapter 602,
Oregon Laws 2011, and section 5, chapter 8, Oregon Laws 2012, and
section 4 of this 2013 Act, is amended to read:
  414.635. (1) The Oregon Health Authority shall adopt by rule
safeguards for members enrolled in coordinated care organizations
that protect against underutilization of services and
inappropriate denials of services. In addition to any other
consumer rights and responsibilities established by law, each
member:
  (a) Must be encouraged to be an active partner in directing the
member's health care and services and not a passive recipient of
care.
  (b) Must be educated about the coordinated care approach being
used in the community and how to navigate the coordinated health
care system.
  (c) Must have access to advocates, including qualified peer
wellness specialists where appropriate, personal health
navigators, and qualified community health workers who are part
of the member's care team to provide assistance that is
culturally and linguistically appropriate to the member's need to
access appropriate services and participate in processes
affecting the member's care and services.
  (d) Shall be encouraged within all aspects of the integrated
and coordinated health care delivery system to use wellness and
prevention resources and to make healthy lifestyle choices.
  (e) Shall be encouraged to work with the member's care team,
including providers and community resources appropriate to the
member's needs as a whole person.
  (2) The authority shall establish and maintain an enrollment
process for individuals who are dually eligible for Medicare and
Medicaid that promotes continuity of care and that allows the
member to disenroll from a coordinated care organization that
fails to promptly provide adequate services and:
  (a) To enroll in another coordinated care organization of the
member's choice; or
  (b) If another organization is not available, to receive
Medicare-covered services on a fee-for-service basis.
  (3) Members and their providers and coordinated care
organizations have the right to appeal decisions about care and
services through the authority in an expedited manner and in
accordance with the contested case procedures in ORS chapter 183.

  (4) A health care entity may not unreasonably refuse to
contract with an organization seeking to form a coordinated care
organization if the participation of the entity is necessary for
the organization to qualify as a coordinated care organization.
  (5) A health care entity may refuse to contract with a
coordinated care organization if the reimbursement established
for a service provided by the entity under the contract is below
the reasonable cost to the entity for providing the service.
  (6) A health care entity that unreasonably refuses to contract
with a coordinated care organization may not receive
fee-for-service reimbursement from the authority for services
that are available through a coordinated care organization either
directly or by contract.
  (7) The authority shall adopt by rule a process for resolving
disputes involving an entity's refusal to contract with a
coordinated care organization under subsections (4) and (5) of
this section. The process must include the use of an independent
third party arbitrator.
  (8) A coordinated care organization may not unreasonably refuse
to contract with a licensed health care provider.
  (9) The authority shall:
  (a) Monitor and enforce consumer rights and protections within
the Oregon Integrated and Coordinated Health Care Delivery System
and ensure a consistent response to complaints of violations of
consumer rights or protections.
  (b) Monitor and report on the statewide health care
expenditures and recommend actions appropriate and necessary to
contain the growth in health care costs incurred by all sectors
of the system.
  (c) Decertify a coordinated care organization that  { - : - }
    { - (A) - }  substantially fails to comply with rules adopted
pursuant to ORS 414.625 or this section  { - ; or - }
    { - (B) Fails to comply with section 1 (3) of this 2013
Act - } .
  SECTION 10.  { + The amendments to ORS 414.625 and 414.635 by
sections 8 and 9 of this 2013 Act become operative January 2,
2018. + }
  SECTION 11.  { + Sections 1 and 2 of this 2013 Act are repealed
January 2, 2018. + }
  SECTION 12.  { + 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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