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

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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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-Amended.html

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     77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session

HA to HB 3309

LC 2931/HB 3309-4

                       HOUSE AMENDMENTS TO
                         HOUSE BILL 3309

                      By COMMITTEE ON RULES

                             June 4

  On page 1 of the printed bill, delete lines 5 and 6 and insert:
  '  { +  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'.
  In line 22, delete the period and insert '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. + } ' .
  On page 3, line 30, delete '2' and insert '1'.
  In line 31, delete 'board of directors' and insert ' governing
body'.
  In line 33, delete 'board' and insert 'governing body'.
  On page 5, line 16, delete '2' and insert '1'.
  On page 9, after line 42, insert:
  '  { +  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. + } ' .
  In line 43, delete '8' and insert '12'.
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