Bill Text: OR HB3650 | 2011 | Regular Session | Enrolled
Bill Title: Relating to health; appropriating money; and declaring an emergency.
Spectrum: Committee Bill
Status: (Passed) 2011-07-07 - Chapter 602, (2011 Laws): Effective date July 1, 2011. [HB3650 Detail]
Download: Oregon-2011-HB3650-Enrolled.html
76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
Enrolled
House Bill 3650
Sponsored by JOINT SPECIAL COMMITTEE ON HEALTH CARE
TRANSFORMATION
CHAPTER ................
AN ACT
Relating to health; creating new provisions; amending ORS
192.493, 410.604, 411.404, 411.708, 413.032, 414.018, 414.025,
414.033, 414.065, 414.115, 414.153, 414.211, 414.229, 414.428,
414.620, 414.630, 414.706, 414.707, 414.712, 414.725, 414.728,
414.736, 414.737, 414.742, 414.743, 414.746, 414.760, 416.510,
416.530, 416.540, 416.610, 441.094, 442.464, 442.468, 655.515,
659.830, 735.615 and 743.847 and section 9, chapter 736, Oregon
Laws 2003, sections 1 and 9, chapter 867, Oregon Laws 2009, and
section 10, chapter ___, Oregon Laws 2011 (Enrolled Senate Bill
101); repealing ORS 414.610, 414.630, 414.640, 414.705,
414.736, 414.738, 414.739, 414.740 and 414.741 and section 8,
chapter ___, Oregon Laws 2011 (Enrolled Senate Bill 101), and
sections 128, 129, 131, 142 and 147, chapter ___, Oregon Laws
2011 (Enrolled House Bill 2100); appropriating money; limiting
expenditures; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
{ +
HEALTH SYSTEM TRANSFORMATION + }
SECTION 1. ORS 414.018 is amended to read:
414.018. { + Legislative intent. + } (1) It is the intention
of the Legislative Assembly to achieve the goals of universal
access to an adequate level of high quality health care at an
affordable cost.
(2) The Legislative Assembly finds:
(a) A significant level of public and private funds is expended
each year for the provision of health care to Oregonians;
(b) The state has a strong interest in assisting Oregon
businesses and individuals to obtain reasonably available
insurance or other coverage of the costs of necessary basic
health care services;
(c) The lack of basic health care coverage is detrimental not
only to the health of individuals lacking coverage, but also to
the public welfare and the state's need to encourage employment
growth and economic development, and the lack results in
substantial expenditures for emergency and remedial health care
for all purchasers of health care including the state; and
{ - (d) The use of managed health care systems has
significant potential to reduce the growth of health care costs
incurred by the people of this state. - }
Enrolled House Bill 3650 (HB 3650-C) Page 1
{ + (d) The use of integrated and coordinated health care
systems has significant potential to reduce the growth of health
care costs incurred by the people of this state.
(3) The Legislative Assembly finds that achieving its goals of
improving health, increasing the quality, reliability,
availability and continuity of care and reducing the cost of care
requires an integrated and coordinated health care system in
which:
(a) Medical assistance recipients and individuals who are
dually eligible for both Medicare and Medicaid participate.
(b) Health care services, other than Medicaid-funded long term
care services, are delivered through coordinated care contracts
that use alternative payment methodologies to focus on
prevention, improving health equity and reducing health
disparities, utilizing patient centered primary care homes,
evidence-based practices and health information technology to
improve health and health care.
(c) High quality information is collected and used to measure
health outcomes, health care quality and costs and clinical
health information.
(d) Communities and regions are accountable for improving the
health of their communities and regions, reducing avoidable
health gaps among different cultural groups and managing health
care resources.
(e) Care and services emphasize preventive services and
services supporting individuals to live independently at home or
in their community.
(f) Services are person centered, and provide choice,
independence and dignity reflected in individual plans and
provide assistance in accessing care and services.
(g) Interactions between the Oregon Health Authority and
coordinated care organizations are done in a transparent and
public manner.
(h) Moneys provided by the federal government for medical
education are allocated to the institutions that provide the
education.
(4) The Legislative Assembly further finds that there is an
extreme need for a skilled, diverse workforce to meet the rapidly
growing demand for community-based health care. To meet that
need, this state must:
(a) Build on existing training programs; and
(b) Provide an opportunity for frontline care providers to have
a voice in their workplace in order to effectively advocate for
quality care.
(5) As used in subsection (3) of this section:
(a) 'Community' means the groups within the geographic area
served by a coordinated care organization and includes groups
that identify themselves by age, ethnicity, race, economic
status, or other defining characteristic that may impact delivery
of health care services to the group, as well as the governing
body of each county located wholly or partially within the
coordinated care organization's service area.
(b) 'Region' means the geographical boundaries of the area
served by a coordinated care organization as well as the
governing body of each county that has jurisdiction over all or
part of the coordinated care organization's service area. + }
SECTION 2. ORS 414.620 is amended to read:
414.620. { + Establishment of Oregon Integrated and
Coordinated Health Care Delivery System. + } { + (1) + } There
is established the Oregon { + Integrated and Coordinated + }
Enrolled House Bill 3650 (HB 3650-C) Page 2
Health Care { - Cost Containment - } { + Delivery + } System.
The system shall consist of state policies and actions that
{ - encourage price competition among health care providers,
that monitor services and costs of the health care system in
Oregon, and that maintain the regulatory controls necessary to
assure quality and affordable health services to all Oregonians.
The system shall also include contracts with providers on a
prepaid capitation basis for the provision of at least hospital
or physician medical care, or both, to eligible persons as
described in ORS 414.025. - } { + make coordinated care
organizations accountable for care management and provision of
integrated and coordinated health care for each organization's
members, managed within fixed global budgets, by providing care
so that efficiency and quality improvements reduce medical cost
inflation while supporting the development of regional and
community accountability for the health of the residents of each
region and community, and while maintaining regulatory controls
necessary to ensure quality and affordable health care for all
Oregonians.
(2) The Oregon Health Authority shall seek input from groups
and individuals who are part of underserved communities,
including ethnically diverse populations, geographically isolated
groups, seniors, people with disabilities and people using mental
health services, and shall also seek input from providers,
coordinated care organizations and communities, in the
development of strategies that promote person centered care and
encourage healthy behaviors, healthy lifestyles and prevention
and wellness activities and promote the development of patients'
skills in self-management and illness management.
(3) The authority shall regularly report to the Oregon Health
Policy Board, the Governor and the Legislative Assembly on the
progress of payment reform and delivery system change including:
(a) The achievement of benchmarks;
(b) Progress toward eliminating health disparities;
(c) Results of evaluations;
(d) Rules adopted;
(e) Customer satisfaction;
(f) Use of patient centered primary care homes;
(g) The involvement of local governments in governance and
service delivery; and
(h) Other developments with respect to coordinated care
organizations. + }
SECTION 3. { + Adding to ORS chapter 414. + } { + Sections 4
to 8, 10 to 15 and 17 of this 2011 Act are added to and made a
part of ORS chapter 414. + }
SECTION 4. { + Coordinated care organizations. (1) The Oregon
Health Authority shall adopt by rule the criteria for a
coordinated care organization and shall integrate the criteria
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 be designed so that:
Enrolled House Bill 3650 (HB 3650-C) Page 3
(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 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 409.615,
community health workers and personal health navigators who meet
competency standards established by the authority under section
11 of this 2011 Act 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.
(h) Each coordinated care organization complies with the
safeguards for members described in section 8 of this 2011 Act.
(i) Each coordinated care organization convenes a community
advisory council that includes representatives of the community
and of county government, but with consumers making up a majority
of the membership, and that meets regularly to ensure that the
health care needs of the consumers and the community are being
addressed.
(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.
Enrolled House Bill 3650 (HB 3650-C) Page 4
(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 identified by the authority under section 10 of
this 2011 Act 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) A majority interest consisting of the persons that share in
the financial risk of the organization;
(B) The major components of the health care delivery system;
and
(C) The community at large, to ensure that the organization's
decision-making is consistent with the values of the members and
the community.
(2) The authority shall consider the participation of area
agencies and other nonprofit agencies in the configuration of
coordinated care organizations.
(3) 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 5. { + Alternative payment methodologies. (1) The
Oregon Health Authority shall encourage coordinated care
organizations to use alternative payment methodologies that:
(a) Reimburse providers on the basis of health outcomes and
quality measures instead of the volume of care;
(b) Hold organizations and providers responsible for the
efficient delivery of quality care;
(c) Reward good performance;
(d) Limit increases in medical costs; and
(e) Use payment structures that create incentives to:
(A) Promote prevention;
(B) Provide person centered care; and
(C) Reward comprehensive care coordination using delivery
models such as patient centered primary care homes.
(2) The authority shall encourage coordinated care
organizations to utilize alternative payment methodologies that
move from a predominantly fee-for-service system to payment
methods that base reimbursement on the quality rather than the
quantity of services provided.
(3) The authority shall assist and support coordinated care
organizations in identifying cost-cutting measures.
(4) If a service provided in a health care facility is not
covered by Medicare because the service is related to a health
care acquired condition, the cost of the service may not be:
(a) Charged by a health care facility or any health services
provider employed by or with privileges at the facility, to a
coordinated care organization, a patient or a third-party payer;
or
(b) Reimbursed by a coordinated care organization.
(5)(a) Notwithstanding subsections (1) and (2) of this section,
until July 1, 2014, a coordinated care organization that
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contracts with a Type A or Type B hospital or a rural critical
access hospital, as described in ORS 442.470, shall reimburse the
hospital fully for the cost of covered services based on the
cost-to-charge ratio used for each hospital in setting the global
payments to the coordinated care organization for the contract
period.
(b) The authority shall base the global payments to coordinated
care organizations that contract with rural hospitals described
in this section on the most recent audited Medicare cost report
for Oregon hospitals adjusted to reflect the Medicaid mix of
services.
(c) The authority shall identify any rural hospital that would
not be expected to remain financially viable if paid in a manner
other than as prescribed in paragraphs (a) and (b) of this
subsection based upon an evaluation by an actuary retained by the
authority. On and after July 1, 2014, the authority may, on a
case-by-case basis, require a coordinated care organization to
continue to reimburse a rural hospital determined to be at
financial risk, in the manner prescribed in paragraphs (a) and
(b) of this subsection.
(d) This subsection does not prohibit a coordinated care
organization and a hospital from mutually agreeing to
reimbursement other than the reimbursement specified in paragraph
(a) of this subsection.
(e) Hospitals reimbursed under paragraphs (a) and (b) of this
subsection are not entitled to any additional reimbursement for
services provided.
(6) Notwithstanding subsections (1) and (2) of this section,
coordinated care organizations must comply with federal
requirements for payments to providers of Indian health services,
including but not limited to the requirements of 42 U.S.C. 1396j
and 42 U.S.C. 1396u-2(a)(2)(C). + }
SECTION 6. { + Patient centered primary care homes. (1) The
Oregon Health Authority shall establish standards for the
utilization of patient centered primary care homes in coordinated
care organizations.
(2) Each coordinated care organization shall implement, to the
maximum extent feasible, patient centered primary care homes,
including developing capacity for services in settings that are
accessible to families, diverse communities and underserved
populations. The organization shall require its other health and
services providers to communicate and coordinate care with the
patient centered primary care home in a timely manner using
electronic health information technology.
(3) Standards established by the authority for the utilization
of patient centered primary care homes by coordinated care
organizations may require the use of federally qualified health
centers, rural health clinics, school-based health clinics and
other safety net providers that qualify as patient centered
primary care homes to ensure the continued critical role of those
providers in meeting the needs of underserved populations.
(4) Each coordinated care organization shall report to the
authority on uniform quality measures prescribed by the authority
by rule for patient centered primary care homes.
(5) Patient centered primary care homes must participate in the
learning collaborative described in ORS 442.210 (3). + }
SECTION 7. { + Dually eligible individuals. (1) Subject to
the Oregon Health Authority obtaining any necessary authorization
from the Centers for Medicare and Medicaid Services under section
17 of this 2011 Act, coordinated care organizations that meet the
Enrolled House Bill 3650 (HB 3650-C) Page 6
criteria adopted under section 4 of this 2011 Act 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) A 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 8. { + Consumer and provider protections. (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.
Enrolled House Bill 3650 (HB 3650-C) Page 7
(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 develop 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. The process must be presented to the
Legislative Assembly for approval in accordance with section 13
of this 2011 Act.
(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. + }
SECTION 9. Section 8 of this 2011 Act is amended to read:
{ + Sec. 8. + } (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
Enrolled House Bill 3650 (HB 3650-C) Page 8
(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 { - develop a - } { + maintain
the + } process { + , approved by the Legislative Assembly, + }
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. { - The process must be
presented to the Legislative Assembly for approval in accordance
with section 13 of this 2011 Act. - }
(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.
SECTION 10. { + Quality measures. (1) The Oregon Health
Authority through a public process shall identify objective
outcome and quality measures and benchmarks, including measures
of outcome and quality for ambulatory care, inpatient care,
chemical dependency and mental health treatment, oral health care
and all other health services provided by coordinated care
organizations. The authority shall incorporate these measures
into coordinated care organization contracts to hold the
organizations accountable for performance and customer
satisfaction requirements.
(2) The authority shall evaluate on a regular and ongoing basis
key quality measures, including health status, experience of care
and patient activation, along with key demographic variables
including race and ethnicity, for members in each coordinated
care organization and for members statewide.
(3) Quality measures identified by the authority under this
section must be consistent with existing state and national
quality measures. The authority shall utilize available data
systems for reporting and take actions to eliminate any redundant
reporting or reporting of limited value.
(4) The authority shall publish the information collected under
this section at aggregate levels that do not disclose information
Enrolled House Bill 3650 (HB 3650-C) Page 9
otherwise protected by law. The information published must
report, by coordinated care organization:
(a) Quality measures;
(b) Costs;
(c) Outcomes; and
(d) Other information, as specified by the contract between the
coordinated care organization and the authority, that is
necessary for the authority, members and the public to evaluate
the value of health services delivered by a coordinated care
organization. + }
SECTION 11. { + Standards for health care workers. (1) The
Oregon Health Authority, in consultation with the appropriate
health professional regulatory boards as defined in ORS 676.160
and advocacy groups, shall develop and establish with respect to
community health workers, personal health navigators, peer
wellness specialists and other health care workers who are not
regulated or certified by this state:
(a) The criteria and descriptions of such individuals that may
be utilized by coordinated care organizations; and
(b) Education and training requirements for such individuals.
(2) The criteria and requirements established under subsection
(1) of this section:
(a) Must be broad enough to encompass the potential unique
needs of any coordinated care organization;
(b) Must meet requirements of the Centers for Medicare and
Medicaid Services to qualify for federal financial participation;
and
(c) May not require certification by the Home Care
Commission. + }
SECTION 12. { + Protected information. (1) The Oregon Health
Authority shall ensure the appropriate use of member information
by coordinated care organizations, including the use of
electronic health information and administrative data that is
available when and where the data is needed to improve health and
health care through a secure, confidential health information
exchange.
(2) A member of a coordinated care organization must have
access to the member's personal health information in the manner
provided in 45 C.F.R. 164.524 so the member can share the
information with others involved in the member's care and make
better health care and lifestyle choices.
(3) Notwithstanding ORS 179.505, a coordinated care
organization, its provider network and programs administered by
the Department of Human Services for seniors and persons with
disabilities shall use and disclose member information for
purposes of service and care delivery, coordination, service
planning, transitional services and reimbursement, in order to
improve the safety and quality of care, lower the cost of care
and improve the health and well-being of the organization's
members.
(4) A coordinated care organization and its provider network
shall use and disclose sensitive diagnosis information including
HIV and other health and mental health diagnoses, within the
coordinated care organization for the purpose of providing
whole-person care. Individually identifiable health information
must be treated as confidential and privileged information
subject to ORS 192.518 to 192.529 and applicable federal privacy
requirements. Redisclosure of individually identifiable
information outside of the coordinated care organization and the
organization's providers for purposes unrelated to this section
Enrolled House Bill 3650 (HB 3650-C) Page 10
or the requirements of section 4, 5, 6, 7, 8 or 10 of this 2011
Act remains subject to any applicable federal or state privacy
requirements.
(5) This section does not prohibit the disclosure of
information between a coordinated care organization and the
organization's provider network, and the Oregon Health Authority
and the Department of Human Services for the purpose of
administering the laws of Oregon.
(6) The Health Information Technology Oversight Council shall
develop readily available informational materials that can be
used by coordinated care organizations and providers to inform
all participants in the health care workforce about the
appropriate uses and limitations on disclosure of electronic
health records, including need-based access and privacy
mandates. + }
SECTION 13. { + Legislative approval. + } { + (1) The speed
and pace of the transition to the Oregon Integrated and
Coordinated Health Care Delivery System will be determined by the
availability of coordinated care organizations throughout the
state.
(2) Using a meaningful public process, the Oregon Health
Authority shall develop:
(a) Qualification criteria for coordinated care organizations
in accordance with section 4 of this 2011 Act;
(b) A global budgeting process for determining payments to
coordinated care organizations and for revising required outcomes
with any changes to global budgets;
(c) A process for resolving a health care entity's refusal to
contract with a coordinated care organization, as required by
section 8 of this 2011 Act;
(d) A process that allows a coordinated care organization to
file financial reports with only one regulatory agency and does
not require a coordinated care organization to report information
described in ORS 414.725 (1)(c) to both the authority and the
Department of Consumer and Business Services; and
(e) Plans for contracts with coordinated care organizations for
other public health benefit purchasers, including the private
health option under ORS 414.826, the Public Employees' Benefit
Board and the Oregon Educators Benefit Board.
(3) The authority, in consultation with the Department of
Consumer and Business Services, shall develop a proposal for the
financial reporting requirements for coordinated care
organizations to be implemented under ORS 414.725 (1)(c) to
ensure against the organization's risk of insolvency. The
proposal must include but need not be limited to recommendations
on:
(a) The filing of quarterly and annual audited statements of
financial position, including reserves and retrospective cash
flows, and the filing of quarterly and annual statements of
projected cash flows;
(b) Guidance for a plain-language narrative explanation of the
financial statements required in paragraph (a) of this
subsection;
(c) The filing by a coordinated care organization of a
statement of whether the organization or another entity, such as
a state or local government agency or a reinsurer, will guarantee
the organization's ultimate financial risk;
(d) The disclosure of a coordinated care organization's
holdings of real property and its 20 largest investment holdings,
if any;
Enrolled House Bill 3650 (HB 3650-C) Page 11
(e) The disclosure by category of administrative expenses
related to the provision of health services under the coordinated
care organization's contract with the authority;
(f) The disclosure of the three highest executive salary and
benefit packages of each coordinated care organization;
(g) The process by which a coordinated care organization will
be evaluated or audited for financial soundness and stability and
the organization's ability to accept financial risk under its
contracts, which process may include the use of employed or
retained actuaries;
(h) A description of how the required statements and the final
results of evaluations and audits will be made available to the
public over the Internet at no cost to the public;
(i) A range of sanctions that may be imposed on a coordinated
care organization deemed to be financially unsound and the
process for determining sanctions; and
(j) Whether a new category of license should be created for
coordinated care organizations recognizing their unique role but
avoiding duplicative requirements for organizations that contract
with the authority but are also licensed by the Department of
Consumer and Business Services.
(4) The authority shall regularly report on the development of
the plans, criteria and processes described in subsections (2)
and (3) of this section to the Joint Interim Committee on Health
Care Transformation or, if such committee has not been appointed,
to another appropriate interim committee of the Legislative
Assembly.
(5) The authority shall present the proposals developed under
this section to the Legislative Assembly for approval no later
than February 1, 2012.
(6) Until the coordinated care organization qualification
criteria and the global budgeting process are approved by the
Legislative Assembly, the authority shall renew the contracts of
prepaid managed care health services organizations, as defined in
ORS 414.736, to provide health services.
(7) The authority shall prepare financial models and analyses
to demonstrate the feasibility of a coordinated care organization
being able to realize health care cost savings. The authority
shall present the models and analyses to the Legislative Assembly
along with the proposals developed by the authority under this
section. + }
SECTION 14. { + Transitional provisions. + } { + (1)
Notwithstanding ORS 414.725 and 414.737, in any area of the state
where a coordinated care organization has not been certified, the
Oregon Health Authority shall continue to contract with one or
more prepaid managed care health services organizations, as
defined in ORS 414.736, that serve the area and that are in
compliance with contractual obligations owed to the state or
local government.
(2) Prepaid managed care health services organizations
contracting with the authority under this section are subject to
the applicable requirements for, and are permitted to exercise
the rights of, coordinated care organizations under sections 4,
6, 8, 10 and 12 of this 2011 Act and ORS 414.153, 414.712,
414.725, 414.728, 414.743, 414.746, 414.760, 416.510 to 416.610,
441.094, 442.464, 655.515, 659.830 and 743.847.
(3) The authority may amend contracts that are in place on the
effective date of this 2011 Act to allow prepaid managed care
health services organizations that meet the criteria approved by
Enrolled House Bill 3650 (HB 3650-C) Page 12
the Legislative Assembly under section 13 of this 2011 Act to
become coordinated care organizations.
(4) The authority shall continue to renew the contracts of
prepaid managed care health services organizations that have a
contract with the authority on the effective date of this 2011
Act until the earlier of the date the prepaid managed care health
services organization becomes a coordinated care organization or
July 1, 2014. Contracts with prepaid managed care health services
organizations must terminate no later than July 1, 2017.
(5) The authority shall continue to renew contracts or ensure
that counties renew contracts with providers of residential
chemical dependency treatment until the provider enters into a
contract with a coordinated care organization but no later than
July 1, 2013.
(6) Notwithstanding sections 4 (1)(g) and 6 (2) of this 2011
Act, the authority shall allow for a period of transition to the
full adoption of health information technology by coordinated
care organizations and patient centered primary care homes. The
authority shall explore options for assisting providers and
coordinated care organizations in funding their use of health
information technology. + }
SECTION 15. { + Cooperation of Oregon Health Authority and
Department of Human Services. (1) The Oregon Health Authority and
the Department of Human Services shall cooperate with each other
by coordinating actions and responsibilities necessary to
implement the Oregon Integrated and Coordinated Health Care
Delivery System established in ORS 414.620.
(2) The authority and the department may delegate to each other
any duties, functions or powers that the authority or department
are authorized to perform if necessary to carry out sections 4 to
8, 10 to 15 and 17 of this 2011 Act. + }
SECTION 16. { + Health care cost containment. (1) The Oregon
Health Authority shall conduct a study and develop
recommendations for legislative and administrative remedies that
will contain health care costs by reducing costs attributable to
defensive medicine and the overutilization of health services and
procedures, while protecting access to health care services for
those in need and protecting their access to seek redress through
the judicial system for harms caused by medical malpractice. The
study and recommendations should address but are not limited to:
(a) An analysis of the cost of defensive medicine within the
Oregon health care delivery system and its potential budget
impact, and containment and savings that would result from
recommended changes.
(b) Identification of costs within the health care delivery
system, including costs to taxpayers and consumers related to
care and utilization rates impacted by defensive medical
procedures or medical malpractice concerns.
(c) An analysis of utilization, testing, services ordered,
prescribed or delivered through centers or facilities in which
there is a financial interest between the provider requesting a
test or service and the entity or individual providing the test
or service, including an examination of Stark laws exceptions and
exemptions.
(d) Establishment of criteria for evaluation and reduced
utilization of services and procedures where the health of those
served is not negatively impacted or necessarily improved.
(e) Identification and analysis of the benefits and impact of
caps on medical liability insurance premiums as well as the
benefits and potential cost saving from the extension of coverage
Enrolled House Bill 3650 (HB 3650-C) Page 13
through the Oregon Tort Claims Act to those who serve or act as
agents of the state.
(f) A path for a cap on damages for those acting on behalf of
the state and serving individuals who receive medical assistance
or have medical coverage through other publicly funded programs.
(g) An examination of the possible clarifications and
limitations on joint and several liability requirements for
coordinated care organizations so that these organizations can
assume the risk of their actions but are not liable for the
actions of others within the coordinated care organization or its
contracted services.
(h) The effectiveness of binding and nonbinding medical panels
in addressing claims of medical malpractice.
(2) The authority shall coordinate with the Department of
Consumer and Business Services and other appropriate agencies,
including nongovernmental agencies, in order to collect and
analyze the data generated by the study and to make complete
recommendations to the Legislative Assembly.
(3) The authority shall secure assistance and input from
stakeholder organizations in an effort to secure the best
information available relevant to the impacts on administrative
costs resulting from litigation, as well as to identify cost
containment or cost reduction mechanisms.
(4) The authority shall focus its efforts on the medical
malpractice marketplace and coverage throughout Oregon and the
impact of implementing medical malpractice liability caps, in
order to provide complete information to the Legislative Assembly
as it studies the collective elements of health system
transformation.
(5) The authority shall present the study and recommendations
for addressing health care cost containment and cost reductions
to the Legislative Assembly at the same time that the coordinated
care organization qualification criteria and global budgeting
process are presented to the Legislative Assembly for approval
under section 13 of this 2011 Act. + }
SECTION 17. { + Federal approvals. (1) To promote the adoption
of alternative payment methodologies and contracting with
coordinated care organizations, the Oregon Health Authority shall
apply to the Centers for Medicare and Medicaid Services or Center
for Medicare and Medicaid Innovation for any approval necessary
to obtain federal financial participation in the costs of
activities described in sections 4 to 8, 10 to 15 and 17 of this
2011 Act. The authority may seek necessary federal approval,
including but not limited to:
(a) Federal approval necessary to enroll in coordinated care
organizations individuals who are dually eligible for Medicare
and Medicaid, to integrate Medicare Advantage plans into
coordinated care organizations and to implement the contracting
procedures and blended reimbursement methods for coordinated care
organizations that include members who are dually eligible for
Medicare and Medicaid, as provided in sections 7 and 8 of this
2011 Act. The authority may not seek approval to alter any of the
rights or benefits of Medicare beneficiaries under Title XVIII of
the Social Security Act other than as necessary to implement the
provisions of sections 7 and 8 of this 2011 Act.
(b) Federal approval necessary to support the transition to and
implementation of global and alternative payment systems and the
formation and utilization of coordinated care organizations in
the medical assistance program.
Enrolled House Bill 3650 (HB 3650-C) Page 14
(c) Federal approval necessary to permit the use and
reimbursement of nontraditional personnel such as community
health workers, personal health navigators and peer wellness
specialists and to permit delivery of health services, supports
and supplies that have not traditionally been delivered through
the Medicaid program.
(2) The authority shall seek from the Office of the Inspector
General in the United States Department of Health and Human
Services, the following:
(a) A waiver of the provisions of, or expansion of the safe
harbors to 42 U.S.C. 1320a-7b and implementing regulations or any
other necessary authorization the authority determines may be
necessary to permit certain shared risk and other risk sharing
arrangements among coordinated care organizations and providers.
(b) A waiver of or exemption from the provisions of 42 U.S.C.
1395nn(a) to (e) and implementing regulations or other
authorization the authority determines may be necessary to permit
physician referrals to other providers as needed to support the
transition to and implementation of global and alternative
payment systems and formation of coordinated care organizations.
(3) The authority shall adopt rules and execute contracts with
coordinated care organizations as soon as practicable following
legislative approval of coordinated care organization
qualification criteria and a global budgeting process and after
receipt of the necessary federal approval. The authority may
provide for implementation in stages. + }
SECTION 18. { + Exemption from antitrust laws. (1) The
Legislative Assembly declares that collaboration among public
payers, private health carriers, third party purchasers and
providers to identify appropriate service delivery systems and
reimbursement methods to align incentives in support of
integrated and coordinated health care delivery is in the best
interest of the public. The Legislative Assembly therefore
declares its intent to exempt from state antitrust laws, and to
provide immunity from federal antitrust laws through the state
action doctrine, coordinated care organizations that might
otherwise be constrained by such laws. The Legislative Assembly
does not authorize any person or entity to engage in activities
or to conspire to engage in activities that would constitute per
se violations of state or federal antitrust laws including, but
not limited to, agreements among competing health care providers
as to the prices of specific health services.
(2) The Director of the Oregon Health Authority or the
director's designee may engage in appropriate state supervision
necessary to promote state action immunity under state and
federal antitrust laws, and may inspect or request additional
documentation to verify that the Oregon Integrated and
Coordinated Health Care Delivery System established under ORS
414.620 is implemented in accordance with the legislative intent
expressed in ORS 414.018.
(3) The Oregon Health Authority may convene groups that
include, but are not limited to, health insurance companies,
health care centers, hospitals, health service organizations,
employers, health care providers, health care facilities, state
and local governmental entities and consumers, to facilitate the
development and establishment of the Oregon Integrated and
Coordinated Health Care Delivery System and health care payment
reforms. Any participation by such entities and individuals shall
be on a voluntary basis.
(4) The authority may:
Enrolled House Bill 3650 (HB 3650-C) Page 15
(a) Conduct a survey of the entities and individuals specified
in subsection (3) of this section concerning payment and delivery
reforms; and
(b) Convene meetings at a time and place that is convenient for
the entities and individuals specified in subsection (3) of this
section.
(5) A survey or meeting under subsection (4) of this section is
not a violation of state antitrust laws and shall be considered
state action for purposes of federal antitrust laws through the
state action doctrine. + }
SECTION 19. ORS 413.032 is amended to read:
413.032. { + Duties of Oregon Health Authority. + } (1) The
Oregon Health Authority is established. The authority shall:
(a) Carry out policies adopted by the Oregon Health Policy
Board;
{ - (b) Develop a plan for the Oregon Health Insurance
Exchange in accordance with section 17, chapter 595, Oregon Laws
2009; - }
{ + (b) Administer the Oregon Integrated and Coordinated
Health Care Delivery System established in ORS 414.620; + }
(c) Administer the Oregon Prescription Drug Program;
(d) Administer the Family Health Insurance Assistance Program;
(e) Provide regular reports to the board with respect to the
performance of health services contractors serving recipients of
medical assistance, including reports of trends in health
services and enrollee satisfaction;
(f) Guide and support, with the authorization of the board,
community-centered health initiatives designed to address
critical risk factors, especially those that contribute to
chronic disease;
(g) Be the state Medicaid agency for the administration of
funds from Titles XIX and XXI of the Social Security Act and
administer medical assistance under ORS chapter 414;
(h) In consultation with the Director of the Department of
Consumer and Business Services, periodically review and recommend
standards and methodologies to the Legislative Assembly for:
(A) Review of administrative expenses of health insurers;
(B) Approval of rates; and
(C) Enforcement of rating rules adopted by the Department of
Consumer and Business Services;
(i) Structure reimbursement rates for providers that serve
recipients of medical assistance to reward comprehensive
management of diseases, quality outcomes and the efficient use of
resources and to promote cost-effective procedures, services and
programs including, without limitation, preventive health, dental
and primary care services, web-based office visits, telephone
consultations and telemedicine consultations;
(j) Guide and support community three-share agreements in which
an employer, state or local government and an individual all
contribute a portion of a premium for a community-centered health
initiative or for insurance coverage; { - and - }
(k) Develop, in consultation with the Department of Consumer
and Business Services and the Health Insurance Reform Advisory
Committee, one or more products designed to provide more
affordable options for the small group market { + ; and
(L) Implement policies and programs to expand the skilled,
diverse workforce as described in ORS 414.018 (4) + }.
(2) The Oregon Health Authority is authorized to:
(a) Create an all-claims, all-payer database to collect health
care data and monitor and evaluate health care reform in Oregon
Enrolled House Bill 3650 (HB 3650-C) Page 16
and to provide comparative cost and quality information to
consumers, providers and purchasers of health care about Oregon's
health care systems and health plan networks in order to provide
comparative information to consumers.
(b) Develop uniform contracting standards for the purchase of
health care, including the following:
(A) Uniform quality standards and performance measures;
(B) Evidence-based guidelines for major chronic disease
management and health care services with unexplained variations
in frequency or cost;
(C) Evidence-based effectiveness guidelines for select new
technologies and medical equipment; and
(D) A statewide drug formulary that may be used by publicly
funded health benefit plans.
{ - (c) Submit directly to the Legislative Counsel, no later
than October 1 of each even-numbered year, requests for measures
necessary to provide statutory authorization to carry out any of
the authority's duties or to implement any of the board's
recommendations. The measures may be filed prior to the beginning
of the legislative session in accordance with the rules of the
House of Representatives and the Senate. - }
(3) The enumeration of duties, functions and powers in this
section is not intended to be exclusive nor to limit the duties,
functions and powers imposed on or vested in the Oregon Health
Authority by ORS 413.006 to 413.064 or by other statutes.
SECTION 20. ORS 414.025, as amended by section 1, chapter 73,
Oregon Laws 2010, is amended to read:
414.025. { + Definitions. + } As used in this chapter { +
and ORS chapter 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. + }
{ - (1) - } { + (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.
{ - (2) - } { + (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:
Enrolled House Bill 3650 (HB 3650-C) Page 17
(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 mental
retardation.
(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, 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 of Human Services by rule, but whose
family income is less than the federal poverty level and whose
Enrolled House Bill 3650 (HB 3650-C) Page 18
family investments and savings equal less than the investments
and savings limit established by the department 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 (6).
(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
meeting criteria adopted by the Oregon Health Authority under
section 4 of this 2011 Act.
(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
Services Commission under ORS 414.720:
(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;
Enrolled House Bill 3650 (HB 3650-C) Page 19
(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. + }
{ - (3) - } { + (9) + } 'Income' has the meaning given that
term in ORS 411.704.
{ - (4) - } { + (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 of Human Services may establish by rule that
are available to the applicant or recipient to contribute toward
meeting the needs of the applicant or recipient.
{ - (5) - } { + (11) + } 'Medical assistance' means so much
of the
{ - following - } medical { + , mental health, preventive,
supportive, palliative + }and remedial care and services as may
be prescribed by the Oregon Health Authority according to the
standards established pursuant to ORS { - 413.032 - } { +
414.065 + }, including 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. + }
{ - medical care: - }
{ - (a) Inpatient hospital services, other than services in
an institution for mental diseases; - }
{ - (b) Outpatient hospital services; - }
{ - (c) Other laboratory and X-ray services; - }
{ - (d) Skilled nursing facility services, other than
services in an institution for mental diseases; - }
{ - (e) Physicians' services, whether furnished in the
office, the patient's home, a hospital, a skilled nursing
facility or elsewhere; - }
{ - (f) Medical care, or any other type of remedial care
recognized under state law, furnished by licensed practitioners
within the scope of their practice as defined by state law; - }
{ - (g) Home health care services; - }
{ - (h) Private duty nursing services; - }
{ - (i) Clinic services; - }
{ - (j) Dental services; - }
{ - (k) Physical therapy and related services; - }
{ - (L) Prescribed drugs, including those dispensed and
administered as provided under ORS chapter 689; - }
{ - (m) Dentures and prosthetic devices; and eyeglasses
prescribed by a physician skilled in diseases of the eye or by an
optometrist, whichever the individual may select; - }
{ - (n) Other diagnostic, screening, preventive and
rehabilitative services; - }
{ - (o) Inpatient hospital services, skilled nursing facility
services and intermediate care facility services for individuals
65 years of age or over in an institution for mental
diseases; - }
{ - (p) Any other medical care, and any other type of
remedial care recognized under state law; - }
Enrolled House Bill 3650 (HB 3650-C) Page 20
{ - (q) Periodic screening and diagnosis of individuals under
the age of 21 years to ascertain their physical or mental
impairments, and such health care, treatment and other measures
to correct or ameliorate impairments and chronic conditions
discovered thereby; - }
{ - (r) Inpatient hospital services for individuals under 22
years of age in an institution for mental diseases; and - }
{ - (s) Hospice services. - }
{ - (6) - } { + (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' includes 'health services' as
defined in ORS 414.705. - } 'Medical assistance' does not
include care or services for an inmate in a nonmedical public
institution.
{ - (7) 'Medically needy' means a person who is a resident of
this state and who is considered eligible under federal law for
medically needy assistance. - }
{ + (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
section 6 of this 2011 Act 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 section 10 of this
2011 Act. + }
{ - (8) - } { + (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.
Enrolled House Bill 3650 (HB 3650-C) Page 21
SECTION 21. ORS 414.033 is amended to read:
414.033. { + Agreements with federal government regarding
dually eligible individuals. + } The Oregon Health Authority may:
(1) Subject to the allotment system provided for in ORS 291.234
to 291.260, expend such sums as are required to be expended in
this state to provide medical assistance. Expenditures for
medical assistance include, but are not limited to, expenditures
for deductions, cost sharing, enrollment fees, premiums or
similar charges imposed with respect to hospital insurance
benefits or supplementary health insurance benefits, as
established by federal law.
(2) Enter into agreements with, join with or accept grants
from, the federal government for cooperative research and
demonstration projects for public welfare purposes, including,
but not limited to, any project { - which determines the cost
of - } { + for:
(a) + }Providing medical assistance to { - the medically
needy and evaluates - } { + individuals who are dually eligible
for Medicare and Medicaid using alternative payment methodologies
or integrated and coordinated health care and services; or
(b) Evaluating + } service delivery systems.
SECTION 22. ORS 414.065 is amended to read:
414.065. { + Payments for health services; quality
measures. + } (1)(a) With respect to { - medical and
remedial - } { + health + } care and services to be provided in
medical assistance during any period,
{ - and within the limits of funds available therefor, - } the
Oregon Health Authority shall determine, subject to such
revisions as it may make from time to time and { - with respect
to the 'health services' defined in ORS 414.705, - } subject to
legislative funding
{ - in response to the report of the Health Services
Commission - } and paragraph (b) of this subsection:
(A) The types and extent of { - medical and remedial - }
{ + health + } care and services to be provided to each eligible
group of recipients of medical assistance.
(B) Standards { + , including outcome and quality measures, + }
to be observed in the provision of { - medical and remedial - }
{ + health + } care and services.
(C) The number of days of { - medical and remedial - } { +
health + } care and services toward the cost of which public
assistance funds will be expended in the care of any person.
(D) Reasonable fees, charges { + , + } { - and - } daily
rates { - to which public assistance funds will be applied
toward - } { + and global payments for + }meeting the costs of
providing { - medical and remedial care and - } { +
health + } services to an applicant or recipient.
(E) Reasonable fees for professional medical and dental
services which may be based on usual and customary fees in the
locality for similar services.
(F) The amount and application of any copayment or other
similar cost-sharing payment that the authority may require a
recipient to pay toward the cost of { - medical and
remedial - } { + health + } care or services.
(b) { - Notwithstanding ORS 414.720 (8), - } The authority
shall adopt rules establishing timelines for payment of health
services under paragraph (a) of this subsection.
(2) The types and extent of { - medical and remedial - }
{ + health + } care and services and the amounts to be paid in
meeting the costs thereof, as determined and fixed by the
Enrolled House Bill 3650 (HB 3650-C) Page 22
authority and within the limits of funds available therefor,
shall be the total available for medical assistance and payments
for such medical assistance shall be the total amounts from
public assistance funds available to providers of { - medical
and remedial - } { + health + } care and services in meeting
the costs thereof.
(3) Except for payments under a cost-sharing plan, payments
made by the authority for medical assistance shall constitute
payment in full for all { - medical and remedial - } { +
health + } care and services for which such payments of medical
assistance were made.
{ - (4) Medical benefits, standards and limits established
pursuant to subsection (1)(a)(A), (B) and (C) of this section for
the eligible medically needy, except for persons receiving
assistance under ORS 411.706, may be less than but may not exceed
medical benefits, standards and limits established for the
eligible categorically needy, except that, in the case of a
research and demonstration project entered into under ORS
411.135, medical benefits, standards and limits for the eligible
medically needy may exceed those established for specific
eligible groups of the categorically needy. - }
{ + (4) Notwithstanding subsections (1) and (2) of this
section, the Department of Human Services shall be responsible
for determining the payment for Medicaid-funded long term care
services and for contracting with the providers of long term care
services. + }
SECTION 23. ORS 410.604, as amended by section 8, chapter 100,
Oregon Laws 2010, is amended to read:
410.604. { + Home Care Commission. + } (1) The Home Care
Commission shall ensure the quality of home care services by:
(a) Establishing qualifications for home care workers with the
advice and consent of the Department of Human Services;
(b) Providing training opportunities for home care workers and
elderly persons and persons with disabilities who employ home
care workers;
(c) Establishing and maintaining a registry of qualified home
care workers;
(d) Providing routine, emergency and respite referrals of home
care workers;
(e) Entering into contracts with public and private
organizations and individuals for the purpose of obtaining or
developing training materials and curriculum or other services as
may be needed by the commission; and
(f) Working cooperatively with area agencies and state and
local agencies to accomplish the duties listed in paragraphs (a)
to (e) of this subsection.
(2)(a) The commission shall enter into an interagency agreement
with the department to contract for a department employee to
serve as executive director of the commission. The executive
director shall be appointed by the Director of Human Services in
consultation with the Governor and subject to approval by the
commission, and shall serve at the pleasure of the Director of
Human Services. The commission may delegate to the executive
director the authority to act on behalf of the commission to
carry out its duties and responsibilities, including but not
limited to:
(A) Entering into contracts or agreements; and
(B) Taking reasonable or necessary actions related to the
commission's role as employer of record for home care workers
under ORS 410.612.
Enrolled House Bill 3650 (HB 3650-C) Page 23
(b) The commission shall enter into an interagency agreement
with the department for carrying out any of the duties or
functions of the commission, for department expenditures and for
the provision of staff support by the department.
(3) When conducting its activities, and in making decisions
relating to those activities, the commission shall first consider
the effect of its activities and decisions on:
(a) Improving the quality of service delivered by home care
workers;
(b) Ensuring adequate hours of service are provided to elderly
persons and persons with disabilities by home care workers; and
(c) Ensuring that services, activities and purchases that are
purchased by elderly persons and persons with disabilities other
than home care services, including adult support services, are
not compromised or diminished.
{ + (4) The commission shall work with culturally diverse
community-based organizations to train and certify community
health workers and personal health navigators. The workers and
navigators shall work as part of a multidisciplinary team under
the direction of a licensed or certified health care
professional. The commission shall recruit qualified home care
workers who desire to be trained and certified as community
health workers or personal health navigators.
(5) The commission shall ensure that each coordinated care
organization honors all of the terms and conditions of employment
established by the commission with respect to the community
health workers and personal health navigators referred by the
commission. This subsection does not require a coordinated care
organization to employ or contract with community health workers
and personal health navigators certified by the commission so
long as the community health workers and personal health
navigators employed or otherwise retained by the organization
meet competency standards established by the authority under
section 11 of this 2011 Act. + }
{ - (4) - } { + (6) + } The commission has the authority to
contract for services, lease, acquire, hold, own, encumber,
insure, sell, replace, deal in and with and dispose of real and
personal property in its own name.
{ + (7) As used in this section, 'community health worker, '
' coordinated care organization' and 'personal health navigator'
have the meanings given those terms in ORS 414.025. + }
SECTION 24. ORS 414.153 is amended to read:
414.153. { + Partnering with county government. + } In order
to make advantageous use of the system of public health { + care
and + } services available through county health departments and
other publicly supported programs and to insure access to public
health { + care and + } services through contract under ORS
chapter 414, the state shall:
(1) Unless cause can be shown why such an agreement is not
feasible, require and approve agreements between { - prepaid
health plans - } { + coordinated care organizations + } and
publicly funded providers for authorization of payment for point
of contact services in the following categories:
(a) Immunizations;
(b) Sexually transmitted diseases; and
(c) Other communicable diseases;
(2) Allow enrollees in { - prepaid health plans - } { +
coordinated care organizations + } to receive from
fee-for-service providers:
(a) Family planning services;
Enrolled House Bill 3650 (HB 3650-C) Page 24
(b) Human immunodeficiency virus and acquired immune deficiency
syndrome prevention services; and
(c) Maternity case management if the Oregon Health Authority
determines that a { - prepaid plan - } { + coordinated care
organization + } cannot adequately provide the services;
(3) Encourage and approve agreements between { - prepaid
health plans - } { + coordinated care organizations + } and
publicly funded providers for authorization of and payment for
services in the following categories:
(a) Maternity case management;
(b) Well-child care;
(c) Prenatal care;
(d) School-based clinics;
(e) Health { + care and + } services for children provided
through schools and Head Start programs; and
(f) Screening services to provide early detection of health
care problems among low income women and children, migrant
workers and other special population groups; and
{ - (4) Recognize the social value of partnerships between
county health departments and other publicly supported programs
and other health providers, and take appropriate measures to
involve publicly supported health care and service programs in
the development and implementation of managed health care
programs in their areas of responsibility. - }
{ + (4) Recognize the responsibility of counties under ORS
430.620 to operate community mental health programs by requiring
a written agreement between each coordinated care organization
and the local mental health authority in the area served by the
coordinated care organization, unless cause can be shown why such
an agreement is not feasible under criteria established by the
Oregon Health Authority. The written agreements:
(a) May not limit the ability of coordinated care organizations
to contract with other public or private providers for mental
health or chemical dependency services;
(b) Must include agreed upon outcomes; and
(c) Must describe the authorization and payments necessary to
maintain the mental health safety net system and to maintain the
efficient and effective management of the following
responsibilities of local mental health authorities, with respect
to the service needs of members of the coordinated care
organization:
(A) Management of children and adults at risk of entering or
who are transitioning from the Oregon State Hospital or from
residential care;
(B) Care coordination of residential services and supports for
adults and children;
(C) Management of the mental health crisis system;
(D) Management of community-based specialized services
including but not limited to supported employment and education,
early psychosis programs, assertive community treatment or other
types of intensive case management programs and home-based
services for children; and
(E) Management of specialized services to reduce recidivism of
individuals with mental illness in the criminal justice
system. + }
SECTION 25. ORS 414.712 is amended to read:
414.712. { + Ombudsman services. + } The Oregon Health
Authority shall provide medical assistance under ORS 414.705 to
414.750 to eligible persons who are determined eligible for
medical assistance by the Department of Human Services according
Enrolled House Bill 3650 (HB 3650-C) Page 25
to ORS 411.706. The Oregon Health Authority shall also provide
the following:
(1) Ombudsman services for { - eligible persons who receive
assistance under - } { + individuals who receive medical
assistance under + } ORS 411.706 { + and for recipients who are
members of coordinated care organizations + }. With the
concurrence of the Governor and the Oregon Health Policy Board,
the Director of the Oregon Health Authority shall appoint
ombudsmen and may terminate an ombudsman. Ombudsmen are under the
supervision and control of the director. An ombudsman shall serve
as a { - patient's - } { + recipient's + } advocate whenever
the { - patient - } { + recipient + } or a physician or other
medical personnel serving the { - patient - } { +
recipient + } is reasonably concerned about access to, quality of
or limitations on the care being provided by a health care
provider { + or a coordinated care organization + }.
{ - Patients - } { + Recipients + } shall be informed of the
availability of an ombudsman. Ombudsmen shall report to the
Governor and the Oregon Health Policy Board in writing at least
once each quarter. A report shall include a summary of the
services that the ombudsman provided during the quarter and the
ombudsman's recommendations for improving ombudsman services and
access to or quality of care provided to eligible persons by
health care providers { + and coordinated care
organizations + }.
(2) Case management services in each health care provider
organization { + or coordinated care organization + } for those
{ - eligible persons - } { + individuals + } who receive
assistance under ORS 411.706. Case managers shall be trained in
and shall exhibit skills in communication with and sensitivity to
the unique health care needs of { - people - } { +
individuals + } who receive assistance under ORS 411.706. Case
managers shall be reasonably available to assist
{ - patients - } { + recipients + } served by the organization
with the coordination of the
{ - patient's - } { + recipient's + } health { - care - }
services at the reasonable request of the { - patient - } { +
recipient + } or a physician or other medical personnel serving
the { - patient - } { + recipient + }. { - Patients - }
{ + Recipients + } shall be informed of the availability of
case managers.
(3) A mechanism, established by rule, for soliciting consumer
opinions and concerns regarding accessibility to and quality of
the services of each health care provider.
(4) A choice of available medical plans and, within those
plans, choice of a primary care provider.
(5) Due process procedures for any individual whose request for
medical assistance coverage for any treatment or service is
denied or is not acted upon with reasonable promptness. These
procedures shall include an expedited process for cases in which
a
{ - patient's - } { + recipient's + } medical needs require
swift resolution of a dispute. { + An ombudsman described in
subsection (1) of this section may not act as the recipient's
representative during any grievance or hearing process. + }
SECTION 26. ORS 414.725 is amended to read:
414.725. { + Contracts with coordinated care
organizations. + }
{ - (1)(a) Pursuant to rules adopted by the Oregon Health
Authority, the authority shall execute prepaid managed care
Enrolled House Bill 3650 (HB 3650-C) Page 26
health services contracts for health services funded by the
Legislative Assembly. The contract must require that all
services are provided to the extent and scope of the Health
Services Commission's report for each service provided under the
contract. The contracts are not subject to ORS chapters 279A and
279B, except ORS 279A.250 to 279A.290 and 279B.235.
Notwithstanding ORS 414.720 (8), the rules adopted by the
authority shall establish timelines for executing the contracts
described in this paragraph. - }
{ - (b) - } { + (1)(a) + } { - It is the intent of ORS
414.705 to 414.750 that the state - } { + The Oregon Health
Authority shall + } use, to the greatest extent possible,
{ - prepaid managed care health services - } { + coordinated
care + } organizations to provide { + fully integrated + }
physical { - health, dental, mental health and chemical
dependency services under ORS 414.705 to 414.750 - } { + 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. + }
{ - (c) - } { + (b) + } The authority shall { - solicit
qualified providers or plans to be reimbursed for providing the
covered services. The contracts may be with hospitals and medical
organizations, health maintenance organizations, managed health
care plans and any other qualified public or private prepaid
managed care health services organization. The authority may not
discriminate against any contractors that offer services within
their providers' lawful scopes of practice. - } { + execute
contracts with coordinated care organizations that meet the
criteria adopted by the authority under section 4 of this 2011
Act. Contracts under this subsection are not subject to ORS
chapters 279A and 279B, except ORS 279A.250 to 279A.290 and
279B.235. + }
{ - (d) - } { + (c) + } The authority shall establish
{ - annual - } financial reporting requirements for
{ - prepaid managed care health services - } { + 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
{ - prepaid managed care health services - } { + 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 { - prepaid managed care
health services - } { + 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, prescribed by the authority by
rule. + }
(e) The authority shall require compliance with the provisions
of { - paragraph (d) - } { + paragraphs (c) and (d) + } of
this subsection as a condition of entering into a contract with a
{ - prepaid managed care health services - } { + 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
Enrolled House Bill 3650 (HB 3650-C) Page 27
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 { - that - } provides a
health service to { - an enrollee of a prepaid managed care
health services - } { + 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 { - institute a fee-for-service case
management system or a fee-for-service payment system for the
same physical health, dental, mental health or chemical
dependency services provided under the health services contracts
for persons eligible for health services under ORS 414.705 to
414.750 in designated areas of the state in which a prepaid
managed care health services organization is not able to assign
an enrollee to a person or entity that is primarily responsible
for coordinating the physical health, dental, mental health or
chemical dependency services provided to the enrollee. In
addition, the authority may make other special arrangements as
necessary to increase the interest of providers in participation
in the state's managed care system, including but not limited to
the provision of stop-loss insurance for providers wishing to
limit the amount of risk they wish to underwrite - } { +
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 to 279A.290 and 279B.235 + }.
(3) As provided in subsections (1) and (2) of this section, the
aggregate expenditures by the authority for health services
provided pursuant to ORS 414.705 to 414.750 may not exceed the
total dollars appropriated for health services under ORS 414.705
to 414.750.
(4) Actions taken by providers, potential providers,
contractors and bidders in specific accordance with ORS 414.705
to 414.750 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 414.705 to 414.750 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
Enrolled House Bill 3650 (HB 3650-C) Page 28
same or similar community would do so under the same or similar
circumstances.
(6) A { - prepaid managed care health services - } { +
coordinated care + } organization shall provide information
{ - on contacting available providers to an enrollee in writing
within 30 days of assignment to the health services
organization. - } { + 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. + }
{ - (7) - } { + (8) + } Each { - prepaid managed care
health services - } { + coordinated care + } organization shall
provide upon the request of
{ - an enrollee - } { + a member + } or prospective
{ - enrollee - } { + a member + } annual summaries of the
organization's aggregate data regarding:
(a) Grievances and appeals; and
(b) Availability and accessibility of services provided to
{ - enrollees - } { + members + }.
{ - (8) - } { + (9) + } A { - prepaid managed care health
services - } { + coordinated care + } organization may not
limit enrollment in a
{ - designated - } { + geographic + } area based on the zip
code of { - an enrollee - } { + a member + } or prospective
{ - enrollee - } { + member + }.
SECTION 27. ORS 414.737 is amended to read:
414.737. { + Mandatory enrollment in coordinated care
organization; exemptions. + } (1) Except as provided in
subsections (2) { - and (3) - } { + , (3) and (4) + } of this
section { + and section 7 (2) of this 2011 Act + }, a person who
is eligible for or receiving { - physical health, dental,
mental health or chemical dependency - } { + health + }
services { - under ORS 414.705 to 414.750 - } must be enrolled
in { - the prepaid managed care health services
organizations - } { + a coordinated care organization + } to
receive the health services for which the person is
eligible. { + For purposes of this subsection, Medicaid-funded
long term care services do not constitute health services. + }
(2) { - Subsection (1) - } { + Subsections (1) and (4) + }
of this section
{ - does - } { + do + } not apply to:
(a) A person who is a noncitizen and who is eligible only for
labor and delivery services and emergency treatment services;
(b) A person who is an American Indian and Alaskan Native
beneficiary; { - and - }
{ + (c) An individual described in section 7 (2) of this 2011
Act who is dually eligible for Medicare and Medicaid and enrolled
in a program of all-inclusive care for the elderly; and + }
{ - (c) - } { + (d) + } A person whom the Oregon Health
Authority may by rule exempt from the mandatory enrollment
requirement of subsection (1) of this section, including but not
limited to:
(A) A person who is also eligible for Medicare;
(B) A woman in her third trimester of pregnancy at the time of
enrollment;
Enrolled House Bill 3650 (HB 3650-C) Page 29
(C) A person under 19 years of age who has been placed in
adoptive or foster care out of state;
(D) A person under 18 years of age who is medically fragile and
who has special health care needs; and
(E) A person with major medical coverage.
(3) Subsection (1) of this section does not apply to a person
who resides in { - a designated area in which a prepaid managed
care health services organization providing physical health,
dental, mental health or chemical dependency services is not able
to assign an enrollee to a person or entity that is primarily
responsible for coordinating the physical health, dental, mental
health or chemical dependency services provided to the
enrollee. - } { + an area that is not served by a coordinated
care organization or where the organization's provider network is
inadequate.
(4) In any area that is not served by a coordinated care
organization but is served by a prepaid managed care health
services organization, a person must enroll with the prepaid
managed care health services organization to receive any of the
health services offered by the prepaid managed care health
services organization. + }
{ - (4) - } { + (5) + } As used in this section, 'American
Indian and Alaskan Native beneficiary' means:
(a) A member of a federally recognized Indian tribe { - , band
or group; - }
{ - (b) An Eskimo or Aleut or other Alaskan Native enrolled
by the United States Secretary of the Interior pursuant to the
Alaska Native Claims Settlement Act, 43 U.S.C. 1601; or - }
{ + ;
(b) An individual who resides in an urban center and:
(A) Is a member of a tribe, band or other organized group of
Indians, including those tribes, bands or groups whose
recognition was terminated since 1940 and those recognized now or
in the future by the state in which the member resides, or who is
a descendant in the first or second degree of such a member;
(B) Is an Eskimo or Aleut or other Alaskan Native; or
(C) Is determined to be an Indian under regulations promulgated
by the United States Secretary of the Interior; + }
(c) A person who is considered by the United States Secretary
of the Interior to be an Indian for any purpose { + ; or
(d) An individual who is considered by the United States
Secretary of Health and Human Services to be an Indian for
purposes of eligibility for Indian health care services,
including as a California Indian, Eskimo, Aleut or other Alaskan
Native + }.
SECTION 28. ORS 414.737, as amended by section 8, chapter 751,
Oregon Laws 2007, and section 331, chapter 595, Oregon Laws 2009,
is amended to read:
414.737. { + Mandatory enrollment in coordinated care
organization; exemptions. + } (1) Except as provided in
subsections (2) { - and (3) - } { + , (3), (4) and (5) + } of
this section { + and section 7 (2) of this 2011 Act + }, a
person who is eligible for or receiving
{ - physical health, dental, mental health or chemical
dependency - } { + health + } services { - under ORS 414.705
to 414.750 - } must be enrolled in
{ - the prepaid managed care health services organizations - }
{ + a coordinated care organization + } to receive the health
services for which the person is eligible. { + For purposes of
Enrolled House Bill 3650 (HB 3650-C) Page 30
this subsection, Medicaid-funded long term care services do not
constitute health services. + }
(2) { - Subsection (1) - } { + Subsections (1) and (4) + }
of this section
{ - does - } { + do + } not apply to:
(a) A person who is a noncitizen and who is eligible only for
labor and delivery services and emergency treatment services;
(b) A person who is an American Indian and Alaskan Native
beneficiary; { - and - }
{ + (c) An individual described in section 7 (2) of this 2011
Act who is dually eligible for Medicare and Medicaid and enrolled
in a program of all-inclusive care for the elderly; and + }
{ - (c) - } { + (d) + } A person whom the Oregon Health
Authority may by rule exempt from the mandatory enrollment
requirement of subsection (1) of this section, including but not
limited to:
(A) A person who is also eligible for Medicare;
(B) A woman in her third trimester of pregnancy at the time of
enrollment;
(C) A person under 19 years of age who has been placed in
adoptive or foster care out of state;
(D) A person under 18 years of age who is medically fragile and
who has special health care needs;
(E) A person receiving services under the Medically Involved
Home-Care Program created by ORS 417.345 (1); and
(F) A person with major medical coverage.
(3) Subsection (1) of this section does not apply to a person
who resides in { - a designated area in which a prepaid managed
care health services organization providing physical health,
dental, mental health or chemical dependency services is not able
to assign an enrollee to a person or entity that is primarily
responsible for coordinating the physical health, dental, mental
health or chemical dependency services provided to the
enrollee. - } { + an area that is not served by a coordinated
care organization or where the organization's provider network is
inadequate.
(4) In any area that is not served by a coordinated care
organization but is served by a prepaid managed care health
services organization, a person must enroll with the prepaid
managed care health services organization to receive any of the
health services offered by the prepaid managed care health
services organization. + }
{ - (4) - } { + (5) + } As used in this section, 'American
Indian and Alaskan Native beneficiary' means:
(a) A member of a federally recognized Indian tribe { - , band
or group; - }
{ - (b) An Eskimo or Aleut or other Alaskan Native enrolled
by the United States Secretary of the Interior pursuant to the
Alaska Native Claims Settlement Act, 43 U.S.C. 1601; or - }
{ + ;
(b) An individual who resides in an urban center and:
(A) Is a member of a tribe, band or other organized group of
Indians, including those tribes, bands or groups whose
recognition was terminated since 1940 and those recognized now or
in the future by the state in which the member resides, or who is
a descendant in the first or second degree of such a member;
(B) Is an Eskimo or Aleut or other Alaskan Native; or
(C) Is determined to be an Indian under regulations promulgated
by the United States Secretary of the Interior; + }
Enrolled House Bill 3650 (HB 3650-C) Page 31
(c) A person who is considered by the United States Secretary
of the Interior to be an Indian for any purpose { + ; or
(d) An individual who is considered by the United States
Secretary of Health and Human Services to be an Indian for
purposes of eligibility for Indian health care services,
including as a California Indian, Eskimo, Aleut or other Alaskan
Native + }.
SECTION 29. ORS 414.760 is amended to read:
414.760. { + Requirement to offer patient centered primary
care home delivery model. + } (1) { - As funds are
available, - } The Oregon Health Authority { - may - } { +
shall + } provide reimbursement in the state's medical assistance
program for services provided by patient centered primary care
homes. If practicable, efforts to align financial incentives to
support patient centered primary care homes for enrollees in
medical assistance programs should be aligned with efforts of the
learning collaborative described in ORS 442.210 (3) { - (d) - }
.
{ + (2) The authority shall require each coordinated care
organization, to the extent practicable, to offer patient
centered primary care homes that meet the standards established
in section 6 of this 2011 Act. + }
{ - (2) - } { + (3) + } The authority may reimburse patient
centered primary care homes for interpretive services provided to
people in the state's medical assistance programs if interpretive
services qualify for federal financial participation.
{ - (3) - } { + (4) + } The authority shall require patient
centered primary care homes receiving these reimbursements to
report on quality measures described in ORS 442.210 (1)(c).
SECTION 30. ORS 442.468 is amended to read:
442.468. { + Workforce data collection. + } (1) { + Using
data collected from all health care professional licensing
boards, including but not limited to boards that license or
certify chemical dependency and mental health treatment providers
and other sources, + } the Office for Oregon Health Policy and
Research shall create and maintain a healthcare workforce
database that will provide information upon request to state
agencies and to the Legislative Assembly about Oregon's
healthcare workforce, including:
(a) Demographics, including race and ethnicity.
(b) Practice status.
(c) Education and training background.
(d) Population growth.
(e) Economic indicators.
(f) Incentives to attract qualified individuals, especially
those from underrepresented minority groups, to healthcare
education.
(2) The Administrator for the Office for Oregon Health Policy
and Research may contract with a private or public entity to
establish and maintain the database and to analyze the data. The
office is not subject to the requirements of ORS chapters 279A,
279B and 279C with respect to the contract.
SECTION 31. Section 1, chapter 867, Oregon Laws 2009, as
amended by section 46, chapter 828, Oregon Laws 2009, and section
2, chapter 73, Oregon Laws 2010, is amended to read:
{ + Sec. 1. + } { + Health System Fund. + } (1) The Health
System Fund is established in the State Treasury, separate and
distinct from the General Fund. Interest earned by the Health
System Fund shall be credited to the fund.
Enrolled House Bill 3650 (HB 3650-C) Page 32
(2) Amounts in the Health System Fund are continuously
appropriated to the Oregon Health Authority for the purpose of
funding the Health Care for All Oregon Children program
established in ORS 414.231, health services described in ORS
{ - 414.705 (1)(a) - } { + 414.025 (8)(a) + } to (j) and
other health services. Moneys in the fund may also be used by
the authority to:
(a) Provide grants to community health centers and safety net
clinics under ORS 413.225.
(b) Pay refunds due under section 41, chapter 736, Oregon Laws
2003, and under section 11, chapter 867, Oregon Laws 2009.
(c) Pay administrative costs incurred by the authority to
administer the assessment in section 9, chapter 867, Oregon Laws
2009.
(d) Provide health services described in ORS { - 414.705 - }
{ + 414.025 (8) + }to individuals described in ORS 414.025
{ - (2)(f)(B) - } { + (3)(f)(B) + }.
(3) The authority shall develop a system for reimbursement by
the authority to the Office of Private Health Partnerships out of
the Health System Fund for costs associated with administering
the private health option pursuant to ORS 414.826.
SECTION 32. Section 9, chapter 867, Oregon Laws 2009, as
amended by section 47, chapter 828, Oregon Laws 2009, is amended
to read:
{ + Sec. 9. + } (1) As used in this section { + : + } { - ,
'Medicaid managed care organization' means the following entities
defined in or referred to in ORS 414.736: - }
{ - (a) A fully capitated health plan. - }
{ - (b) A physician care organization. - }
{ - (c) A mental health organization. - }
{ + (a) 'Coordinated care organization' means an organization
that meets the criteria adopted by the Oregon Health Authority
under section 4 of this 2011 Act.
(b) 'Medicaid managed care organization' means a prepaid
managed care health services organization or a coordinated care
organization. + }
(2) No later than 45 days following the end of a calendar
quarter, a Medicaid managed care organization shall pay an
assessment at a rate of one percent of the gross amount of
{ - capitation - } payments received by the Medicaid managed
care organization { + from the authority + } during that
calendar quarter for providing coverage of health services under
ORS 414.705 to 414.750.
(3) The assessment shall be paid to the { - Oregon Health - }
authority in a manner and form prescribed by the authority.
(4) Assessments received by the authority under this section
shall be deposited in the Health System Fund established in
section 1, chapter 867, Oregon Laws 2009.
(5) The assessment imposed under this section is in addition to
and not in lieu of any tax, surcharge or other assessment imposed
on a Medicaid managed care organization.
{ +
CONFORMING AMENDMENTS + }
SECTION 33. ORS 192.493 is amended to read:
192.493. A record of an agency of the executive department as
defined in ORS 174.112 that contains the following information is
a public record subject to inspection under ORS 192.420 and is
not exempt from disclosure under ORS 192.501 or 192.502 except to
Enrolled House Bill 3650 (HB 3650-C) Page 33
the extent that the record discloses information about an
individual's health or is proprietary to a person:
(1) The amounts determined by an independent actuary retained
by the agency to cover the costs of providing each of the
following health services under ORS 414.705 to 414.750 for the
six months preceding the report:
(a) Inpatient hospital services;
(b) Outpatient hospital services;
(c) Laboratory and X-ray services;
(d) Physician and other licensed practitioner services;
(e) Prescription drugs;
(f) Dental services;
(g) Vision services;
(h) Mental health services;
(i) Chemical dependency services;
(j) Durable medical equipment and supplies; and
(k) Other health services provided under a { - prepaid
managed care health services - } { + coordinated care
organization + } contract under ORS 414.725 { + or a contract
with a prepaid managed care health services organization + };
(2) The amounts the agency and each contractor have paid under
each { - prepaid managed care health services - } { +
coordinated care organization + } contract under ORS 414.725
{ + or prepaid managed care health services organization
contract + } for administrative costs and the provision of each
of the health services described in subsection (1) of this
section for the six months preceding the report;
(3) Any adjustments made to the amounts reported under this
section to account for geographic or other differences in
providing the health services; and
(4) The numbers of individuals served under each { - prepaid
managed care health services - } { + coordinated care
organization + } contract { + or prepaid managed care health
services organization contract + }, listed by category of
individual.
SECTION 34. ORS 411.404 is amended to read:
411.404. (1) The Department of Human Services shall determine
eligibility for medical assistance according to criteria
prescribed by rule, taking into account:
(a) The requirements and needs of the applicant and of the
spouse and dependents of the applicant;
(b) The income, resources and maintenance available to the
applicant; and
(c) The responsibility of the spouse of the applicant and, with
respect to an applicant who is blind or is permanently and
totally disabled or is under 21 years of age, the responsibility
of the parents.
(2) Rules adopted by the department under subsection (1) of
this section:
(a) Shall disregard resources for those who are eligible for
medical assistance only by reason of ORS 414.025 { - (2)(s) - }
{ + (3)(s) + }, except for the resources described in ORS
414.025 { - (2)(s) - } { + (3)(s) + }.
(b) May disregard income and resources within the limits
required or permitted by federal law, regulations or orders.
(3) The department may not require any needy person over 65
years of age, as a condition of entering or remaining in a
hospital, nursing home or other congregate care facility, to sell
any real property normally used as such person's home. Any rule
Enrolled House Bill 3650 (HB 3650-C) Page 34
of the department inconsistent with this section is to that
extent invalid.
SECTION 35. ORS 411.708 is amended to read:
411.708. (1) The amount of any assistance paid under ORS
411.706 is a claim against the property or interest in the
property belonging to and a part of the estate of any deceased
recipient. If the deceased recipient has no estate, the estate of
the surviving spouse of the deceased recipient, if any, shall be
charged for assistance granted under ORS 411.706 to the deceased
recipient or the surviving spouse. There shall be no adjustment
or recovery of assistance correctly paid on behalf of any
deceased recipient under ORS 411.706 except after the death of
the surviving spouse of the deceased recipient, if any, and only
at a time when the deceased recipient has no surviving child who
is under 21 years of age or who is blind or has a disability.
Transfers of real or personal property by recipients of
assistance without adequate consideration are voidable and may be
set aside under ORS 411.620 (2).
(2) Except when there is a surviving spouse, or a surviving
child who is under 21 years of age or who is blind or has a
disability, the amount of any assistance paid under ORS 411.706
is a claim against the estate in any conservatorship proceedings
and may be paid pursuant to ORS 125.495.
(3) A claim under this section shall exclude benefits paid to
or on behalf of a beneficiary under a policy of qualified long
term care insurance, as defined in ORS 414.025 { - (2)(t) - }
{ + (3)(t) + }.
(4) Nothing in this section authorizes the recovery of the
amount of any assistance from the estate or surviving spouse of a
recipient to the extent that the need for assistance resulted
from a crime committed against the recipient.
SECTION 36. ORS 414.115 is amended to read:
414.115. (1) In lieu of providing one or more of the
{ - medical and remedial - } { + health + } care and services
available under medical assistance by direct payments to
providers thereof and in lieu of providing such { - medical and
remedial - } { + health + } care and services made available
pursuant to ORS 414.065, the Oregon Health Authority shall use
available medical assistance funds to purchase and pay premiums
on policies of insurance, or enter into and pay the expenses on
health care service contracts, or medical or hospital service
contracts that provide one or more of the
{ - medical and remedial - } { + health + } care and services
available under medical assistance for the benefit of the
categorically needy. Notwithstanding other specific provisions,
the use of available medical assistance funds to purchase
{ - medical or remedial - } { + health + } care and services
may provide the following insurance or contract options:
(a) Differing services or levels of service among groups of
eligibles as defined by rules of the authority; and
(b) Services and reimbursement for these services may vary
among contracts and need not be uniform.
(2) The policy of insurance or the contract by its terms, or
the insurer or contractor by written acknowledgment to the
authority must guarantee:
(a) To provide { - medical and remedial - } { + health + }
care and services of the type, within the extent and according to
standards prescribed under ORS 414.065;
(b) To pay providers of { - medical and remedial - } { +
health + } care and services the amount due, based on the number
Enrolled House Bill 3650 (HB 3650-C) Page 35
of days of care and the fees, charges and costs established under
ORS 414.065, except as to medical or hospital service contracts
which employ a method of accounting or payment on other than a
fee-for-service basis;
(c) To provide { - medical and remedial - } { + health + }
care and services under policies of insurance or contracts in
compliance with all laws, rules and regulations applicable
thereto; and
(d) To provide such statistical data, records and reports
relating to the provision, administration and costs of providing
{ - medical and remedial - } { + health + } care and services
to the authority as may be required by the authority for its
records, reports and audits.
SECTION 37. ORS 414.211 is amended to read:
414.211. (1) There is established a Medicaid Advisory Committee
consisting of not more than 15 members appointed by the Governor.
(2) The committee shall be composed of:
(a) A physician licensed under ORS chapter 677;
(b) Two members of health care consumer groups that include
Medicaid recipients;
(c) Two Medicaid recipients, one of whom shall be a person with
a disability;
(d) The Director of the Oregon Health Authority or designee;
(e) Health care providers;
(f) Persons associated with health care organizations,
including but not limited to { - managed care plans - } { +
coordinated care organizations + } under contract to the Medicaid
program; and
(g) Members of the general public.
(3) In making appointments, the Governor shall consult with
appropriate professional and other interested organizations. All
members appointed to the committee shall be familiar with the
medical needs of low income persons.
(4) The term of office for each member shall be two years, but
each member shall serve at the pleasure of the Governor.
(5) Members of the committee shall receive no compensation for
their services but, subject to any applicable state law, shall be
allowed actual and necessary travel expenses incurred in the
performance of their duties from the Oregon Health Authority
Fund.
SECTION 38. ORS 414.229 is amended to read:
414.229. (1) There is established in the Oregon Health
Authority the Office for Oregon Health Policy and Research
Advisory Committee composed of members appointed by the Governor.
Members shall include:
(a) Representatives of { - managed care health services - }
{ + coordinated care + } organizations under contract with the
Oregon Health Authority pursuant to ORS 414.725 and serving
primarily rural areas of the state;
(b) Representatives of { - managed care health services - }
{ + coordinated care + } organizations under contract with the
Oregon Health Authority pursuant to ORS 414.725 and serving
primarily urban areas of the state;
(c) Representatives of medical organizations representing
health care providers under contract with { - managed care
health services - } { + coordinated care + } organizations
pursuant to ORS 414.725 who serve patients in both rural and
urban areas of the state;
{ - and - }
Enrolled House Bill 3650 (HB 3650-C) Page 36
(d) One representative from Type A hospitals and one
representative from Type B hospitals { + ; and
(e) Representatives of health care organizations serving areas
of this state that are not served by coordinated care
organizations + }.
(2) Members of the advisory committee shall not be entitled to
compensation or per diem.
SECTION 39. ORS 414.428 is amended to read:
414.428. (1) An individual described in ORS 414.025
{ - (2)(s) - } { + (3)(s) + } who is eligible for or receiving
medical assistance and who is an American Indian and Alaskan
Native beneficiary shall receive the benefit package of health
{ - care - } services described in ORS 414.707 (1) if:
(a) The Oregon Health Authority receives 100 percent federal
medical assistance percentage for payments made by the authority
for the health { - care - } services provided as part of the
benefit package described in ORS 414.707 (1); or
(b) The authority receives funding from the Indian tribes for
which federal financial participation is available.
(2) As used in this section, 'American Indian and Alaskan
Native beneficiary' { - means: - }
{ - (a) A member of a federally recognized Indian tribe, band
or group; - }
{ - (b) An Eskimo or Aleut or other Alaskan native enrolled
by the United States Secretary of the Interior pursuant to the
Alaska Native Claims Settlement Act, 43 U.S.C. 1601; or - }
{ - (c) A person who is considered by the United States
Secretary of the Interior to be an Indian for any purpose - }
{ + has the meaning given that term in ORS 414.737 + }.
SECTION 40. ORS 414.630 is amended to read:
414.630. (1) { + In areas that are not served by a coordinated
care organization, + } the Oregon Health Authority
{ - shall - } { + may + } execute prepaid capitated health
service contracts for at least hospital or physician medical
care, or both, with hospital and medical organizations, health
maintenance organizations and any other appropriate public or
private persons.
(2) For purposes of ORS 279A.025, 279A.140, 414.145 and 414.610
to 414.640, instrumentalities and political subdivisions of the
state are authorized to enter into prepaid capitated health
service contracts with the { - Oregon Health - } authority
{ - or the Oregon Health Policy Board - } and shall not thereby
be considered to be transacting insurance.
(3) In the event that there is an insufficient number of
qualified bids for { + coordinated care organizations or + }
prepaid capitated health services contracts for hospital or
physician medical care, or both, in some areas of the state, the
{ - Oregon Health - } authority may continue a fee for service
payment system.
(4) Payments to providers may be subject to contract provisions
requiring the retention of a specified percentage in an incentive
fund or to other contract provisions by which adjustments to the
payments are made based on utilization efficiency.
{ + (5) Contracts described in this section are not subject
to ORS chapters 279A and 279B, except that the contracts are
subject to ORS 279A.235 and 279A.250 to 279A.290. + }
SECTION 41. ORS 414.706 is amended to read:
414.706. The Legislative Assembly shall approve and fund health
services to the following persons:
Enrolled House Bill 3650 (HB 3650-C) Page 37
(1) Persons who are categorically needy as described in ORS
414.025 { - (2)(o) - } { + (3)(o) + } and (p);
(2) Pregnant women with incomes no more than 185 percent of the
federal poverty guidelines;
(3) Persons under 19 years of age with incomes no more than 200
percent of the federal poverty guidelines;
(4) Persons described in ORS 414.708; and
(5) Persons 19 years of age or older with incomes no more than
100 percent of the federal poverty guidelines who do not have
federal Medicare coverage.
SECTION 42. ORS 414.707 is amended to read:
414.707. (1) Persons described in ORS 414.706 (1), (2), (3) and
(5) are eligible to receive all the health services approved and
funded by the Legislative Assembly.
(2) Persons described in ORS 414.708 are eligible to receive
the health services described in ORS { - 414.705 (1)(c) - }
{ + 414.025 (8)(c) + }, (f) and (g).
SECTION 43. ORS 414.728 is amended to read:
414.728. For services provided { + on a fee-for-service
basis + } to persons who are entitled to receive medical
assistance { - and whose medical assistance benefits are not
administered by a prepaid managed care health services
organization, as defined in ORS 414.736 - } , the Oregon Health
Authority shall reimburse Type A and Type B hospitals and rural
critical access hospitals, as described in ORS 442.470 and
identified by the Office of Rural Health as rural hospitals,
fully for the cost of covered services based on the most recent
audited Medicare cost report for Oregon hospitals adjusted to
reflect the Medicaid mix of services.
{ + NOTE: + } Section 44 was deleted by amendment. Subsequent
sections were not renumbered.
SECTION 45. ORS 414.736, as amended by section 6, chapter 886,
Oregon Laws 2009, and section 4, chapter 417, Oregon Laws 2011
(Enrolled Senate Bill 201), is amended to read:
414.736. As used in { + ORS 192.493, + } this chapter, { +
+ }ORS chapter 416 and section 9, chapter 867, Oregon Laws 2009:
(1) 'Designated area' means a geographic area of the state
defined by the Oregon Health Authority by rule that is served by
a prepaid managed care health services organization.
(2) 'Fully capitated health plan' means an organization that
contracts with the { - Oregon Health - } authority on a
prepaid capitated basis under ORS { - 414.725 - } { +
414.630 + }.
(3) 'Physician care organization' means an organization that
contracts with the { - Oregon Health - } authority on a
prepaid capitated basis under ORS { - 414.725 - } { +
414.630 + } to provide the health services described in ORS
{ - 414.705 (1)(b) - } { + 414.025 (8)(b) + }, (c), (d), (e),
{ + (f), + } (g) and (j). A physician care organization may also
contract with the authority on a prepaid capitated basis to
provide the health services described in ORS { - 414.705
(1)(k) - } { + 414.025 (8)(k) + } and (L).
(4) 'Prepaid managed care health services organization ' means
a managed physical health, dental, mental health or chemical
dependency organization that contracts with the authority on a
prepaid capitated basis under ORS { - 414.725 - } { +
414.630 + }. A prepaid managed care health services organization
may be a dental care organization, fully capitated health plan,
physician care organization, mental health organization or
chemical dependency organization.
Enrolled House Bill 3650 (HB 3650-C) Page 38
SECTION 46. ORS 414.742 is amended to read:
414.742. The Oregon Health Authority may not establish
capitation rates { + or global budgets + } that include payment
for mental health drugs. The authority shall reimburse pharmacy
providers for mental health drugs only on a fee-for-service
payment basis.
SECTION 47. ORS 414.743 is amended to read:
414.743. (1) A { - fully capitated health plan - } { +
coordinated care organization + } that does not have a contract
with a hospital to provide inpatient or outpatient hospital
services under ORS 414.705 to 414.750 must, using a Medicare
payment methodology, reimburse the noncontracting hospital for
services provided to an enrollee of the plan at a rate no less
than a percentage of the Medicare reimbursement rate for those
services. The percentage of the Medicare reimbursement rate that
is used to determine the reimbursement rate under this subsection
is equal to two percentage points less than the percentage of
Medicare cost used by the authority in calculating the base
hospital capitation payment to the plan, excluding any
supplemental payments.
(2) A hospital that does not have a contract with a { - fully
capitated health plan - } { + coordinated care organization + }
to provide inpatient or outpatient hospital services under ORS
414.705 to 414.750 must accept as payment in full for hospital
services the rates described in subsection (1) of this section.
(3) This section does not apply to type A and type B hospitals,
as described in ORS 442.470, and rural critical access hospitals,
as defined in ORS 315.613.
(4) The Oregon Health Authority shall adopt rules to implement
and administer this section.
SECTION 48. ORS 414.746 is amended to read:
414.746. (1) The Oregon Health Authority shall establish an
adjustment to the { - capitation rate paid to a Medicaid
managed - } { + payments made to a coordinated + }care
organization defined in section 9, chapter 867, Oregon Laws 2009.
(2) The contracts entered into between the authority and
{ - Medicaid managed - } { + coordinated + } care
organizations must include provisions that ensure that the
adjustment to the { - capitation rate - } { + payments + }
established under subsection (1) of this section is distributed
by the { - Medicaid managed - } { + coordinated + } care
organizations to hospitals located in Oregon that receive
Medicare reimbursement based upon diagnostic related groups.
(3) The adjustment to the capitation rate paid to
{ - Medicaid managed - } { + coordinated + } care
organizations shall be established in an amount consistent with
the legislatively adopted budget and the aggregate assessment
imposed pursuant to section 2, chapter 736, Oregon Laws 2003.
SECTION 49. 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. + }
{ - (2) - } { + (3) + } 'Applicant' means an applicant for
assistance.
{ - (3) - } { + (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
Enrolled House Bill 3650 (HB 3650-C) Page 39
organization + } for services provided under contract pursuant to
ORS 414.725 to others for the benefit of such persons.
{ - (4) - } { + (5) + } 'Authority' means the Oregon Health
Authority.
{ - (5) - } { + (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.
{ - (6) - } { + (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 adopted by the authority under section 4
of this 2011 Act. + }
{ - (7) - } { + (9) + } 'Judgment' means a judgment in any
action or proceeding brought by a recipient to enforce the claim
of the recipient.
{ - (8) - } { + (10) + } 'Prepaid managed care health
services organization' means a managed health, dental or mental
health care organization that { - contracts - } { +
contracted + } with the authority on a prepaid capitated basis
{ - pursuant to ORS 414.725 - } . Prepaid managed care health
services organizations may be dental care organizations, fully
capitated health plans, mental health organizations or chemical
dependency organizations.
{ - (9) - } { + (11) + } 'Recipient' means a recipient of
assistance.
{ - (10) - } { + (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 50. ORS 416.530 is amended to read:
416.530. (1) If any applicant or recipient makes a claim or,
without making a claim, begins an action to enforce such claim,
the applicant or recipient, or the attorney for the applicant or
the recipient, shall immediately notify the Department of Human
Services or the Oregon Health Authority and the recipient's
{ - prepaid managed care health services - } { + coordinated
care + } organization, if the recipient is receiving services
from the organization. If an applicant or recipient, or the
attorney for the applicant or the recipient, has given notice
that the applicant or recipient has made a claim, it shall not be
necessary for the applicant or recipient, or the attorney for the
applicant or the recipient, to give notice that the applicant or
recipient has begun an action to enforce such claim. The
notification shall include the name and address of each person or
public body, agency or commission against whom claim is made or
action is brought. If claim is made or action is brought against
a corporation, the address given in such notification shall be
that of its principal place of business. If the applicant or
recipient is a minor, the parents, legal guardian or foster
parents of the minor shall give the notification required by this
section.
(2) The notification required by subsection (1) of this section
shall be provided to:
(a) The Oregon Health Authority by applicants for or recipients
of assistance provided by the authority; and
(b) The Department of Human Services for assistance provided by
the department.
SECTION 51. ORS 416.540 is amended to read:
Enrolled House Bill 3650 (HB 3650-C) Page 40
416.540. (1) Except as provided in subsection (2) of this
section and in ORS 416.590, the Department of Human Services and
the Oregon Health Authority shall have a lien upon the amount of
any judgment in favor of a recipient or amount payable to the
recipient under a settlement or compromise for all assistance
received by such recipient from the date of the injury of the
recipient to the date of satisfaction of such judgment or payment
under such settlement or compromise.
(2) The lien does not attach to the amount of any judgment,
settlement or compromise to the extent of attorney's fees, costs
and expenses incurred by a recipient in securing such judgment,
settlement or compromise and to the extent of medical, surgical
and hospital expenses incurred by the recipient on account of the
personal injuries for which the recipient had a claim.
(3) The authority may assign the lien described in subsection
(1) of this section to a prepaid managed care health services
organization { + or a coordinated care organization + } for
medical costs incurred by a recipient:
(a) During a period for which the authority paid a capitation
or enrollment fee { + or a payment using an alternative payment
methodology + }; and
(b) On account of the personal injury for which the recipient
had a claim.
(4) A prepaid managed care health services organization { + or
a coordinated care organization + } to which the authority has
assigned a lien shall notify the authority no later than 10 days
after filing notice of a lien.
(5) For the purposes of ORS 416.510 to 416.610, the authority
may designate the prepaid managed care health services
organization { + or the coordinated care organization + } to
which a lien is assigned as its designee.
(6) If the authority and a prepaid managed care health services
organization { + or a coordinated care organization + } both
have filed a lien, the authority's lien shall be satisfied first.
SECTION 52. ORS 416.610 is amended to read:
416.610. The Oregon Health Authority or the recipient's
{ - prepaid managed care health services - } { + coordinated
care + } organization, if the recipient is receiving services
from the organization, shall have a cause of action against any
recipient who fails to give the notification required by ORS
416.530 for amounts received by the recipient pursuant to a
judgment, settlement or compromise to the extent that the
department or the authority or the { - prepaid managed care
health services - } { + coordinated care + } organization could
have had a lien against such amounts had such notice been given.
SECTION 53. ORS 441.094 is amended to read:
441.094. (1) No officer or employee of a hospital licensed by
the Oregon Health Authority that has an emergency department may
deny to a person an appropriate medical screening examination
within the capability of the emergency department, including
ancillary services routinely available to the emergency
department, to determine whether a need for emergency medical
services exists.
(2) No officer or employee of a hospital licensed by the
authority may deny to a person diagnosed by an admitting
physician as being in need of emergency medical services the
emergency medical services customarily provided at the hospital
because the person is unable to establish the ability to pay for
the services.
Enrolled House Bill 3650 (HB 3650-C) Page 41
(3) Nothing in this section is intended to relieve a person of
the obligation to pay for services provided by a hospital.
(4) A hospital that does not have physician services available
at the time of the emergency shall not be in violation of this
section if, after a reasonable good faith effort, a physician is
unable to provide or delegate the provision of emergency medical
services.
(5) All { - prepaid capitated health service - } { +
coordinated care organization + } contracts executed by the
authority and private health maintenance organizations and
managed care organizations shall include a provision that
encourages { - a managed care plan - } { + the
organization + } to establish agreements with hospitals in the
{ - plan's - } { + organization's + } service area for
payment of emergency screening examinations.
(6) As used in subsections (1) and (2) of this section, '
emergency medical services' means medical services that are
usually and customarily available at the respective hospital and
that must be provided immediately to sustain a person's life, to
prevent serious permanent disfigurement or loss or impairment of
the function of a bodily member or organ, or to provide care of a
woman in her labor where delivery is imminent if the hospital is
so equipped and, if the hospital is not equipped, to provide
necessary treatment to allow the woman to travel to a more
appropriate facility without undue risk of serious harm.
SECTION 54. ORS 442.464 is amended to read:
442.464. As used in this section and ORS 442.466, 'reporting
entity' means:
(1) An insurer as defined in ORS 731.106 or fraternal benefit
society as described in ORS 748.106 required to have a
certificate of authority to transact health insurance business in
this state.
(2) A health care service contractor as defined in ORS 750.005
that issues medical insurance in this state.
(3) A third party administrator required to obtain a license
under ORS 744.702.
(4) A pharmacy benefit manager or fiscal intermediary, or other
person that is by statute, contract or agreement legally
responsible for payment of a claim for a health care item or
service.
(5) A { - prepaid managed care health services organization
as defined in ORS 414.736 - } { + coordinated care organization
as defined in ORS 414.025 + }.
(6) An insurer providing coverage funded under Part A, Part B
or Part D of Title XVIII of the Social Security Act, subject to
approval by the United States Department of Health and Human
Services.
SECTION 55. ORS 655.515 is amended to read:
655.515. If an inmate sustains an injury as described in ORS
655.510, benefits shall be delivered in a manner similar to that
provided for injured workers under the workers' compensation laws
of this state, except that:
(1) No benefits, except medical services and any occupational
training or rehabilitation services provided by the Department of
Corrections, shall accrue to the inmate until the date of release
from confinement and shall be based upon the condition of the
inmate at that time.
(2) Benefits shall be discontinued during any subsequent period
of reconfinement in a penal institution.
Enrolled House Bill 3650 (HB 3650-C) Page 42
(3) Costs of rehabilitation services to inmates with
disabilities shall be paid out of the Insurance Fund established
under ORS 278.425 in an amount approved by the Oregon Department
of Administrative Services, which shall be the reasonable and
necessary cost of such services.
(4) Medical services when the inmate is confined in a
Department of Corrections facility shall be those provided by the
Department of Corrections. After release, medical services shall
be paid only if necessary to the process of recovery and as
prescribed by the attending practitioner. No medical services may
be paid after the attending practitioner has determined that the
inmate is medically stationary other than for reasonable,
periodic repair or replacement of prosthetic appliances. The
department, by rule, may require that medical and rehabilitation
services after release must be provided directly by the state or
its contracted
{ - managed - } { + coordinated + } care organization.
SECTION 56. ORS 659.830 is amended to read:
659.830. (1) An employee benefit plan may not include any
provision which has the effect of limiting or excluding coverage
or payment for any health care for an individual who would
otherwise be covered or entitled to benefits or services under
the terms of the employee benefit plan because that individual is
provided, or is eligible for, benefits or services pursuant to a
plan under Title XIX of the Social Security Act. This section
applies to employee benefit plans, whether sponsored by an
employer or a labor union.
(2) A group health plan is prohibited from considering the
availability or eligibility for medical assistance in this or any
other state under 42 U.S.C. 1396a (section 1902 of the Social
Security Act), herein referred to as Medicaid, when considering
eligibility for coverage or making payments under its plan for
eligible enrollees, subscribers, policyholders or certificate
holders.
(3) To the extent that payment for covered expenses has been
made under the state Medicaid program for health care items or
services furnished to an individual, in any case where a third
party has a legal liability to make payments, the state is
considered to have acquired the rights of the individual to
payment by any other party for those health care items or
services.
(4) An employee benefit plan, self-insured plan, managed care
organization or group health plan, a third party administrator,
fiscal intermediary or pharmacy benefit manager of the plan or
organization, or other party that is, by statute, contract or
agreement legally responsible for payment of a claim for a health
care item or service, may not deny a claim submitted by the state
Medicaid agency under subsection (3) of this section based on the
date of submission of the claim, the type or format of the claim
form or a failure to present proper documentation at the point of
sale that is the basis of the claim if:
(a) The claim is submitted by the agency within the three-year
period beginning on the date on which the health care item or
service was furnished; and
(b) Any action by the agency to enforce its rights with respect
to the claim is commenced within six years of the agency's
submission of the claim.
(5) An employee benefit plan, self-insured plan, managed care
organization or group health plan, a third party administrator,
fiscal intermediary or pharmacy benefit manager of the plan or
Enrolled House Bill 3650 (HB 3650-C) Page 43
organization, or other party that is, by statute, contract or
agreement legally responsible for payment of a claim for a health
care item or service, must provide to the state Medicaid agency
or
{ - prepaid managed care health services - } { + coordinated
care + } organization described in ORS 414.725, upon the request
of the agency or contractor, the following information:
(a) The period during which a Medicaid recipient, the spouse or
dependents may be or may have been covered by the plan or
organization;
(b) The nature of coverage that is or was provided by the plan
or organization; and
(c) The name, address and identifying numbers of the plan or
organization.
(6) A group health plan may not deny enrollment of a child
under the health plan of the child's parent on the grounds that:
(a) The child was born out of wedlock;
(b) The child is not claimed as a dependent on the parent's
federal tax return; or
(c) The child does not reside with the child's parent or in the
group health plan service area.
(7) Where a child has health coverage through a group health
plan of a noncustodial parent, the group health plan must:
(a) Provide such information to the custodial parent as may be
necessary for the child to obtain benefits through that coverage;
(b) Permit the custodial parent or the provider, with the
custodial parent's approval, to submit claims for covered
services without the approval of the noncustodial parent; and
(c) Make payments on claims submitted in accordance with
paragraph (b) of this subsection directly to the custodial
parent, to the provider or, if a claim is filed by the state
Medicaid agency, directly to the state Medicaid agency.
(8) Where a parent is required by a court or administrative
order to provide health coverage for a child, and the parent is
eligible for family health coverage, the group health plan is
required:
(a) To permit the parent to enroll, under the family coverage,
a child who is otherwise eligible for the coverage without regard
to any enrollment season restrictions;
(b) If the parent is enrolled but fails to make application to
obtain coverage for the child, to enroll the child under family
coverage upon application of the child's other parent, the state
agency administering the Medicaid program or the state agency
administering 42 U.S.C. 651 to 669, the child support enforcement
program; and
(c) Not to disenroll or eliminate coverage of the child unless
the group health plan is provided satisfactory written evidence
that:
(A) The court or administrative order is no longer in effect;
or
(B) The child is or will be enrolled in comparable health
coverage through another insurer which will take effect not later
than the effective date of disenrollment.
(9) A group health plan may not impose requirements on a state
agency that has been assigned the rights of an individual
eligible for medical assistance under Medicaid and covered for
health benefits from the plan if the requirements are different
from requirements applicable to an agent or assignee of any other
individual so covered.
Enrolled House Bill 3650 (HB 3650-C) Page 44
(10)(a) In any case in which a group health plan provides
coverage for dependent children of participants or beneficiaries,
the plan must provide benefits to dependent children placed with
participants or beneficiaries for adoption under the same terms
and conditions as apply to the natural, dependent children of the
participants and beneficiaries, regardless of whether the
adoption has become final.
(b) A group health plan may not restrict coverage under the
plan of any dependent child adopted by a participant or
beneficiary, or placed with a participant or beneficiary for
adoption, solely on the basis of a preexisting condition of the
child at the time that the child would otherwise become eligible
for coverage under the plan if the adoption or placement for
adoption occurs while the participant or beneficiary is eligible
for coverage under the plan.
(11) As used in this section:
(a) 'Child' means, in connection with any adoption, or
placement for adoption of the child, an individual who has not
attained 18 years of age as of the date of the adoption or
placement for adoption.
(b) 'Group health plan' means a group health plan as defined in
29 U.S.C. 1167.
(c) 'Placement for adoption' means the assumption and retention
by a person of a legal obligation for total or partial support of
a child in anticipation of the adoption of the child. The
child's placement with a person terminates upon the termination
of such legal obligations.
SECTION 57. ORS 735.615, as amended by section 20, chapter 70,
Oregon Laws 2011 (Enrolled Senate Bill 104), is amended to read:
735.615. (1) Except as provided in subsection (3) of this
section, a person who is a resident of this state, as defined by
the Oregon Medical Insurance Pool Board, is eligible for medical
pool coverage if:
(a) An insurer, or an insurance company with a certificate of
authority in any other state, has made within a time frame
established by the board an adverse underwriting decision, as
defined in ORS 746.600 (1)(a)(A), (B) or (D), on individual
medical insurance for health reasons while the person was a
resident;
(b) The person has a history of any medical or health
conditions on the list adopted by the board under subsection (2)
of this section;
(c) The person is a spouse or dependent of a person described
in paragraph (a) or (b) of this subsection; or
(d) The person is eligible for the credit for health insurance
costs under section 35 of the federal Internal Revenue Code, as
amended and in effect on December 31, 2004.
(2) The board may adopt a list of medical or health conditions
for which a person is eligible for pool coverage without applying
for individual medical insurance pursuant to this section.
(3) A person is not eligible for coverage under ORS 735.600 to
735.650 if:
(a) Except as provided in ORS 735.625 (3) and subsection (5) of
this section, the person is eligible for Medicare;
(b) The person is eligible to receive health services as
defined in ORS { - 414.705 - } { + 414.025 + } that meet or
exceed those adopted by the board;
(c) The person has terminated coverage in the pool within the
last 12 months and the termination was for:
Enrolled House Bill 3650 (HB 3650-C) Page 45
(A) A reason other than becoming eligible to receive health
services as defined in ORS { - 414.705 - } { + 414.025 + };
or
(B) A reason that does not meet exception criteria established
by the board;
(d) The person has exceeded the maximum lifetime benefit
established by the board;
(e) The person is an inmate of or a patient in a public
institution named in ORS 179.321;
(f) The person has, on the date of issue of coverage by the
board, coverage under health insurance or a self-insurance
arrangement that is substantially equivalent to coverage under
ORS 735.625; or
(g) The person has the premiums paid or reimbursed by a public
entity or a health care provider, reducing the financial loss or
obligation of the payer.
(4) A person applying for coverage shall establish initial
eligibility by providing evidence that the board requires.
(5)(a) Notwithstanding ORS 735.625 (4)(c), if a person:
(A) Becomes eligible for Medicare after being enrolled in the
pool for a period of time as determined by the board by rule,
that person may continue coverage within the pool as secondary
coverage to Medicare.
(B) Is eligible for Medicare but is not yet eligible to enroll
in Medicare Parts B and D, the individual may receive coverage
under the pool until enrolled in Medicare Parts B and D.
(b) The board may adopt rules concerning the terms and
conditions for the coverage provided under paragraph (a) of this
subsection.
(6) The board may adopt rules to establish additional
eligibility requirements for a person described in subsection
{ - (1)(e) - } { + (1)(d) + } of this section.
SECTION 58. ORS 743.847 is amended to read:
743.847. (1) For the purposes of this section:
(a) 'Health insurer' or 'insurer' means an employee benefit
plan, self-insured plan, managed care organization or group
health plan, a third party administrator, fiscal intermediary or
pharmacy benefit manager of the plan or organization, or other
party that is by statute, contract or agreement legally
responsible for payment of a claim for a health care item or
service.
(b) 'Medicaid' means medical assistance provided under 42
U.S.C. 1396a (section 1902 of the Social Security Act).
(2) A health insurer is prohibited from considering the
availability or eligibility for medical assistance in this or any
other state under Medicaid when considering eligibility for
coverage or making payments under its group or individual plan
for eligible enrollees, subscribers, policyholders or certificate
holders.
(3) To the extent that payment for covered expenses has been
made under the state Medicaid program for health care items or
services furnished to an individual, in any case when a third
party has a legal liability to make payments, the state is
considered to have acquired the rights of the individual to
payment by any other party for those health care items or
services.
(4) An insurer may not deny a claim submitted by the state
Medicaid agency, { - or - } a prepaid managed care health
services { + organization or a coordinated care + }
organization described in ORS 414.725 { - , - } under
Enrolled House Bill 3650 (HB 3650-C) Page 46
subsection (3) of this section based on the date of submission of
the claim, the type or format of the claim form or a failure to
present proper documentation at the point of sale that is the
basis of the claim if:
(a) The claim is submitted by the agency { + , + } { - or - }
the prepaid managed care health services organization { + or the
coordinated care organization + } within the three-year period
beginning on the date on which the health care item or service
was furnished; and
(b) Any action by the agency { + , + } { - or - } the
prepaid managed care health services organization { + or the
coordinated care organization + } to enforce its rights with
respect to the claim is commenced within six years of the
agency's or organization's submission of the claim.
(5) An insurer must provide to the state Medicaid
agency { + , + }
{ - or - } a prepaid managed care health services organization
{ + or a coordinated care organization + }, upon request, the
following information:
(a) The period during which a Medicaid recipient, the spouse or
dependents may be or may have been covered by the plan;
(b) The nature of coverage that is or was provided by the plan;
and
(c) The name, address and identifying numbers of the plan.
(6) An insurer may not deny enrollment of a child under the
group or individual health plan of the child's parent on the
ground that:
(a) The child was born out of wedlock;
(b) The child is not claimed as a dependent on the parent's
federal tax return; or
(c) The child does not reside with the child's parent or in the
insurer's service area.
(7) When a child has group or individual health coverage
through an insurer of a noncustodial parent, the insurer must:
(a) Provide such information to the custodial parent as may be
necessary for the child to obtain benefits through that coverage;
(b) Permit the custodial parent or the provider, with the
custodial parent's approval, to submit claims for covered
services without the approval of the noncustodial parent; and
(c) Make payments on claims submitted in accordance with
paragraph (b) of this subsection directly to the custodial
parent, the provider or, if a claim is filed by the state
Medicaid agency { + , + }
{ - or - } a prepaid managed { - health - } care
{ + health + } services organization { + or a coordinated care
organization + }, directly to the agency or the organization.
(8) When a parent is required by a court or administrative
order to provide health coverage for a child, and the parent is
eligible for family health coverage, the insurer must:
(a) Permit the parent to enroll, under the family coverage, a
child who is otherwise eligible for the coverage without regard
to any enrollment season restrictions;
(b) If the parent is enrolled but fails to make application to
obtain coverage for the child, enroll the child under family
coverage upon application of the child's other parent, the state
agency administering the Medicaid program or the state agency
administering 42 U.S.C. 651 to 669, the child support enforcement
program; and
(c) Not disenroll or eliminate coverage of the child unless the
insurer is provided satisfactory written evidence that:
Enrolled House Bill 3650 (HB 3650-C) Page 47
(A) The court or administrative order is no longer in effect;
or
(B) The child is or will be enrolled in comparable health
coverage through another insurer which will take effect not later
than the effective date of disenrollment.
(9) An insurer may not impose requirements on a state agency
that has been assigned the rights of an individual eligible for
medical assistance under Medicaid and covered for health benefits
from the insurer if the requirements are different from
requirements applicable to an agent or assignee of any other
individual so covered.
(10) The provisions of ORS 743A.001 do not apply to this
section.
SECTION 59. Section 9, chapter 736, Oregon Laws 2003, as
amended by section 2, chapter 757, Oregon Laws 2005, section 2,
chapter 780, Oregon Laws 2007, section 53, chapter 828, Oregon
Laws 2009, and section 19, chapter 867, Oregon Laws 2009, is
amended to read:
{ + Sec. 9. + } (1) The Hospital Quality Assurance Fund is
established in the State Treasury, separate and distinct from the
General Fund. Interest earned by the Hospital Quality Assurance
Fund shall be credited to the Hospital Quality Assurance Fund.
(2) Amounts in the Hospital Quality Assurance Fund are
continuously appropriated to the Oregon Health Authority for the
purpose of paying refunds due under section 6, chapter 736,
Oregon Laws 2003, and funding services under ORS 414.705 to
414.750, including but not limited to:
(a) Increasing reimbursement rates for inpatient and outpatient
hospital services under ORS 414.705 to 414.750;
(b) Maintaining, expanding or modifying services for persons
described in ORS 414.025 { - (2)(s) - } { + (3)(s) + };
(c) Maintaining or increasing the number of persons described
in ORS 414.025 { - (2)(s) - } { + (3)(s) + } who are enrolled
in the medical assistance program; and
(d) Paying administrative costs incurred by the authority to
administer the assessments imposed under section 2, chapter 736,
Oregon Laws 2003.
(3) Except for assessments imposed pursuant to section 2
(3)(b), chapter 736, Oregon Laws 2003, the authority may not use
moneys from the Hospital Quality Assurance Fund to supplant,
directly or indirectly, other moneys made available to fund
services described in subsection (2) of this section.
{ +
MISCELLANEOUS + }
SECTION 60. { + For the purpose of harmonizing and clarifying
statutory law, the Legislative Counsel may substitute for words
designating a 'prepaid managed care health services organization'
wherever they occur in ORS chapters 413 and 414, other words
designating a 'coordinated care organization.' + }
SECTION 61. { + The unit and section captions used in this
2011 Act are provided only for the convenience of the reader and
do not become part of the statutory law of this state or express
any legislative intent in the enactment of this 2011 Act. + }
{ +
REPEALS; APPROPRIATIONS; + }
{ +
OPERATIVE AND EFFECTIVE DATES + }
Enrolled House Bill 3650 (HB 3650-C) Page 48
SECTION 62. { + (1) The Oregon Health Authority may not
implement any provisions of this 2011 Act that require federal
approval or that require federal approval to receive federal
financial participation until the authority has received the
approval.
(2) Until the authority has received the approval of the
Legislative Assembly under section 13 of this 2011 Act, the
authority may not:
(a) Adopt by rule the qualification criteria for a coordinated
care organization under section 4 of this 2011 Act or contract
with a coordinated care organization;
(b) Adopt by rule a global budgeting process or establish
global budgets for coordinated care organizations; or
(c) Implement a process for financial reporting by coordinated
care organizations or establish financial reporting requirements
under ORS 414.725 (1)(c). + }
SECTION 63. { + The amendments to section 8 of this 2011 Act
by section 9 of this 2011 Act become operative January 1,
2014. + }
SECTION 64. { + (1) ORS 414.705 is repealed.
(2) Sections 13, 14 and 17 of this 2011 Act are repealed
January 2, 2014.
(3) ORS 414.610, 414.630, 414.640, 414.736, 414.738, 414.739,
414.740 and 414.741 are repealed July 1, 2017. + }
SECTION 65. { + Except as provided in section 62 of this 2011
Act, the Director of the Oregon Health Authority may take any
action on or after the effective date of this 2011 Act that is
necessary to carry out the provisions of this 2011 Act upon the
receipt of legislative approval under section 13 of this 2011 Act
and federal approval under section 17 of this 2011 Act,
including, but not limited to:
(1) Applying for necessary federal approval;
(2) Applying for federal grants; and
(3) Adopting rules. + }
SECTION 66. { + (1) Notwithstanding any other provision of
law, the General Fund appropriation made to the Oregon Health
Authority by section 1 (2), chapter ___, Oregon Laws 2011
(Enrolled Senate Bill 5529), for the biennium beginning July 1,
2011, is increased by $147,500.
(2) Notwithstanding any other law limiting expenditures, the
limitation on expenditures established by section 4 (2), chapter
___ , Oregon Laws 2011 (Enrolled Senate Bill 5529), for the
biennium beginning July 1, 2011, as the maximum limit for payment
of expenses from federal funds, excluding federal funds described
in section 2, chapter ___, (Enrolled Senate Bill 5529), collected
or received by the Oregon Health Authority is increased by
$147,500. + }
SECTION 67. { + Notwithstanding any other provision of law,
the General Fund appropriation made to the Department of Human
Services by section 1 (3), chapter ___, Oregon Laws 2011
(Enrolled House Bill 5030), for the biennium beginning July 1,
2011, for seniors and people with disabilities, is increased by
$960,103. + }
SECTION 68. { + If House Bill 2100 becomes law, sections 128
(amending ORS 414.025), 129 (amending ORS 414.033), 131 (amending
ORS 414.065), 142 (amending ORS 414.705) and 147 (amending ORS
414.725), chapter ___, Oregon Laws 2011 (Enrolled House Bill
2100), are repealed. + }
Enrolled House Bill 3650 (HB 3650-C) Page 49
SECTION 69. If House Bill 2100 becomes law, ORS 414.025, as
amended by section 1, chapter 73, Oregon Laws 2010, and section
20 of this 2011 Act, is amended to read:
414.025. { + Definitions. + } As used in this chapter and ORS
{ - chapter - } { + 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
{ - mental retardation - } { + developmental disabilities + }.
Enrolled House Bill 3650 (HB 3650-C) Page 50
(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 { - of Human Services - } { + or
the authority + } by rule, but whose family income is less than
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 (6).
(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;
Enrolled House Bill 3650 (HB 3650-C) Page 51
(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
meeting criteria adopted by the Oregon Health Authority under
section 4 of this 2011 Act.
(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
{ - Services Commission under ORS 414.720 - } { + Evidence
Review Commission under section 24, chapter ___, Oregon Laws 2011
(Enrolled House Bill 2100) + }:
(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
{ - of Human Services - } { + 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.
Enrolled House Bill 3650 (HB 3650-C) Page 52
(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 { - Oregon Health - }
authority according to the standards established pursuant to ORS
414.065, including 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 section 6 of
this 2011 Act 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 section 10 of this
2011 Act.
(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 70. If House Bill 2100 becomes law, section 64 of this
2011 Act is amended to read:
{ + Sec. 64. + } (1) ORS 414.705 is repealed.
(2) Sections 13, 14 and 17 of this 2011 Act are repealed
January 2, 2014.
Enrolled House Bill 3650 (HB 3650-C) Page 53
(3) ORS 414.610, 414.630, 414.640, 414.736, 414.738, 414.739
{ - , - } { + and + } 414.740 { - and 414.741 - } are
repealed July 1, 2017.
SECTION 71. { + If Senate Bill 101 becomes law, section 8,
chapter ___, Oregon Laws 2011 (Enrolled Senate Bill 101)
(amending ORS 414.743), is repealed and ORS 414.743, as amended
by section 47 of this 2011 Act, is amended to read: + }
414.743. (1) { + Except as provided in subsection (2) of this
section, + } a coordinated care organization that does not have a
contract with a hospital to provide inpatient or outpatient
hospital services under ORS 414.705 to 414.750 must, using
{ - a - } Medicare payment methodology, reimburse the
noncontracting hospital for services provided to an enrollee of
the plan at a rate no less than a percentage of the Medicare
reimbursement rate for those services. The percentage of the
Medicare reimbursement rate that is used to determine the
reimbursement rate under this subsection is equal to
{ - two - } { + four + } percentage points less than the
percentage of Medicare cost used by the authority in calculating
the base hospital capitation payment to the plan, excluding any
supplemental payments.
{ + (2)(a) If a coordinated care organization does not have a
contract with a hospital, and the hospital provides less than 10
percent of the hospital admissions and outpatient hospital
services to enrollees of the organization, the percentage of the
Medicare reimbursement rate that is used to determine the
reimbursement rate under subsection (1) of this section is equal
to two percentage points less than the percentage of Medicare
cost used by the Oregon Health Authority in calculating the base
hospital capitation payment to the organization, excluding any
supplemental payments.
(b) This subsection is not intended to discourage a coordinated
care organization and a hospital from entering into a contract
and is intended to apply to hospitals that provide primarily, but
not exclusively, specialty and emergency care to enrollees of the
organization. + }
{ - (2) - } { + (3) + } A hospital that does not have a
contract with a coordinated care organization to provide
inpatient or outpatient hospital services under ORS 414.705 to
414.750 must accept as payment in full for hospital services the
rates described in
{ - subsection (1) - } { + subsections (1) and (2) + } of
this section.
{ - (3) - } { + (4) + } This section does not apply to type
A and type B hospitals, as described in ORS 442.470, and rural
critical access hospitals, as defined in ORS 315.613.
{ - (4) - } { + (5) + } The Oregon Health Authority shall
adopt rules to implement and administer this section.
SECTION 72. If Senate Bill 101 becomes law, section 10, chapter
___, Oregon Laws 2011 (Enrolled Senate Bill 101), is amended to
read:
{ + Sec. 10. + } (1) The amendments to ORS 414.826, 414.841
and 414.851 by sections 1 to 4 { - of this 2011 Act - } { + ,
chapter ___, Oregon Laws 2011 (Enrolled Senate Bill 101), + }
become operative January 1, 2012.
(2) The amendments to ORS 414.743 by { - section 8 of this
2011 Act - } { + section 71 of this 2011 Act + } become
operative September 1, 2011.
SECTION 73. { + This 2011 Act being necessary for the
immediate preservation of the public peace, health and safety, an
Enrolled House Bill 3650 (HB 3650-C) Page 54
emergency is declared to exist, and this 2011 Act takes effect on
its passage. + }
----------
Passed by House June 27, 2011
Repassed by House June 30, 2011
.............................................................
Ramona Kenady Line, Chief Clerk of House
.............................................................
Bruce Hanna, Speaker of House
.............................................................
Arnie Roblan, Speaker of House
Passed by Senate June 29, 2011
.............................................................
Peter Courtney, President of Senate
Enrolled House Bill 3650 (HB 3650-C) Page 55
Received by Governor:
......M.,............., 2011
Approved:
......M.,............., 2011
.............................................................
John Kitzhaber, Governor
Filed in Office of Secretary of State:
......M.,............., 2011
.............................................................
Kate Brown, Secretary of State
Enrolled House Bill 3650 (HB 3650-C) Page 56
