Bill Text: OR SB1580 | 2012 | Regular Session | Enrolled
Bill Title: Relating to health care delivery; and declaring an emergency.
Spectrum: Unknown
Status: (Passed) 2012-03-13 - Effective date, March 2, 2012. [SB1580 Detail]
Download: Oregon-2012-SB1580-Enrolled.html
76th OREGON LEGISLATIVE ASSEMBLY--2012 Regular Session
Enrolled
Senate Bill 1580
Printed pursuant to Senate Interim Rule 213.28 by order of the
President of the Senate in conformance with presession filing
rules, indicating neither advocacy nor opposition on the part
of the President (at the request of Governor John A. Kitzhaber
for Oregon Health Authority)
CHAPTER ................
AN ACT
Relating to health care delivery; creating new provisions;
amending ORS 414.033, 414.065, 414.625, 414.632, 414.635,
414.638, 414.740, 416.540 and 646.735 and sections 14, 62, 63
and 64, chapter 602, Oregon Laws 2011; and declaring an
emergency.
Be It Enacted by the People of the State of Oregon:
{ +
LEGISLATIVE APPROVAL OF COORDINATED CARE + }
{ +
ORGANIZATION PROPOSAL + }
SECTION 1. { + The Legislative Assembly approves the proposals
presented by the Oregon Health Authority as required by section
13, chapter 602, Oregon Laws 2011. + }
SECTION 2. Section 14, chapter 602, Oregon Laws 2011, is
amended to read:
{ + Sec. 14. + } (1) Notwithstanding ORS { - 414.725 and
414.737 - } { + 414.631 and 414.651 + }, 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, { + 414.625, 414.635, 414.638, 414.651, 414.655,
414.679, + } 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 - } { + July 1,
2011, + } to allow prepaid managed care health services
organizations that meet the criteria { - approved by the
Enrolled Senate Bill 1580 (SB 1580-A) Page 1
Legislative Assembly under section 13 of this 2011 Act - } { +
adopted by the authority under ORS 414.625 + } 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 - } { + July 1, 2011, + } 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 - } { + ORS 414.625 (2)(g) and 414.655 (2) + }, 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 3. Section 62, chapter 602, Oregon Laws 2011, is
amended to read:
{ + Sec. 62. + } { - (1) - } The Oregon Health Authority
may not implement any { - provisions of this 2011 Act that
require - } { + provision of chapter 602, Oregon Laws 2011,
that requires + } federal approval { + , + } or that
{ - require - } { + requires + } federal approval to receive
federal financial participation { + , + } until the authority has
received the { + federal + } 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 4. Section 63, chapter 602, Oregon Laws 2011, is
amended to read:
{ + Sec. 63. + } The amendments to { - section 8 of this
2011 Act - } { + ORS 414.635 + } by section 9 { - of this
2011 Act - } { + , chapter 602, Oregon Laws 2011, + } become
operative { - January 1, 2014 - } { + on the effective date
of this 2012 Act + }.
SECTION 5. ORS 414.635, as amended by section 9, chapter 602,
Oregon Laws 2011, is amended to read:
414.635. (1) The Oregon Health Authority shall adopt by rule
safeguards for members enrolled in coordinated care organizations
that protect against underutilization of services and
inappropriate denials of services. In addition to any other
consumer rights and responsibilities established by law, each
member:
Enrolled Senate Bill 1580 (SB 1580-A) Page 2
(a) Must be encouraged to be an active partner in directing the
member's health care and services and not a passive recipient of
care.
(b) Must be educated about the coordinated care approach being
used in the community and how to navigate the coordinated health
care system.
(c) Must have access to advocates, including qualified peer
wellness specialists where appropriate, personal health
navigators, and qualified community health workers who are part
of the member's care team to provide assistance that is
culturally and linguistically appropriate to the member's need to
access appropriate services and participate in processes
affecting the member's care and services.
(d) Shall be encouraged within all aspects of the integrated
and coordinated health care delivery system to use wellness and
prevention resources and to make healthy lifestyle choices.
(e) Shall be encouraged to work with the member's care team,
including providers and community resources appropriate to the
member's needs as a whole person.
(2) The authority shall establish and maintain an enrollment
process for individuals who are dually eligible for Medicare and
Medicaid that promotes continuity of care and that allows the
member to disenroll from a coordinated care organization that
fails to promptly provide adequate services and:
(a) To enroll in another coordinated care organization of the
member's choice; or
(b) If another organization is not available, to receive
Medicare-covered services on a fee-for-service basis.
(3) Members and their providers and coordinated care
organizations have the right to appeal decisions about care and
services through the authority in an expedited manner and in
accordance with the contested case procedures in ORS chapter 183.
(4) A health care entity may not unreasonably refuse to
contract with an organization seeking to form a coordinated care
organization if the participation of the entity is necessary for
the organization to qualify as a coordinated care organization.
(5) A health care entity may refuse to contract with a
coordinated care organization if the reimbursement established
for a service provided by the entity under the contract is below
the reasonable cost to the entity for providing the service.
(6) A health care entity that unreasonably refuses to contract
with a coordinated care organization may not receive
fee-for-service reimbursement from the authority for services
that are available through a coordinated care organization either
directly or by contract.
(7) The authority shall { - maintain the process, approved by
the Legislative Assembly, - } { + adopt by rule a process + }
for resolving disputes involving an entity's refusal to contract
with a coordinated care organization under subsections (4) and
(5) of this section. The process must include the use of an
independent third party arbitrator.
(8) A coordinated care organization may not unreasonably refuse
to contract with a licensed health care provider.
(9) The authority shall:
(a) Monitor and enforce consumer rights and protections within
the Oregon Integrated and Coordinated Health Care Delivery System
and ensure a consistent response to complaints of violations of
consumer rights or protections.
(b) Monitor and report on the statewide health care
expenditures and recommend actions appropriate and necessary to
Enrolled Senate Bill 1580 (SB 1580-A) Page 3
contain the growth in health care costs incurred by all sectors
of the system.
{ +
IMPLEMENTATION OF OREGON INTEGRATED + }
{ +
AND COORDINATED CARE DELIVERY SYSTEM + }
SECTION 6. { + (1) The Department of Consumer and Business
Services and the Oregon Health Authority may enter into
agreements governing the disclosure of information reported to
the department by insurers with certificates of authority to
transact insurance in this state.
(2) The authority may use information disclosed under
subsection (1) of this section for the purpose of carrying out
ORS 414.625, 414.635, 414.638, 414.645 and 414.651. + }
SECTION 7. { + Section 8 of this 2012 Act is added to and made
a part of ORS chapter 414. + }
SECTION 8. { + (1) A fully capitated health plan, physician
care organization or coordinated care organization may not
discriminate in the participation or reimbursement of any health
care provider based on the provider's license or certification if
the provider is acting within the scope of the provider's license
or certification. A plan or organization must give written notice
containing the reasons for its action if the plan or organization
declines the participation of any provider or group of providers.
(2) Subsection (1) of this section does not:
(a) Require a plan or organization to contract with more
providers than are necessary to meet the needs of its members;
(b) Preclude the plan or organization from using different
reimbursement amounts for different specialties or different
practitioners in the same specialty; or
(c) Preclude the plan or organization from establishing
measures that are designed to maintain the quality of services
and control costs and are consistent with the plan's or
organization's responsibilities to its members.
(3) A plan or organization may establish an internal review
process for a provider aggrieved under this section, including an
alternative dispute resolution or peer review process. An
aggrieved provider may appeal the determination of the internal
review to the Oregon Health Authority.
(4) The authority shall adopt by rule a process for resolving
claims of discrimination under this section and, in making a
determination of whether there has been discrimination, must
consider the plan's or organization's:
(a) Network adequacy;
(b) Provider types and qualifications;
(c) Provider disciplines; and
(d) Provider reimbursement rates.
(5) A prevailing party in an appeal under this section shall be
awarded the costs of the appeal. + }
SECTION 9. Section 8 of this 2012 Act is amended to read:
{ + Sec. 8. + } (1) A { - fully capitated health plan,
physician care organization or - } coordinated care organization
may not discriminate in the participation or reimbursement of any
health care provider based on the provider's license or
certification if the provider is acting within the scope of the
provider's license or certification. { - A plan or - } { +
An + } organization must give written notice containing the
Enrolled Senate Bill 1580 (SB 1580-A) Page 4
reasons for its action if the { - plan or - } organization
declines the participation of any provider or group of providers.
(2) Subsection (1) of this section does not:
(a) Require { - a plan or - } { + an + } organization to
contract with more providers than are necessary to meet the needs
of its members;
(b) Preclude the { - plan or - } organization from using
different reimbursement amounts for different specialties or
different practitioners in the same specialty; or
(c) Preclude the { - plan or - } organization from
establishing measures that are designed to maintain the quality
of services and control costs and are consistent with the
{ - plan's or - } organization's responsibilities to its
members.
(3) { - A plan or - } { + An + } organization may establish
an internal review process for a provider aggrieved under this
section, including an alternative dispute resolution or peer
review process. An aggrieved provider may appeal the
determination of the internal review to the Oregon Health
Authority.
(4) The authority shall adopt by rule a process for resolving
claims of discrimination under this section and, in making a
determination of whether there has been discrimination, must
consider the { - plan's or - } organization's:
(a) Network adequacy;
(b) Provider types and qualifications;
(c) Provider disciplines; and
(d) Provider reimbursement rates.
(5) A prevailing party in an appeal under this section shall be
awarded the costs of the appeal.
SECTION 10. { + The amendments to section 8 of this 2012 Act
by section 9 of this 2012 Act become operative July 1, 2017. + }
SECTION 11. { + In each calendar quarter, the Oregon Health
Authority shall report to the appropriate committees or interim
committees of the Legislative Assembly:
(1) On the implementation of the Oregon Integrated and
Coordinated Care Delivery System;
(2) On the progress in implementing an arbitration process in
accordance with ORS 414.635 (7);
(3) For the purpose of developing a baseline with which to
compare future costs, per member costs for each category of
service; and
(4) The administrative costs to the authority in the
implementation of the system and the aggregate financial
information reported to the authority by coordinated care
organizations, including but not limited to the coordinated care
organizations':
(a) Payments for each category of service as prescribed by the
authority; and
(b) Reserves, projected cash flows and other financial
information prescribed by the authority by rule. + }
SECTION 12. { + Section 11 of this 2012 Act is repealed July
1, 2017. + }
SECTION 13. { + (1) A coordinated care organization must have
a community advisory council to ensure that the health care needs
of the consumers and the community are being addressed. The
council must:
(a) Include representatives of the community and of each county
government served by the coordinated care organization, but
Enrolled Senate Bill 1580 (SB 1580-A) Page 5
consumer representatives must constitute a majority of the
membership;
(b) Meet no less frequently than once every three months; and
(c) Have its membership selected by a committee composed of
equal numbers of county representatives from each county served
by the coordinated care organization and members of the governing
body of the coordinated care organization.
(2) The duties of the council include, but are not limited to:
(a) Identifying and advocating for preventive care practices to
be utilized by the coordinated care organization;
(b) Overseeing a community health assessment and adopting a
community health improvement plan to serve as a strategic
population health and health care system service plan for the
community served by the coordinated care organization; and
(c) Annually publishing a report on the progress of the
community health improvement plan.
(3) The community health improvement plan adopted by the
council should describe the scope of the activities, services and
responsibilities that the coordinated care organization will
consider upon implementation of the plan. The activities,
services and responsibilities defined in the plan may include,
but are not limited to:
(a) Analysis and development of public and private resources,
capacities and metrics based on ongoing community health
assessment activities and population health priorities;
(b) Health policy;
(c) System design;
(d) Outcome and quality improvement;
(e) Integration of service delivery; and
(f) Workforce development. + }
SECTION 14. { + (1) Upon the request of a coordinated care
organization, the Oregon Health Authority shall assign to the
coordinated care organization one employee of the authority,
called an innovator agent, to act as the single point of contact
between the coordinated care organization and the authority. The
innovator agent must be available to the organization on a
day-to-day basis to facilitate the exchange of information
between the coordinated care organization and the authority. The
organization may provide a work space to enable the agent to be
colocated at a site of the coordinated care organization if
practical.
(2) Innovator agents must observe the meetings of the community
advisory councils and report on the meetings to the authority.
(3) Not less than once every calendar quarter, all of the
innovator agents must meet in person to discuss the ideas,
projects and creative innovations planned or undertaken by their
assigned coordinated care organizations.
(4) The innovator agent shall be made available by the
authority for a period of four years beginning on the date that
the coordinated care organization first contracts with the
authority to be a coordinated care organization. Upon the request
of the coordinated care organization, the authority may extend
the period. + }
SECTION 15. { + Section 16 of this 2012 Act is added to and
made a part of ORS 192.553 to 192.581. + }
SECTION 16. { + (1) Notwithstanding ORS 179.505, a health care
provider that is a participant in a coordinated care
organization, as defined in ORS 414.025, shall disclose protected
health information:
Enrolled Senate Bill 1580 (SB 1580-A) Page 6
(a) To other health care providers participating in the
coordinated care organization for treatment purposes, and to the
coordinated care organization for health care operations and
payment purposes, as permitted by ORS 192.558; and
(b) To public health entities as required for health oversight
purposes.
(2) The disclosures described in subsection (1) of this section
may be provided without the authorization of the patient or the
patient's personal representative.
(3) Subsection (1) of this section does not apply to
psychotherapy notes, as defined in ORS 179.505. + }
SECTION 17. { + (1) The work group on Patient Safety and
Defensive Medicine is established, consisting of eight members
appointed as follows:
(a) The President of the Senate shall appoint two members from
among members of the Senate as follows:
(A) One member from the Democratic party.
(B) One member recommended by the leadership of the Republican
party in the Senate.
(b) Each Co-Speaker of the House of Representatives shall
appoint one member from among members of the House of
Representatives.
(c) The Governor shall appoint four members, including:
(A) At least one member who is a physician licensed under ORS
chapter 677 and in active practice; and
(B) At least one member who is a trial lawyer.
(2) Under the direction of the Governor, the work group shall
recommend legislation to be introduced in the 2013 regular
session of the Legislative Assembly to improve health care
delivery in this state and to reduce medical errors. The work
group shall prioritize legislation that:
(a) Improves patient safety;
(b) More effectively compensates individuals who are injured as
a result of medical errors; and
(c) Reduces the collateral costs associated with the medical
liability system, including the costs associated with insurance
administration, litigation and defensive medicine.
(3) A majority of the voting members of the work group
constitutes a quorum for the transaction of business.
(4) Official action by the work group requires the approval of
a majority of the voting members of the work group.
(5) The Governor shall select one member of the work group to
serve as chairperson and another to serve as vice chairperson,
for the terms and with the duties and powers necessary for the
performance of the functions of such offices as the Governor
determines.
(6) If there is a vacancy for any cause, the appointing
authority shall make an appointment to become immediately
effective.
(7) Members of the Legislative Assembly appointed to the work
group are nonvoting members of the work group and may act in an
advisory capacity only.
(8) The work group shall meet at times and places specified by
the call of the chairperson or of a majority of the voting
members of the work group.
(9) The work group may adopt rules necessary for the operation
of the work group.
(10) The work group shall submit its recommendations for
legislation to the interim committees of the Legislative Assembly
related to health care no later than October 1, 2012.
Enrolled Senate Bill 1580 (SB 1580-A) Page 7
(11) The Oregon Health Authority shall provide staff support to
the work group.
(12) Members of the work group who are not members of the
Legislative Assembly are not entitled to compensation, but may be
reimbursed for actual and necessary travel and other expenses
incurred by them in the performance of their official duties in
the manner and amounts provided for in ORS 292.495. Claims for
expenses incurred in performing functions of the work group shall
be paid out of funds appropriated to Oregon Health Authority for
purposes of the work group.
(13) All agencies of state government, as defined in ORS
174.111, are directed to assist the work group in the performance
of its duties and, to the extent permitted by laws relating to
confidentiality, to furnish such information and advice as the
members of the work group consider necessary to perform their
duties. + }
SECTION 18. { + Section 17 of this 2012 Act is repealed on the
date of the convening of the 2013 regular session of the
Legislative Assembly as specified in ORS 171.010. + }
SECTION 19. ORS 414.065 is amended to read:
414.065. (1)(a) With respect to health care and services to be
provided in medical assistance during any period, the Oregon
Health Authority shall determine, subject to such revisions as it
may make from time to time and subject to legislative funding and
paragraph (b) of this subsection:
(A) The types and extent of 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 health care and services.
(C) The number of days of 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, daily rates and global payments
for meeting the costs of providing 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 health care or services.
(b) The authority shall adopt rules establishing timelines for
payment of health services under paragraph (a) of this
subsection.
(2) The types and extent of health care and services and the
amounts to be paid in meeting the costs thereof, as determined
and fixed by the 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 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 health care and services for which such
payments of medical assistance were made.
(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
Enrolled Senate Bill 1580 (SB 1580-A) Page 8
services and for contracting with the providers of long term care
services.
{ + (5) In determining a global budget for a coordinated care
organization:
(a) The allocation of the payment, the risk and any cost
savings shall be determined by the governing body of the
organization; and
(b) The authority shall consider the community health
assessment conducted by the organization and reviewed annually,
and the organization's health care costs.
(6) Under the supervision of the Governor, the authority may
work with the Centers for Medicare and Medicaid Services to
develop, in addition to global budgets, payment streams:
(a) To support improved delivery of health care to recipients
of medical assistance; and
(b) That are funded by coordinated care organizations, counties
or other entities other than the state whose contributions
qualify for federal matching funds under Title XIX or XXI of the
Social Security Act. + }
SECTION 20. ORS 414.625 is amended to read:
414.625. (1) The Oregon Health Authority shall adopt by rule
the { + qualification + } criteria { + and requirements + } for
a coordinated care organization and shall integrate the criteria
{ + and requirements + } into each contract with a coordinated
care organization. Coordinated care organizations may be local,
community-based organizations or statewide organizations with
community-based participation in governance or any combination of
the two. Coordinated care organizations may contract with
counties or with other public or private entities to provide
services to members. The authority may not contract with only
one statewide organization. A coordinated care organization may
be a single corporate structure or a network of providers
organized through contractual relationships. The criteria adopted
by the authority under this section must { - be designed - }
{ + include, but are not limited to, the coordinated care
organization's demonstrated experience and capacity for:
(a) Managing financial risk and establishing financial
reserves.
(b) Meeting the following minimum financial requirements:
(A) Maintaining restricted reserves of $250,000 plus an amount
equal to 50 percent of the coordinated care organization's total
actual or projected liabilities above $250,000.
(B) Maintaining a net worth in an amount equal to at least five
percent of the average combined revenue in the prior two quarters
of the participating health care entities.
(c) Operating within a fixed global budget.
(d) Developing and implementing alternative payment
methodologies that are based on health care quality and improved
health outcomes.
(e) Coordinating the delivery of physical health care, mental
health and chemical dependency services, oral health care and
covered long-term care services.
(f) Engaging community members and health care providers in
improving the health of the community and addressing regional,
cultural, socioeconomic and racial disparities in health care
that exist among the coordinated care organization's members and
in the coordinated care organization's community.
(2) In addition to the criteria specified in subsection (1) of
this section, the authority must adopt by rule requirements for
Enrolled Senate Bill 1580 (SB 1580-A) Page 9
coordinated care organizations contracting with the authority
+ }so that:
(a) Each member of the coordinated care organization receives
integrated person centered care and services designed to provide
choice, independence and dignity.
(b) Each member has a consistent and stable relationship with a
care team that is responsible for comprehensive care management
and service delivery.
(c) The supportive and therapeutic needs of each member are
addressed in a holistic fashion, using patient centered primary
care homes { + or other models that support patient centered
primary care + } and individualized care plans to the extent
feasible.
(d) Members receive comprehensive transitional care, including
appropriate follow-up, when entering and leaving an acute care
facility or a long term care setting.
(e) Members receive assistance in navigating the health care
delivery system and in accessing community and social support
services and statewide resources, including through the use of
certified health care interpreters, as defined in ORS 413.550,
community health workers and personal health navigators who meet
competency standards established by the authority under ORS
414.665 or who are certified by the Home Care Commission under
ORS 410.604.
(f) Services and supports are geographically located as close
to where members reside as possible and are, if available,
offered in nontraditional settings that are accessible to
families, diverse communities and underserved populations.
(g) Each coordinated care organization uses health information
technology to link services and care providers across the
continuum of care to the greatest extent practicable { + and if
financially viable + }.
(h) Each coordinated care organization complies with the
safeguards for members described in ORS 414.635.
(i) Each coordinated care organization convenes a community
advisory council that { - 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 - } { + meets the criteria specified in section
13 of this 2012 Act + }.
(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.
Enrolled Senate Bill 1580 (SB 1580-A) Page 10
(D) Are permitted to participate in the networks of multiple
coordinated care organizations.
(E) Include providers of specialty care.
(F) Are selected by coordinated care organizations using
universal application and credentialing procedures, objective
quality information and are removed if the providers fail to meet
objective quality standards.
(G) Work together to develop best practices for culturally
appropriate care and service delivery to reduce waste, reduce
health disparities and improve the health and well-being of
members.
(L) Each coordinated care organization reports on outcome and
quality measures { - identified by the authority - } { +
adopted + } under ORS 414.638 and participates in the health care
data reporting system established in ORS 442.464 and 442.466.
(m) Each coordinated care organization uses best practices in
the management of finances, contracts, claims processing, payment
functions and provider networks.
(n) Each coordinated care organization participates in the
learning collaborative described in ORS 442.210 (3).
(o) Each coordinated care organization has a governance
structure that includes:
(A) { - A majority interest consisting of the - } Persons
that share in the financial risk of the organization { + who
must constitute a majority of the governance structure + };
(B) The major components of the health care delivery system;
{ - and - }
{ + (C) At least two health care providers in active
practice, including:
(i) A physician licensed under ORS chapter 677 or a nurse
practitioner certified under ORS 678.375, whose area of practice
is primary care; and
(ii) A mental health or chemical dependency treatment
provider; + }
{ - (C) - } { + (D) At least two members from + } the
community at large, to ensure that the organization's
decision-making is consistent with the values of the members and
the community { - . - } { + ; and
(E) At least one member of the community advisory council. + }
{ - (2) - } { + (3) + } The authority shall consider the
participation of area agencies and other nonprofit agencies in
the configuration of coordinated care organizations.
{ + (4) In selecting one or more coordinated care
organizations to serve a geographic area, the authority shall:
(a) For members and potential members, optimize access to care
and choice of providers;
(b) For providers, optimize choice in contracting with
coordinated care organizations; and
(c) Allow more than one coordinated care organization to serve
the geographic area if necessary to optimize access and choice
under this subsection. + }
{ - (3) - } { + (5) + } On or before July 1, 2014, each
coordinated care organization must have a formal contractual
relationship with any dental care organization that serves
members of the coordinated care organization in the area where
they reside.
SECTION 21. ORS 414.638 is amended to read:
414.638. { + (1) There is created a nine-member metrics and
scoring committee appointed by the Director of the Oregon Health
Enrolled Senate Bill 1580 (SB 1580-A) Page 11
Authority. The members of the committee serve two-year terms and
must include:
(a) Three members at large;
(b) Three individuals with expertise in health outcomes
measures; and
(c) Three representatives of coordinated care
organizations. + }
{ - (1) - } { + (2) + } { - The Oregon Health Authority
through a public process shall - } { + The committee shall use
a public process to + } 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.
{ + Quality measures adopted by the committee must be consistent
with existing state and national quality measures. + } The
{ + Oregon Health + } Authority shall incorporate these measures
into coordinated care organization contracts to hold the
organizations accountable for performance and customer
satisfaction requirements.
{ + (3) The committee must adopt outcome and quality measures
annually and adjust the measures to reflect:
(a) The amount of the global budget for a coordinated care
organization;
(b) Changes in membership of the organization;
(c) The organization's costs for implementing outcome and
quality measures; and
(d) The community health assessment and the costs of the
community health assessment conducted by the organization under
section 13 of this 2012 Act. + }
{ - (2) - } { + (4) + } The authority shall evaluate on a
regular and ongoing basis { - key - } { + the outcome and + }
quality measures { + adopted by the committee under this
section + } { - , 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) - } { + (5) + } { - 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 { + outcome
and quality measures adopted by the committee + } and take
actions to eliminate any redundant reporting or reporting of
limited value.
{ - (4) - } { + (6) + } The authority shall publish the
information collected under this section at aggregate levels that
do not disclose information 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 22. ORS 646.735 is amended to read:
646.735. (1) The Legislative Assembly declares that
collaboration among public payers, private health carriers, third
Enrolled Senate Bill 1580 (SB 1580-A) Page 12
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 - } { + shall + } 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, { + may meet + }
to facilitate the development { + , + } { - and establishment
of the Oregon Integrated and Coordinated Health Care Delivery
System and health care payment reforms - } { + implementation
and operation of a coordinated care organization in accordance
with criteria and requirements adopted by the Oregon Health
Authority under ORS 414.625 + }. Any participation by such
entities and individuals shall be on a voluntary basis.
(4) The authority may { - : - }
{ - (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 { + (3) or + } (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.
{ +
TECHNICAL CORRECTIONS AND CONFORMING AMENDMENTS + }
SECTION 23. Section 64, chapter 602, Oregon Laws 2011, as
amended by section 70, chapter 602, Oregon Laws 2011, is amended
to read:
{ + Sec. 64. + } (1) ORS 414.705 is repealed.
(2) Sections 13 { - , 14 - } and 17 { - of this 2011
Act - } { + , chapter 602, Oregon Laws 2011, + } are repealed
January 2, 2014.
(3) ORS 414.610, 414.630, 414.640, 414.736, 414.738, 414.739
and 414.740 are repealed July 1, 2017.
{ + (4) Section 14, chapter 602, Oregon Laws 2011, as amended
by section 2 of this 2012 Act, is repealed July 1, 2017. + }
Enrolled Senate Bill 1580 (SB 1580-A) Page 13
SECTION 24. ORS 414.033 is amended to read:
414.033. 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 for:
(a) Providing medical assistance to individuals who are dually
eligible for Medicare and Medicaid using { + global or + }
alternative payment methodologies or integrated and coordinated
health care and services; or
(b) Evaluating service delivery systems.
SECTION 25. ORS 414.632 is amended to read:
414.632. (1) Subject to the Oregon Health Authority obtaining
any necessary authorization from the Centers for Medicare and
Medicaid Services { - under section 17, chapter 602, Oregon
Laws 2011 - } , coordinated care organizations that meet the
criteria adopted under ORS 414.625 are responsible for providing
covered Medicare and Medicaid services, other than
Medicaid-funded long term care services, to members who are
dually eligible for Medicare and Medicaid in addition to medical
assistance recipients.
(2) An individual who is dually eligible for Medicare and
Medicaid shall be permitted to enroll in and remain enrolled in
a:
(a) Program of all-inclusive care for the elderly, as defined
in 42 C.F.R. 460.6; and
(b) { - 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 26. ORS 414.740 is amended to read:
414.740. (1) Notwithstanding ORS 414.738 (1), the Oregon Health
Authority shall contract under ORS 414.651 with a prepaid group
practice health plan that serves at least 200,000 members in this
state and that has been issued a certificate of authority by the
Department of Consumer and Business Services as a health care
service contractor to provide health services as described in ORS
{ - 414.705 (1)(b) - } { + 414.025 (8)(b) + }, (c), (d), (e),
(g) and (j). A health plan 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). The
authority may accept financial contributions from any public or
private entity to help implement and administer the contract. The
authority shall seek federal matching funds for any financial
contributions received under this section.
(2) In a designated area, in addition to the contract described
in subsection (1) of this section, the authority shall contract
with prepaid managed care health services organizations to
Enrolled Senate Bill 1580 (SB 1580-A) Page 14
provide health services under ORS 414.631, 414.651 and 414.688 to
414.750.
SECTION 27. ORS 416.540 is amended to read:
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 - }
{ + a global + } 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 28. { + ORS 414.631, 414.651 and 414.688 to 414.750
are added to and made a part of ORS chapter 414. + }
{ +
CAPTIONS + }
SECTION 29. { + The unit captions used in this 2012 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 2012 Act. + }
{ +
EMERGENCY CLAUSE + }
SECTION 30. { + This 2012 Act being necessary for the
immediate preservation of the public peace, health and safety, an
emergency is declared to exist, and this 2012 Act takes effect on
its passage. + }
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Enrolled Senate Bill 1580 (SB 1580-A) Page 15
Passed by Senate February 14, 2012
.............................................................
Robert Taylor, Secretary of Senate
.............................................................
Peter Courtney, President of Senate
Passed by House February 23, 2012
.............................................................
Bruce Hanna, Speaker of House
.............................................................
Arnie Roblan, Speaker of House
Enrolled Senate Bill 1580 (SB 1580-A) Page 16
Received by Governor:
......M.,............., 2012
Approved:
......M.,............., 2012
.............................................................
John Kitzhaber, Governor
Filed in Office of Secretary of State:
......M.,............., 2012
.............................................................
Kate Brown, Secretary of State
Enrolled Senate Bill 1580 (SB 1580-A) Page 17
