Oregon Administrative Code

409-050-0130 Pain Management Education Program Requirements (1) Licensed health care professionals must complete a pain management education program in order to improve the care and treatment of individuals with painful conditions. The program includes: (a) Six accredited hours o…

409-055-0000 Purpose and Scope These rules (OAR 409-055-0000 to 409-055-0090) establish the Patient-Centered Primary Care Home (PCPCH) Program and define criteria and process that the Authority shall use to recognize and verify status as PCPCHs. The PCPCH is a model of primary ca…

409-055-0010 Definitions The following definitions apply to OAR 409-055-0000 to 409-055-0090: (1) “Authority” means the Oregon Health Authority. (2) “NCQA” means National Committee for Quality Assurance. (3) “Patient Centered Medical Home (PCMH)” means a practice or provider who …

409-055-0020 Program Administration (1) The Program is intended to ensure that there is a uniform process for recognizing PCPCHs throughout the State of Oregon in order to support primary care transformation. (2) The Authority shall recognize practices as PCPCHs upon meeting defi…

409-055-0030 Practice Application and Recognition Process (1) Practices, or other entities on behalf of the practice, that wish to be recognized as a PCPCH shall submit a PCPCH Recognition Application electronically to the Authority via the Program’s online application system fou…

409-055-0040 Recognition Criteria (1) The PCPCH recognition criteria are divided into “Must-Pass” measures and other measures that place the practice on a scale of maturity or ‘tier’ that reflect basic to more advanced PCPCH functions. (2) Must-Pass and 5-point measures focus on …

409-055-0045 Health Equity Designation (1) The Authority shall award Health Equity designations to practices implementing multiple PCPCH Health Equity measures. (2) A practice seeking the Health Equity Designation, must meet the following criteria: (a) Be recognized as a PCPCH un…

409-055-0050 Data Reporting Requirements for Recognized PCPCHs (1) To be recognized as a PCPCH, a practice must attest to meeting the criteria and submit quantitative data elements to support its attestation in accordance with 409-055-0040 Table 1 incorporated by reference. (2) Q…

409-055-0060 Verification (1) The Authority shall conduct at least one on-site verification review of each recognized PCPCH to determine compliance with PCPCH criteria every five years and at such other times as the Authority deems necessary or at the request of the Health System…

409-055-0070 Compliance (1) If the Authority finds that the practice is not in compliance with processes as attested to, the Authority shall issue a written warning requiring the practice to submit an improvement plan within 90 days of the date of the written warning. The improve…

409-055-0080 Insurance Carrier, Managed Care Plan, and Public Stakeholder Communication (1) The Authority shall develop a system for making recognized PCPCH Tier status recognition information available to insurance carriers and managed care organizations. (2) The Authority shall…

409-055-0090 Reimbursement Objectives (1) One objective of these standards is to facilitate appropriate reimbursement for PCPCHs consistent with their recognized Tier levels. The standards and Tier recognition process established in this rule are consistent with statutory objecti…

409-058-0100 Scope These rules (OAR 409-058-0100 to 409-058-0110) require the Health Evidence Review Commission to adopt bylaws to govern, among other things, the management of potential conflicts of interest, actual conflicts of interest, and significant personal interests among…

409-058-0110 Health Evidence Review Commission Bylaws The Health Evidence Review Commission shall adopt bylaws to govern its operations. The bylaws shall, among other things: (1) Require Commission, subcommittee members, and appointed ad hoc experts to disclose potential or actua…

409-060-0100 Scope (1) These rules (OAR 409-060-0100 to 409-060-0150) define criteria and processes that the Health Evidence Review Commission shall use to develop evidence-based reports, including medical technology assessments, evidence-based guidelines and coverage guidances. …

409-060-0110 Definitions The following definitions apply to OAR 409-060-0100 to 409-060-0150: (1) “Ad hoc expert” means an individual identified by the Commission as having particular expertise in a technology or its application. (2) “Authority” means the Oregon Health Authority.…

409-060-0120 Health Evidence Review Commission Process for Evidence-based Reports (1) The Commission shall base its reports on scientific evidence, taking into account the strength of the evidence, including an assessment of any biases present. Meetings shall be public and conduc…

409-060-0130 Medical Technology Assessments Medical technology assessments undertaken by the Commission shall be developed by HTAS and may include any technologies listed in the definition in ORS 414.695 and 414.698(1). Medical technology assessments shall be performed in cases w…

409-060-0140 Evidence-based Guidelines The EbGS shall develop evidence-based guidelines based on one or more existing guidelines which may involve the consideration of additional research. Evidence-based guidelines shall be developed according to the process described in OAR 409-…

409-060-0150 Coverage Guidances (1) A Subcommittee shall develop coverage guidances based on evidence searches using scope statements approved by the EbGS or HTAS after a seven-day public comment period. These evidence searches may be supplemented as necessary to provide addition…

409-062-0100 Purpose These rules establish a public notice for advance meeting materials, which must be posted for an advance comment period, before being considered by the Value-based Benefits Subcommittee (VbBS) of the Health Evidence Review Commission (HERC). Public comments h…

409-062-0110 VbBS Meeting Material Requirements (1) Advance meeting materials include draft materials developed by Health Evidence Review Commission (HERC) staff in preparation for a scheduled Value-based Benefits Subcommittee (VbBS) meeting. Each item includes, but is not limite…

409-062-0120 Notice and Comment Process (1) Prior to each Value-based Benefits Subcommittee (VbBS) meeting, Health Evidence Review Commission (HERC) staff must develop advance meeting materials, comprised of materials and draft recommendations related to all topics planned for di…

409-065-0000 Purpose Senate Bill 889 (2019 Legislature) established the Sustainable Health Care Cost Growth Target Program within the Oregon Health Authority and House Bill 2081 (2021 Legislature) authorized accountability mechanisms to achieve a sustainable rate of health care c…

409-065-0005 Definitions The following definitions apply to OAR 409-065-0000 to 409-065-0055: (1) “Accident policy” means an insurance policy that provides benefits only for a loss due to accidental bodily injury. (2) “Authority” means the Oregon Health Authority. (3) “Calendar y…

409-065-0010 General Reporting Requirements for Mandatory Reporters (1) Determination of a mandatory reporter. (a) For payers or licensed third-party administrators, the Authority must identify mandatory reporters using health insurance enrollment data from DCBS and Medicaid enro…

409-065-0015 Data Submission Requirements (1) Annual data submission dates are provided in the CGT-2; the data submission dates must not be before September 1st of each year. (2) Annual data submissions must be submitted on the CGT-1 in accordance with instructions published by t…

409-065-0020 Data Submission Waivers (1) The Authority may grant a waiver or deadline extension to the data submission requirements in OAR 409-065-0015. (2) If a mandatory reporter believes they are eligible for a waiver of all or part of the data submission requirements they may…

409-065-0025 Data Submission Compliance and Enforcement (1) Unless the Authority approves a waiver submitted pursuant to OAR 409-065-0020, a mandatory reporter fails to comply with general data submission requirements under OAR 409-065-0015 when a mandatory reporter: (a) Fails to…

409-065-0028 General Reporting Requirements for Provider Organizations (1) Determination of a provider organization that is required to report data. (a) The Authority must identify provider organizations with 10,000 or more attributed patients in at least one market using the ann…

409-065-0029 Automatic Change in Monetary Limits for Frontline Workers Monetary limits for frontline workers will automatically change, without the necessity for amending such rules, by annual percentage increase (if any) in the Consumer Price Index for All Urban Consumers, West …

409-065-0030 Data Access and Disclosure (1) The Authority may use and disclose data submitted to it under these rules in accordance with ORS 442.386 and any applicable Authority policies and state and federal rules, regulations, and statutes. (2) The Authority may disclose data t…

409-065-0035 Reasonable Causes of Cost Growth (1) The Authority must not impose a performance improvement plan outlined in OAR 409-065-0040 or financial penalty outlined in OAR 409-065-0045 on an entity that exceeded the cost growth target due to unforeseen market conditions or o…

409-065-0040 Performance Improvement Plans (PIP) (1) A payer or provider organization that exceeds the cost growth target with statistical confidence, as such term is described by the Authority in the Statistical Analysis guidance posted on the Program website, and without reason…

409-065-0042 Confidential Information (1) An entity that submits information to the Authority may claim portions of the information a trade secret and exempt from disclosure under ORS 192.311 to 192.478. (a) The entity must submit two versions of such materials to the Authority: …

409-065-0045 Cost Growth Target Financial Penalties (1) Pursuant to ORS 442.386, the Authority may impose a financial penalty on a payer or provider organization when: (a) The cost growth exceeded the target with statistical confidence, as defined by the Authority; and (b) The pa…

409-065-0050 Cost Growth Target Accountability Request for Consideration and Contested Case Hearings (1) A payer or provider organization may request that the Authority reconsider any Notice of Intent or determination made under OAR 409-065-0000 through OAR 409-065-0055. (a) A re…

409-065-0055 Annual Public Hearings (1) The cost growth target program must hold an annual public hearing regarding the growth in total health care expenditures in relation to the health care cost growth in the previous calendar year. The director of the Authority may request any…

409-070-0000 Scope and Purpose (1) OAR 409-070-0000 through OAR 409-070-0085 are adopted pursuant to authority in ORS 415.501. OAR 409-070-0000 through OAR 409-070-0085 govern the procedure for filing notices of material change transactions and the criteria and procedure for revi…

409-070-0005 Definitions When used and not otherwise defined in OAR 409-070-0000 through OAR 409-070-0085, the following terms have the meaning given in this section: (1) "Administrative services" means support and administration services, outsourced and subcontracted services an…

409-070-0010 Covered Transactions (1) Pursuant to ORS 415.500(6) and (10) and subject to the materiality standards under OAR 409-070-0015, transactions that are subject to review under these rules are the following: (a) A merger or consolidation of a health care entity with anoth…

409-070-0015 Materiality Standard (1) Pursuant to ORS 415.500(6) and (9) and ORS 415.501(4), a covered transaction under OAR 409-070-0010 is a material change transaction and must be subject to review under these rules if: (a) At least one party to the transaction had average ann…

409-070-0020 Excluded Transactions (1) Pursuant to ORS 415.500(6)(b) and (7), the following transactions are not material change transactions subject to review under these rules: (a) A clinical affiliation of health care entities formed to collaborate on clinical trials or gradua…

409-070-0022 Emergency and Exempt Transactions (1) Pursuant to ORS 415.501(8)(a), the Authority, for good cause shown, may exempt an otherwise covered transaction from review if the Authority finds that: (a) There is an emergency situation, including but not limited to a public h…

409-070-0025 Acquisition of Control; Presumptions and Disclaimers (1) The following presumptions will apply in determining whether a transaction involving a health care entity results in the acquisition of direct or indirect control of that health care entity: (a) A transaction m…

409-070-0030 Requirement to File a Notice of Material Change Transaction (1) Any health care entity must: (a) Submit to the Authority a notice of material change transaction not involving an activity described in ORS 732.521 with respect to a domestic health insurer. The notice m…

409-070-0035 Material Change Transaction Involving a Domestic Health Insurer (1) The Authority must review a proposed material change transaction for an activity described in ORS 732.521 with respect to a domestic health insurer pursuant to the procedures set forth in OAR 409-070…

409-070-0040 Material Change Transaction Involving a Charitable Organization or Hospital (1) The parties must provide a copy of any notice of a material change transaction involving a health care entity that is, controls, or is controlled by a charitable organization to the Chari…

409-070-0042 Optional Application for Determination of Covered Transaction Status (1) Any party to a proposed transaction may, but must not be required to, submit a written application to the Authority requesting a determination whether such transaction is a covered transaction p…

409-070-0045 Form and Contents of Notice of Material Change Transaction (1) A notice of material change transaction required to be filed under OAR 409-070-0030(1)(a) must be made using the form available at the Program website. Unless expressly provided otherwise, if any item is …