Chapter 414 — Chapter 414

ORS 414.426 Payment of cost of medical care for institutionalized persons. The Oregon Health Authority is hereby authorized to pay the cost of care for patients in institutions operated under ORS 179.321 under the medical assistance program established by ORS chapter 414. [Formerly 414.028; 2009 c.595 §310]

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ORS 414.428 Coverage for American Indian and Alaska Native beneficiaries. (1) An individual who is eligible for or receiving medical assistance, as defined in ORS 414.025, pursuant to a demonstration project under section 1115 of the Social Security Act and who is an American Indian and Alaska Native beneficiary shall receive the same package of health services as individuals described in ORS 414.706 (1), (2) and (3) if

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ORS 414.430 Access to dental care for pregnant medical assistance recipients; rules. (1) The Oregon Health Authority shall prescribe by rule appropriate time frames within which a pregnant medical assistance recipient whose medical assistance is reimbursed on a fee-for-service basis and who needs general or specialty dental care must have the opportunity to be seen, or referred for, and provided

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ORS 414.432 Reproductive health services for noncitizens. (1) The Oregon Health Authority shall administer a program to reimburse the cost of medically appropriate services, drugs, devices, products and procedures described in ORS 743A.067, for individuals who can become pregnant and who would be eligible for medical assistance if not for 8 U.S.C. 1611 or 1612

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ORS 414.434 Eligibility for individuals under age 26 who have aged out of foster care in Oregon or another state. Medical assistance shall be provided to an individual who

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ORS 414.436 Oregon Health Authority to review rules and contracts to ensure timely access to services for individuals under 21 years of age. (1) The Oregon Health Authority shall review, and amend as needed, current administrative rules and contracts to ensure that individuals receiving medical assistance who are under 21 years of age have timely access to the services described in subsection (2) of this section

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ORS 414.440 [2011 c.207 §1; 2013 c.640 §1; renumbered 411.447 in 2013]

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ORS 414.500 Findings regarding medical assistance for persons with hemophilia. The Legislative Assembly finds that there are citizens of this state who have the disease of hemophilia and that hemophilia is generally excluded from any private medical insurance coverage except in an employment situation under group coverage which is usually ended upon termination of employment. The Legislative Assembly further finds that there is a need for a statewide program for the medical care of persons with hemophilia who are unable to pay for their necessary medical services, wholly or in part. [1975 c.513 §1; 1989 c.224 §81]

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ORS 414.510 Definitions. (1) “Eligible individual” means a resident of the State of Oregon over the age of 20 years

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ORS 414.520 Hemophilia services. Within the limit of funds expressly appropriated and available for medical assistance to hemophiliacs, hemophilia services under ORS 414.500 to 414.530 shall be made available to eligible persons as recommended by the Medical Advisory Committee of the Oregon Chapter of the National Hemophilia Foundation. [1975 c.513 §3]

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ORS 414.530 When payments not made for hemophilia services. Payments under ORS 414.500 to 414.530 shall not be made for any services which are available to the recipient under any other private, state or federal programs or under other contractual or legal entitlements. However, no provision of ORS 414.500 to 414.530 is intended to limit in any way state participation in any federal program for medical care of persons with hemophilia. [1975 c.513 §4]

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ORS 414.532 Definitions for ORS 414.534 to 414.538. As used in ORS 414.534 to 414.538

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ORS 414.534 Treatment for breast or cervical cancer; eligibility criteria for medical assistance; rules. (1) The Oregon Health Authority shall provide medical assistance, as defined in ORS 414.025, to a woman who

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ORS 414.536 Presumptive eligibility for medical assistance for treatment of breast or cervical cancer. (1) If the Department of Human Services or the Oregon Health Authority determines that a woman likely is eligible for medical assistance under ORS 414.534, the department or the authority shall determine her to be presumptively eligible for medical assistance until a formal determination on eligibility is made

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ORS 414.538 Prohibition on coverage limitations; priority to low-income women. (1) The Department of Human Services and the Oregon Health Authority may not impose income or resource limitations or a prior period of uninsurance on a woman who otherwise qualifies for medical assistance under ORS 414.534 or 414.536

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ORS 414.540 Rules. The Oregon Health Authority shall adopt rules necessary for the implementation and administration of ORS 414.534 to 414.538. [2001 c.902 §5; 2009 c.595 §316]

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ORS 414.550 Definitions for ORS 414.550 to 414.565. As used in ORS 414.550 to 414.565

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ORS 414.555 Findings regarding medical assistance for persons with cystic fibrosis. The Legislative Assembly finds that there are citizens of this state who have the disease of cystic fibrosis and that cystic fibrosis is generally excluded from any private medical insurance coverage except in an employment situation under group coverage which is usually ended upon termination of employment. The Legislative Assembly further finds that there is a need for a statewide program for the medical care of persons with cystic fibrosis who are unable to pay for their necessary medical services, wholly or in part. [1985 c.532 §1; 1989 c.224 §82]

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ORS 414.560 Cystic fibrosis services. (1) Within the limit of funds expressly appropriated and available for medical assistance to individuals who have cystic fibrosis, cystic fibrosis services under ORS 414.550 to 414.565 shall be made available by the Services for Children with Special Health Needs to eligible individuals as recommended by the review committee. The review committee shall consist of the Cystic Fibrosis Center Director, the Oregon Cystic Fibrosis Chapter Medical Advisory Committee and other recognized and knowledgeable community leaders in the area of health care delivery designated to serve on the review committee by the Director of the Services for Children with Special Health Needs

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ORS 414.565 When payments not made for cystic fibrosis services. Payments under ORS 414.550 to 414.565 shall not be made for any services which are available to the recipient under any other private, state or federal programs or under other contractual or legal entitlements. However, no provision of ORS 414.550 to 414.565 is intended to limit in any way state participation in any federal program for medical care of persons with cystic fibrosis. [1985 c.532 §4]

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ORS 414.570 System established. (1) There is established the Oregon Integrated and Coordinated Health Care Delivery System. The system shall consist of state policies and actions that make coordinated care organizations accountable for care management and provision of integrated and coordinated health care for each organization’s members, primarily 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

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ORS 414.572 Coordinated care organizations; rules. (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 and requirements adopted by the authority under this section must include, but are not limited to, a requirement that the coordinated care organization

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ORS 414.575 Community advisory councils. (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

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ORS 414.577 Community health assessment and adoption of community health improvement plan; rules. (1) As used in this section

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ORS 414.578 Community health improvement plan to address health of children and youth. (1) A community health improvement plan adopted by a coordinated care organization and its community advisory council in accordance with ORS 414.577 shall include a component for addressing the health of children and youth in the areas served by the coordinated care organization including, to the extent practicable, a strategy and a plan for

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ORS 414.581 Tribal Advisory Council established; membership; terms. (1) The Tribal Advisory Council is established. The duties of the council are to

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ORS 414.584 Meetings of coordinated care organization governing body to be open to public; recording and taking of minutes required. (1) Meetings of a governing body of a coordinated care organization in which substantive decisions are made final must

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ORS 414.590 Coordinated care organization contracts; terms and amendments; 60 days’ advance notice; refusal to renew. (1) As used in this section

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ORS 414.591 Coordinated care organization contracts; financial reporting; rules. (1) The Oregon Health Authority shall use, to the greatest extent possible, coordinated care organizations to provide fully integrated physical 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

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ORS 414.592 Requirements for contracts between authority and providers; alignment with behavioral quality health metrics and incentives. Notwithstanding ORS 414.590

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ORS 414.593 Reporting and public disclosure of expenditures by coordinated care organizations. (1) As used in this section

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ORS 414.595 External quality reviews of coordinated care organizations; limits on documentation and reporting requirements. (1) As used in this section

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ORS 414.598 Alternative payment methodologies. (1) The Oregon Health Authority shall encourage coordinated care organizations to use alternative payment methodologies that

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ORS 414.605 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

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ORS 414.607 Use and disclosure of member information; access by member to personal health 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

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ORS 414.609 Network adequacy; member transfers. (1) A coordinated care organization that contracts with the Oregon Health Authority must maintain a network of providers, including but not limited to addiction treatment providers, sufficient in numbers and areas of practice and geographically distributed in a manner to ensure that the health services provided under the contract are reasonably accessible to members

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ORS 414.610 [1983 c.590 §1; 1985 c.747 §8; repealed by 2011 c.602 §§64,70, 2012 c.8 §23 and 2015 c.792 §2]

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ORS 414.611 Transfer of 500 or more members of coordinated care organization. (1) The Oregon Health Authority may approve the transfer of 500 or more members from one coordinated care organization to another coordinated care organization if

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ORS 414.613 Discrimination based on scope of practice prohibited; appeals; rules. (1) A coordinated care organization may not discriminate with respect to participation in the organization or coverage against any health care provider who is acting within the scope of the provider’s license or certification under applicable state law. This section does not require that an organization contract with any health care provider willing to abide by the terms and conditions for participation established by the organization. This section does not prevent an organization from establishing varying reimbursement rates based on quality or performance measures

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ORS 414.615 [Formerly 414.640; 2017 c.356 §34; repealed by 2011 c.602 §§64,70, 2012 c.8 §23 and 2015 c.792 §2]

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ORS 414.618 [Formerly 414.630; 2014 c.45 §39; 2017 c.356 §35; repealed by 2011 c.602 §§64,70, 2012 c.8 §23 and 2015 c.792 §2]

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ORS 414.619 Coordination between 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 414.570

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ORS 414.620 [1983 c.590 §2; 1985 c.747 §2; 2011 c.602 §2; 2015 c.798 §10; renumbered 414.570 in 2019]

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ORS 414.625 [2011 c.602 §4; 2012 c.8 §20; 2013 c.535 §3; 2015 c.798 §11; 2017 c.101 §25; 2017 c.273 §6; 2017 c.429 §1; 2017 c.489 §§1,14; 2018 c.49 §§3,4; 2019 c.358 §§7,8; 2019 c.364 §§1,2; 2019 c.478 §§57,58; 2019 c.529 §§6,7; renumbered 414.572 in 2019]

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ORS 414.627 [2012 c.8 §13; 2013 c.535 §§4,5; 2017 c.82 §1; 2019 c.529 §8; renumbered 414.575 in 2019]

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ORS 414.628 Innovator agents. (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

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ORS 414.629 [2013 c.598 §1; 2015 c.402 §3; 2019 c.529 §10; renumbered 414.578 in 2019]

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ORS 414.630 [1983 c.590 §3; 1991 c.66 §24; 2003 c.794 §275; 2009 c.595 §317; 2011 c.602 §40; renumbered 414.618 in 2011]

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ORS 414.631 Mandatory enrollment in coordinated care organization; exemptions. (1) Except as provided in subsections (2), (3), (4) and (5) of this section and ORS 414.632 (2), a person who is eligible for or receiving health services must be enrolled in 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

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ORS 414.632 Services to individuals who are dually eligible for Medicare and Medicaid. (1) Subject to the Oregon Health Authority obtaining any necessary authorization from the Centers for Medicare and Medicaid Services, coordinated care organizations that meet the criteria adopted under ORS 414.572 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

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