2007 Oregon Code - Chapter 414 :: Chapter 414 - Medical Assistance
Chapter 414
Medical Assistance
2007 EDITION
MEDICAL ASSISTANCE
HUMAN SERVICES; JUVENILE CODE; CORRECTIONS
414.018 Goals;
findings
414.019 Laws
comprising Oregon Health Plan
414.021 Duties
of administrator; staff; advisory committees; grants; meetings
414.022 Provision
of mental health services; goals; criteria; reports
414.023 Chemical
dependency services; goal
414.024 Guidelines
for selecting areas for initial operation of programs
414.025 Definitions
MISCELLANEOUS PROVISIONS
414.031 Oregon
Health Policy Commission to review changes proposed by Department of Human
Services for medical assistance program and other health care programs
414.032 Medical
assistance to categorically needy and medically needy
414.033 Expenditures
for medical assistance authorized
414.034 Acceptance
of federal billing, reimbursement and reporting forms
414.036 Policy
on persons without access to health services
PROCEDURE TO OBTAIN MEDICAL ASSISTANCE
414.038 Medically
needy program; determination of income
414.039 Medically
needy program; rules
414.042 Determination
of need for and amount of medical assistance; rules
414.047 Application
for medical assistance
414.049 Documentation
required for person applying for medical assistance under ORS 414.705 to
414.750
414.051 Authorization
and payment for dental services
414.055 Hearing
on eligibility
414.057 Notice
of change in circumstances
MEDICAL ASSISTANCE
414.065 Determination
of health services covered; standards; cost sharing; payments by department as
payment in full; rules
414.073 Information
on all licensed healing arts to be made available
414.075 Payment
of deductibles imposed under federal law
414.085 Cooperative
agreements authorized
414.095 Exemptions
applicable to payments
414.105 Recovery
of medical assistance; estate claims; transfer of assets; rules
414.106 Possible
limitation on recovery of certain medical assistance; federal law
414.107 Entitlement
to mental health care and chemical dependency services
414.109
INSURANCE AND SERVICE CONTRACTS
414.115 Medical
assistance by insurance or service contracts; rules
414.125 Rates
on insurance or service contracts; requirements for insurer or contractor
414.135 Contracts
relating to direct providers of care and services
414.145 Implementation
of ORS 414.115, 414.125 or 414.135
STATE AND LOCAL PUBLIC HEALTH PARTNERSHIP
414.150 Purpose
of ORS 414.150 to 414.153
414.151 Enrollment
of poverty level medical assistance program clients; agreements with local
governments
414.152 Duties
of state agencies
414.153 Authorization
for payment for certain services
ADVISORY COMMITTEES
414.211 Medicaid
Advisory Committee
414.221 Duties
of committee
414.225 Department
to consult with committee
414.227 Application
of public meetings law to advisory committees
PRESCRIPTION DRUGS
(
414.312
414.314 Application
and participation in Oregon Prescription Drug Program; prescription drug
charges; fees
414.316 Preferred
drug list for Oregon Prescription Drug Program
414.318 Prescription
Drug Purchasing Fund
414.320 Rules
(Prescription Drug Coverage by Medical
Assistance)
414.325 Prescription
drugs; use of legend or generic drugs; prior authorization; rules
414.327 Electronically
transmitted prescriptions; federal waiver; rules
414.329 Prescription
drug benefits for certain persons who are eligible for Medicare Part D
prescription drug coverage; rules
(Practitioner-Managed Prescription Drug Plan)
414.330 Legislative
findings on prescription drugs
414.332 Policy
for Practitioner-Managed Prescription Drug Plan
414.334 Practitioner-Managed
Prescription Drug Plan for
414.336 Limitation
on rules regarding Practitioner-Managed Prescription Drug Plan
(Patient Prescription Drug Assistance
Program)
414.338 Patient
Prescription Drug Assistance Program;
(Senior Prescription Drug Assistance Program)
414.340 Definitions
for ORS 414.340, 414.342 and 414.348
414.342 Senior
Prescription Drug Assistance Program; application and enrollment; enrollment
fee; critical access pharmacies; rules
414.344 Contracts
to provide services under Senior Prescription Drug Assistance Program
414.346 Rules
414.348 Senior
Prescription Drug Assistance Fund
DRUG USE REVIEW BOARD
414.350 Definitions
for ORS 414.350 to 414.415
414.355 Drug
Use Review Board created; duties; members; term; qualifications
414.360 Duties
of board regarding retrospective and prospective drug use review programs;
rules
414.365 Educational
and informational duties of board; procedures to insure confidentiality
414.370 Authorized
intervention procedures
414.375 Standards
for prospective drug use review program
414.380 Standards
for retrospective drug use review program
414.385 Compliance
with Omnibus Budget Reconciliation Act of 1990
414.390 Unauthorized
disclosure of information prohibited; staff access to information
414.395 When
executive session authorized; public testimony
414.400 Board
subject to public record laws; chairperson; expenses; quorum; advisory
committees
414.410 Staff
414.415 Contents
of annual report; public comment
MEDICAL ASSISTANCE FOR CERTAIN INDIVIDUALS
414.420 Suspension
of medical assistance for pregnant women who are incarcerated
414.422 Conditions
for coverage for pregnant women who are incarcerated
414.424 Suspension
of medical assistance of persons with serious mental illness under certain
circumstances
414.426 Payment
of cost of medical care for institutionalized persons
414.428 Coverage
for American Indian and Alaskan Native beneficiaries
414.500 Findings
regarding medical assistance for persons with hemophilia
414.510 Definitions
414.520 Hemophilia
services
414.530 When
payments not made for hemophilia services
414.532 Definitions
for ORS 414.534 to 414.538
414.534 Treatment
for breast or cervical cancer; eligibility criteria for medical assistance
414.536 Presumptive
eligibility for medical assistance for treatment of breast or cervical cancer
414.538 Prohibition
on coverage limitations; priority to low-income women
414.540 Rules
414.550 Definitions
for ORS 414.550 to 414.565
414.555 Findings
regarding medical assistance for persons with cystic fibrosis
414.560 Cystic
fibrosis services
414.565 When
payments not made for cystic fibrosis services
414.610 Legislative
intent
414.620 System
established
414.630 Prepaid
capitated health care service contracts; when fee for services to be paid
414.640 Selection
of providers; reimbursement for services not covered; actions as trade
practice; actions not insurance; rules
414.660 Demonstration
projects for medical service contracts
414.670 Phasing
in eligible clients
SCOPE OF COVERED HEALTH SERVICES
414.705 Definitions
for ORS 414.705 to 414.750
414.706 Legislative
approval and funding of health services to certain persons
414.707 Level
of health services provided to certain persons
414.708 Conditions
for coverage for certain elderly persons, blind persons or persons who have
disabilities
414.709 Adjustment
of population of eligible persons in event of insufficient resources
414.710 Services
available to certain eligible persons
414.712 Medical
assistance for certain eligible persons
414.715 Health
Services Commission; confirmation; qualifications; terms; expenses;
subcommittees
414.720 Public
hearings; public involvement; biennial reports on health services priorities;
funding
414.725 Prepaid
managed care health services contracts; financial reporting; rules
414.727 Reimbursement
of rural hospitals by prepaid managed care health services organization
414.728 Reimbursement
of rural hospitals by Department of Human Services
414.730 Subcommittee
on Mental Health Care and Chemical Dependency
414.735 Adjustment
of reimbursement in event of insufficient resources; approval of Legislative
Assembly or Emergency Board; notice to providers
414.736 Definitions
414.737 Mandatory
enrollment in prepaid managed care health services organization
414.738 Use
of physician care organizations
414.739 Circumstances
under which fully capitated health plan may contract as physician care
organization
414.740 Contracts
with certain prepaid group practice health plan
414.741 Determination
of benchmarks for setting per capita rates
414.742 Payment
for mental health drugs
414.743 Payment
to noncontracting hospital by fully capitated health plan; rules
414.744 Pharmacy
benefit manager to manage prescription drug benefits
414.745 Liability
of health care providers and plans
414.747 Supplemental
rebates from pharmaceutical manufacturers
414.750 Authority
of Legislative Assembly to authorize services for other persons
414.751 Office
for
PAYMENT OF MEDICAL EXPENSES OF PERSON IN CUSTODY OF LAW ENFORCEMENT
OFFICER
414.805 Liability
of individual for medical services received while in custody of law enforcement
officer
414.807 Department
to pay for medical services related to law enforcement activity; certification
of injury
414.815 Law
Enforcement Medical Liability Account; limited liability; rules; report
EXPANSION OF
414.825 Policy
414.831 Family
Health Insurance Assistance Program
414.839 Subsidies
for health insurance coverage
(Temporary provisions relating to Healthy Oregon Act are compiled as
notes following ORS 414.839)
414.001 [Repealed by 1953 c.378 §2]
414.002 [Repealed by 1953 c.378 §2]
414.003 [Repealed by 1953 c.378 §2]
414.004 [Repealed by 1953 c.378 §2]
414.005 [Repealed by 1953 c.378 §2]
414.006 [Repealed by 1953 c.378 §2]
414.007 [Repealed by 1953 c.378 §2]
414.008 [Repealed by 1953 c.378 §2]
414.009 [Repealed by 1953 c.378 §2]
414.010 [Repealed by 1953 c.378 §2]
414.011 [Repealed by 1953 c.378 §2]
414.012 [Repealed by 1953 c.378 §2]
414.013 [Repealed by 1953 c.378 §2]
414.014 [Repealed by 1953 c.378 §2]
414.015 [Repealed by 1953 c.30 §2]
414.016 [Repealed by 1953 c.30 §2]
414.017 [Repealed by 1953 c.30 §2]
414.018
Goals; findings. (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
(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 states 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. [1993 c.815 §1]
Note: 414.018 to 414.024 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.019
Laws comprising
Note: See note under 414.018.
414.020 [Repealed by 1953 c.204 §9]
414.021
Duties of administrator; staff; advisory committees; grants; meetings. (1) The Administrator of the Office for
Oregon Health Policy and Research shall be responsible for analyzing and
reporting on the implementation of the elements of the Oregon Health Plan that
are assigned to various state agencies, including but not limited to the
Department of Human Services and the Department of Consumer and Business
Services.
(2) The administrator shall administer the
Health Services Commission, the Medicaid Advisory Committee and the Health
Resources Commission and provide administrative support to the Oregon Health
Policy Commission. Pursuant to the responsibilities described in this
subsection and subsection (1) of this section, the administrator may review and
monitor the progress of the various activities that comprise
(3) The administrator shall employ such
staff or utilize such state agency personnel as are necessary to fulfill the
responsibilities and duties of the administrator. In addition, the
administrator may contract with third parties for technical and administrative
services necessary to carry out Oregon Health Plan activities where contracting
promotes economy, avoids duplication of effort and makes best use of available
expertise. The administrator may call upon other state agencies to provide
available information as necessary to assist the administrator in meeting the
responsibilities under ORS 414.018 to 414.024, 414.042, 414.107, 414.710,
414.720 and 735.712. The information shall be supplied as promptly as
circumstances permit.
(4) The Oregon Health Policy Commission
shall serve as the primary advisory committee to the administrator, the
Governor and the Legislative Assembly. The administrator also may appoint other
technical or advisory committees to assist the Oregon Health Policy Commission
in formulating its advice. Individuals appointed to any technical or other
advisory committee shall serve without compensation for their services as
members, but may be reimbursed for their travel expenses pursuant to ORS
292.495.
(5) The administrator may apply for,
receive and accept grants, gifts and other payments, including property and
services, from any governmental or other public or private entity or person and
may make arrangements for the use of these receipts, including the undertaking
of special studies and other projects relating to health care costs and access
to health care.
(6) The directors of the Departments of
Human Services and Consumer and Business Services and other state agency
personnel responsible for implementing elements of the Oregon Health Plan shall
cooperate fully with the administrator in carrying out their responsibilities
under the Oregon Health Plan.
(7) All health policy advisory committees
reporting to the Office for Oregon Health Policy and Research and all advisory
task forces on health policy appointed by the administrator shall report
directly to the Oregon Health Policy Commission.
(8)(a) ORS 192.610 to 192.690 apply to any
meeting of any technical or advisory committee or advisory task force with the
authority to make decisions for, conduct policy research for or make
recommendations to the Office for Oregon Health Policy and Research.
(b) Paragraph (a) of this subsection
applies only to meetings attended by two or more committee or task force
members who are not employed by a public body. [1993 c.815 §3; 1995 c.727 §19;
1997 c.683 §14; 1999 c.547 §5; 2003 c.47 §1; 2003 c.784 §6]
Note: See note under 414.018.
414.022
Provision of mental health services; goals; criteria; reports. Mental health services shall be provided by
the Department of Human Services, in collaboration with the Health Services
Commission, for the purpose of determining how best to serve the range of
mental health conditions statewide utilizing a capitated managed care system.
The services shall begin as soon as feasible following receipt of the necessary
waiver in anticipation that the services are to be available not later than
January 1, 1995, and shall cover up to 25 percent of state-funded mental health
services until July 1, 1997. After July 1, 1997, the services shall cover all
of the state-funded eligible mental health services. The provision of services
under this section shall support and be consistent with community mental health
and developmental disabilities programs established and operated or contracted
for under ORS chapter 430. The goals and criteria are:
(1) Test actuarial assumptions used to project
costs and utilization rates, and revise estimates of cost for statewide
implementation.
(2) Compare current medical assistance fee
for service with capitated managed care mental health system, using state
determined quality assurance standards to evaluate capacity, diagnosis,
utilization and treatment:
(a) Including components for testing full
integration of physical medicine and mental health services and measuring the
impact of mental health services on utilization of physical health services.
(b) Comparing current medical assistance
fee for service with capitated managed care system for utilization and length
of stay in private and public hospitals, and in nonhospital residential care
facilities.
(c) Comparing for specific conditions,
treatment configuration, effectiveness and disposition rates.
(3) Design the services to assure
geographic coverage of urban and rural areas including significant population
bases, and areas with and without existing capacity to provide fully capitated
managed care services including:
(a) Requiring providers to maintain and
report information about clients by type and amount of services in a
predetermined uniform format for comparison with state established quality
assurance standards.
(b) Within the geographic areas in which
services are provided, requiring providers to serve the full range of mental
health populations and conditions.
(c) Requiring providers to have the full
range of eligible mental health services available including, but not limited
to, assessment, case management, outpatient treatment and hospitalization.
(4) The department shall report to the
Emergency Board and other appropriate interim legislative committees and task
forces by October 1, 1996, on the implementation of the services. [1993 c.815 §29;
1995 c.806 §3; 1995 c.807 §4; 1999 c.835 §1; 2001 c.900 §100]
Note: See note under 414.018.
414.023
Chemical dependency services; goal. Chemical dependency services shall begin on January 1, 1995, to
operate through June 30, 1996, in the Department of Human Services for the
purpose of demonstrating the relationship of alcohol and drug services to the
costs of physical medicine. After July 1, 1996, the services shall cover all of
the eligible state-funded chemical dependency services. The goal of the
services is to reduce the inappropriate use of physical medicine by providing
treatment services in an integrated and managed care system. The services shall
consist of outpatient services only and may be either statewide or
geographically limited depending on the waiver agreement negotiated with the
federal government. [1993 c.815 §30; 1997 c.249 §128]
Note: See note under 414.018.
414.024
Guidelines for selecting areas for initial operation of programs. In the selection of any area of the state
for the initial operation of the programs authorized by ORS 414.018 to 414.024,
414.042, 414.107, 414.710, 414.720 and 735.712, the Administrator of the Office
for Oregon Health Policy and Research shall take into account the levels and
rates of unemployment in different areas of the state, the need to provide
basic health care coverage to a population reasonably representative of the
portion of the states population that lacks such coverage and the need for
geographic, demographic and economic diversity. [1993 c.815 §31; 1997 c.683 §15;
1999 c.547 §6]
Note: See note under 414.018.
414.025
Definitions. As used in this
chapter, unless the context or a specially applicable statutory definition
requires otherwise:
(1) 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) 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, 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, is in a
foster family home or licensed child-caring agency or institution under a
purchase of care agreement and is one for whom a public agency of this state is
assuming financial responsibility, in whole or in part.
(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; or is under the age of 22 years and is in a psychiatric
hospital.
(k) 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.
(L) Is a member of a family that received
aid under ORS 412.006 or 412.014 in at least three of the six months
immediately preceding the month in which the family 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.
(m) Is an adopted person under 21 years of
age for whom a public agency is assuming financial responsibility in whole or
in part.
(n) Is an individual or is a member of a
group who is required by federal law to be included in the states medical
assistance program in order for that program to qualify for federal funds.
(o) Is an individual or member of a group
who, subject to the rules of the department and within available funds, may
optionally be included in the states medical assistance program under federal
law and regulations concerning the availability of federal funds for the
expenses of that individual or group.
(p) 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.
(q) Except as otherwise provided in this
section and to the extent of available funds, is a pregnant woman or child for
whom federal financial participation is available under Title XIX of the
federal Social Security Act.
(r) 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 family investments and savings
equal less than the investments and savings limit established by the department
by rule.
(s) 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).
(3) Income has the meaning given that
term in ORS 411.704.
(4) 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) Medical assistance means so much of
the following medical and remedial care and services as may be prescribed by
the Department of Human Services 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 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 patients 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;
(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) 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.
(8) 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.
[1965 c.556 §2; 1967 c.502 §3; 1969 c.507 §1; 1971 c.488 §1; 1973 c.651 §10;
1974 c.16 §1; 1977 c.114 §1; 1981 c.825 §3; 1983 c.415 §3; 1985 c.747 §9; 1987
c.872 §1; 1989 c.697 §2; 1989 c.836 §19; 1991 c.66 §6; 1995 c.343 §42; 1995
c.807 §1; 1997 c.581 §22; 1999 c.59 §107; 1999 c.350 §1; 1999 c.515 §1; 2003
c.14 §188; 2005 c.381 §13; 2007 c.70 §190; 2007 c.486 §11; 2007 c.861 §18]
Note: The amendments to 414.025 by section 18a,
chapter 861,
414.025. As used in this chapter, unless the context
or a specially applicable statutory definition requires otherwise:
(1) 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) 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, 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, is in a
foster family home or licensed child-caring agency or institution under a
purchase of care agreement and is one for whom a public agency of this state is
assuming financial responsibility, in whole or in part.
(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; or is under the age of 22 years and is in a psychiatric
hospital.
(k) 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.
(L) 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.
(m) Is an adopted person under 21 years of
age for whom a public agency is assuming financial responsibility in whole or
in part.
(n) Is an individual or is a member of a
group who is required by federal law to be included in the states medical
assistance program in order for that program to qualify for federal funds.
(o) Is an individual or member of a group
who, subject to the rules of the department and within available funds, may
optionally be included in the states medical assistance program under federal
law and regulations concerning the availability of federal funds for the
expenses of that individual or group.
(p) 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.
(q) Except as otherwise provided in this
section and to the extent of available funds, is a pregnant woman or child for
whom federal financial participation is available under Title XIX of the
federal Social Security Act.
(r) 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 family investments and savings
equal less than the investments and savings limit established by the department
by rule.
(s) 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).
(3) Income has the meaning given that
term in ORS 411.704.
(4) 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) Medical assistance means so much of
the following medical and remedial care and services as may be prescribed by
the Department of Human Services 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 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 patients 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;
(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) 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.
(8) 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.
414.026 [2001 c.980 §2; renumbered 414.420 in 2005]
414.027 [2001 c.980 §3; renumbered 414.422 in 2005]
414.028 [Formerly 414.305; renumbered 414.426 in
2005]
414.029 [2003 c.76 §1; renumbered 414.428 in 2005]
414.030 [Repealed by 1953 c.204 §9]
MISCELLANEOUS
PROVISIONS
414.031
(2) If the commission has concerns
regarding a State Medicaid Plan amendment, a modification in Medicaid
operational protocols, an application for a waiver or adoption or amendment of
an administrative rule proposed by the department, the department shall
consider the concerns expressed by the commission during administrative
decision-making. [2003 c.784 §9]
Note: 414.031 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.032
Medical assistance to categorically needy and medically needy. Within the limits of funds available
therefor, medical assistance shall be made available to persons who are
categorically needy or medically needy. [1967 c.502 §4; 1985 c.747 §10]
414.033
Expenditures for medical assistance authorized. The Department of Human Services 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 providing medical assistance to
the medically needy and evaluates service delivery systems. [1991 c.66 §5]
414.034
Acceptance of federal billing, reimbursement and reporting forms. The Department of Human Services shall
accept federal Centers for Medicare and Medicaid Services billing,
reimbursement and reporting forms instead of department billing, reimbursement
and reporting forms if the federal forms contain substantially the same
information as required by the department forms. [2003 c.135 §1]
Note: 414.034 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.035 [1965 c.556 §1; repealed by 1967 c.502 §21]
414.036
Policy on persons without access to health services. (1) The Legislative Assembly finds that:
(a) Hundreds of thousands of Oregonians
have no health insurance or other coverage and lack the income and resources
needed to obtain health care;
(b) The number of persons without access
to health services increases dramatically during periods of high unemployment;
(c) Without health coverage, persons who
lack access to health services may receive treatment, but through costly,
inefficient, acute care;
(d) The unpaid cost of health services for
such persons is shifted to paying patients, driving up the cost of
hospitalization and health insurance for all Oregonians; and
(e) The states medical assistance program
is increasingly unable to fund the health care needs of low-income citizens.
(2) In order to provide access to health
services for those in need, to contain rising health services costs through
appropriate incentives to providers, payers and consumers, to reduce or
eliminate cost shifting and to promote the stability of the health services
delivery system and the health and well-being of all Oregonians, it is the
policy of the State of Oregon to provide medical assistance to those
individuals in need whose family income is below the federal poverty level and
who are eligible for services under the programs authorized by this chapter. [1983
c.415 §2; 1989 c.836 §1; 1991 c.753 §1]
414.037 [1967 c.502 §5; repealed by 1975 c.509 §2
(414.038 enacted in lieu of 414.037)]
PROCEDURE TO
OBTAIN MEDICAL ASSISTANCE
414.038
Medically needy program; determination of income. (1) Payments in behalf of medically needy
individuals may be made for a member of a family which has annual income within
the following levels:
(a) One hundred thirty-three and one-third
(133-1/3) percent of the highest money payment which would ordinarily be made
under the states ADC plan to a family of the same size without any income or
resources.
(b) In the case of a single individual, an
amount reasonably related to amounts payable to families consisting of two or
more individuals who are without income or resources.
(2) In computing a familys or individuals
income, as provided in subsection (1) of this section, any costs, whether in
the form of insurance premiums or otherwise, incurred by the family or
individual for medical care or for any other type of remedial care recognized
under state law may be excluded, except to the extent that they are reimbursed by
a third party. [1975 c.509 §§3,4 (enacted in lieu of 414.037)]
414.039
Medically needy program; rules.
(1) The Department of Human Services shall establish by rule a medically needy
program providing services to which the categorically eligible are entitled.
(2) These services shall be provided to
persons who meet categorical eligibility requirements, other than requirements
relating to income limitations. Maximum income eligibility for services through
the medically needy program shall be set at up to 133-1/3 percent of the
payment standard for temporary assistance for needy families eligibility, the
percent to be set by the department in consultation with the Legislative
Assembly. [1985 c.747 §12; 1989 c.31 §1; 1991 c.66 §7; 1997 c.581 §23]
414.040 [1953 c.204 §2; renumbered 414.810 and then
566.310]
414.042
Determination of need for and amount of medical assistance; rules. (1) The need for and the amount of medical
assistance to be made available for each eligible group of recipients of
medical assistance shall be determined, in accordance with the rules of the
Department of Human Services, taking into account:
(a) The requirements and needs of the
person, the spouse and other dependents;
(b) The income, resources and maintenance
available to the person but, except as provided in ORS 414.025 (2)(r),
resources shall be disregarded for those eligible by reason of having income
below the federal poverty level and who are eligible for medical assistance
only because of the enactment of chapter 836, Oregon Laws 1989;
(c) The responsibility of the spouse and,
with respect to a person who is blind or is permanently and totally disabled or
is under 21 years of age, the responsibility of the parents; and
(d) The report of the Health Services
Commission as funded by the Legislative Assembly and such other programs as the
Legislative Assembly may authorize. However, medical assistance, including
health services, shall not be provided to persons described in ORS 414.025
(2)(r) unless the Legislative Assembly specifically appropriates funds to
provide such assistance.
(2) Such amounts of income and resources
may be disregarded as the department may prescribe by rules, except that 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 persons home. Any
rule of the department inconsistent with this section is to that extent
invalid. The amounts to be disregarded shall be within the limits required or
permitted by federal law, rules or orders applicable thereto.
(3) In the determination of the amount of
medical assistance available to a medically needy person, all income and
resources available to the person in excess of the amounts prescribed in ORS
414.038, within limits prescribed by the department, shall be applied first to
costs of needed medical and remedial care and services not available under the
medical assistance program and then to the costs of benefits under the medical
assistance program. [1967 c.502 §6; 1971 c.503 §1; 1989 c.836 §20; 1991 c.66 §8;
1991 c.753 §2; 1993 c.815 §20; 1995 c.807 §2; 1997 c.581 §24; 2007 c.861 §21]
414.045 [1965 c.556 §3; repealed by 1967 c.502 §21]
414.047
Application for medical assistance. (1) Application for any category of aid shall also constitute
application for medical assistance.
(2) Except as otherwise provided in this
section, each person requesting medical assistance shall make application
therefor to the Department of Human Services. The department shall determine
eligibility for and fix the date on which such assistance may begin, and shall
obtain such other information required by the rules of the department.
(3) If an applicant is unable to make
application for medical assistance, an application may be made by someone
acting responsibly for the applicant. [1967 c.502 §7; 1969 c.68 §8; 1971 c.779 §46;
1991 c.66 §9; 2003 c.14 §189]
414.049
Documentation required for person applying for medical assistance under ORS
414.705 to 414.750. For each
person applying for health services under ORS 414.705 to 414.750, the
Department of Human Services shall fully document:
(1) The category of aid as defined in ORS
414.025 that makes the person eligible for medical assistance or the way in
which the person qualifies as categorically needy as defined in ORS 414.025;
(2) The status of the person as a resident
of this state; and
(3) The financial income and resources of
the person. [2003 c.810 §17]
Note: 414.049 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.050 [1953 c.204 §2; renumbered 414.820 and then
566.320]
414.051
Authorization and payment for dental services. The Department of Human Services shall
approve or deny prior authorization requests for dental services not later than
30 days after submission thereof by the provider, and shall make payments to
providers of prior authorized dental services not later than 30 days after
receipt of the invoice of the provider. [1979 c.296 §2; 1991 c.66 §10]
414.055
Hearing on eligibility. Any
individual whose claim for medical assistance is denied or is not acted upon
with reasonable promptness may petition the Department of Human Services for a
fair hearing. The hearing shall be held at a time and place and shall be
conducted in accordance with the rules of the department. [1965 c.556 §4; 1971
c.734 §45; 1971 c.779 §47; 1991 c.66 §11]
414.057
Notice of change in circumstances. Upon the receipt of property or income or upon any other change in
circumstances which directly affects the eligibility of the recipient to
receive medical assistance or the amount of medical assistance available to the
recipient, the recipient shall immediately notify the Department of Human
Services of the receipt or possession of such property or income, or other
change in circumstances. Failure to give the notice shall entitle the
Department of Human Services to recover from the recipient the amount of
assistance improperly disbursed by reason thereof. [1967 c.502 §8; 1971 c.779 §48;
1991 c.66 §12]
414.060 [1953 c.204 §3; renumbered 414.830 and then
566.330]
MEDICAL
ASSISTANCE
414.065
Determination of health services covered; standards; cost sharing; payments by
department as payment in full; rules. (1)(a) With respect to medical and remedial care and services to be
provided in medical assistance during any period, and within the limits of
funds available therefor, the Department of Human Services 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 care and services to be provided to each eligible group of recipients
of medical assistance.
(B) Standards to be observed in the
provision of medical and remedial care and services.
(C) The number of days of medical and
remedial 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 meeting the costs
of providing medical and remedial care and 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 department may require
a recipient to pay toward the cost of medical and remedial care or services.
(b) Notwithstanding ORS 414.720 (8), the
department 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 care and services and the amounts to be paid in meeting the costs
thereof, as determined and fixed by the department 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 care and
services in meeting the costs thereof.
(3) Except for payments under a
cost-sharing plan, payments made by the department for medical assistance shall
constitute payment in full for all medical and remedial 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. [1965 c.556 §5; 1967 c.502 §12; 1975 c.509 §5; 1981 c.825 §4; 1987 c.918
§4; 1989 c.836 §21; 1991 c.66 §13; 1991 c.753 §3; 1995 c.271 §1; 1995 c.807 §3;
1999 c.546 §1; 2001 c.875 §1; 2005 c.381 §14; 2005 c.806 §1]
414.070 [1953 c.204 §4; renumbered 414.840 and then
566.340]
414.073
Information on all licensed healing arts to be made available. When giving information concerning medical
assistance, the Department of Human Services shall make available to applicants
or recipients materials which include at least a listing of all the healing
arts licensed in this state. [1971 c.188 §2; 1991 c.66 §14]
414.075
Payment of deductibles imposed under federal law. Medical assistance provided to any
individual who is covered by the hospital insurance benefits or supplementary
health insurance benefits, or either of them, as established by federal law,
may include:
(1) The full amount of any deductible
imposed with respect to such individual under the hospital insurance benefits;
and
(2) All or any part of any deductible,
cost sharing, or similar charge imposed with respect to such individual under
the health insurance benefits. [1965 c.556 §§8,9; 1967 c.502 §13; 1977 c.114 §2]
414.080 [1953 c.204 §5; renumbered 414.850 and then
566.350]
414.085
Cooperative agreements authorized. (1) The Department of Human Services may enter into cooperative
arrangements with other state agencies and with public or private local
agencies:
(a) To establish and maintain standards
for private or public institutions in which recipients of medical assistance
may receive care or services.
(b) To obtain maximum utilization of
health services and vocational rehabilitation services in the provision of
medical assistance.
(c) To provide medical assistance in a
manner consistent with simplicity of administration and the best interests of the
recipients.
(d) To arrange for joint planning and for
development of alternate methods of care, making maximum utilization of
available resources, with respect to recipients with mental diseases or
tuberculosis, and to provide an individual plan for each such patient to assure
that the institutional care provided is in the best interests of the patient.
(e) To obtain satisfactory progress toward
attaining a comprehensive mental health program, utilizing community mental
health centers, nursing homes and other alternatives to care in a public
institution for mental diseases.
(2) Nothing in subsection (1) of this
section shall be construed to impose upon or grant to the department
responsibility or authority for state programs relating to standards, licensing,
vocational rehabilitation, mental health or tuberculosis not otherwise
expressly so imposed or granted by law. [1965 c.556 §10; 1991 c.66 §15]
414.090 [1953 c.204 §6; renumbered 414.860 and then
566.360]
414.095
Exemptions applicable to payments. Neither medical assistance nor amounts payable to vendors out of
public assistance funds are transferable or assignable at law or in equity and
none of the money paid or payable under the provisions of this chapter is
subject to execution, levy, attachment, garnishment or other legal process. [1965
c.556 §11; 1967 c.502 §14; 2001 c.900 §222]
414.105
Recovery of medical assistance; estate claims; transfer of assets; rules. (1) The Department of Human Services may
recover from any person the amounts of medical assistance incorrectly paid on
behalf of such person.
(2) Medical assistance pursuant to this
chapter paid on behalf of an individual who was 55 years of age or older when
the individual received such assistance, or paid on behalf of a person of any
age who was a permanently institutionalized inpatient in a nursing facility,
intermediate care facility for persons with mental retardation or other medical
institution, may be recovered from the estate of the individual or from any
recipient of property or other assets held by the individual at the time of
death including the estate of the surviving spouse. Claim for such medical
assistance correctly paid to the individual may be established against the
estate, but there shall be no adjustment or recovery thereof until after the
death of the surviving spouse, if any, and only at a time when the individual
has no surviving child who is under 21 years of age or who is blind or
permanently and totally disabled. Transfers of real or personal property by recipients
of such aid without adequate consideration are voidable and may be set aside
under ORS 411.620 (2).
(3) Nothing in this section authorizes the
recovery of the amount of any aid from the estate or surviving spouse of a
recipient to the extent that the need for aid resulted from a crime committed
against the recipient.
(4) In any action or proceeding under this
section to recover medical assistance paid, it shall be the legal burden of the
person who receives the property or other assets from a Medicaid recipient to
establish the extent and value of the Medicaid recipients legal title or
interest in the property or assets in accordance with rules established by the
department.
(5) As used in this section, estate
includes all real and personal property and other assets in which the deceased
individual had any legal title or interest at the time of death including
assets conveyed to a survivor, heir or assign of the deceased individual
through joint tenancy, tenancy in common, survivorship, life estate, living
trust or other similar arrangement. [1965 c.556 §12; 1967 c.502 §15; 1969 c.507
§2; 1971 c.334 §1; 1973 c.334 §1; part renumbered 416.280; 1975 c.386 §4; 1985
c.522 §4; 1991 c.66 §16; 1993 c.249 §5; 1995 c.642 §1; 2001 c.620 §5; 2001
c.900 §223; 2007 c.70 §191]
414.106
Possible limitation on recovery of certain medical assistance; federal law. (1) Subject to the requirements of
subsection (2) of this section, if 42 U.S.C. 1396p (b)(1)(B) as in effect on
January 1, 1995, is repealed without replacement or is declared
unconstitutional, the Director of Human Services shall limit the recovery of
medical assistance paid pursuant to ORS chapter 414 from the estate of an
individual or a recipient of property or other assets held by an individual at
the time of death, including a surviving spouse of the individual, to the
recovery of medical assistance payments paid on behalf of the individual on or
after the date that the individual attained 65 years of age.
(2) The director shall limit the recovery
of medical assistance as described under subsection (1) of this section only if
the director determines, after receiving the written opinion of the Attorney
General, that the recovery limitation will not violate any federal law in
effect on the operative date of the recovery limitation. The director may
condition, limit, modify or terminate any recovery limitation as the director
considers necessary to avoid a violation of federal law. [1995 c.642 §2; 2001
c.900 §224]
Note: 414.106 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.107
Entitlement to mental health care and chemical dependency services. Until such time as mental health care and
chemical dependency services are integrated into the Health Services Commission
priority list and the integrated list is funded by the Legislative Assembly and
the necessary federal waivers are obtained, persons eligible for care and
treatment under this chapter shall be entitled to such care and services. [1991
c.753 §5a; 1993 c.815 §15]
Note: 414.107 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 by
legislative action. See Preface to Oregon Revised Statutes for further
explanation.
414.109
(2) Moneys in the Oregon Health Plan Fund
are continuously appropriated to the Department of Human Services for the
purposes of funding the maintenance and expansion of the number of persons
eligible for medical assistance under the Oregon Health Plan and funding the
maintenance of the benefits available under the Oregon Health Plan. [2002 s.s.3
c.2 §9]
Note: 414.109 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
INSURANCE AND
SERVICE CONTRACTS
414.115
Medical assistance by insurance or service contracts; rules. (1) In lieu of providing one or more of the
medical and remedial care and services available under medical assistance by
direct payments to providers thereof and in lieu of providing such medical and
remedial care and services made available pursuant to ORS 414.065, the Department
of Human Services 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 care and services available
under medical assistance for the benefit of the categorically needy or the
medically needy, or both. Notwithstanding other specific provisions, the use of
available medical assistance funds to purchase medical or remedial 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 department; 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 department must guarantee:
(a) To provide medical and remedial 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 care and services the amount due, based on the number 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 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 care and services to the department as may be
required by the department for its records, reports and audits. [1967 c.502 §9;
1975 c.401 §1; 1981 c.825 §5; 1991 c.66 §17]
414.125
Rates on insurance or service contracts; requirements for insurer or
contractor. (1) Any payment
of available medical assistance funds for policies of insurance or service
contracts shall be according to such uniform area-wide rates as the Department
of Human Services shall have established and which it may revise from time to
time as may be necessary or practical, except that, in the case of a research
and demonstration project entered into under ORS 411.135 special rates may be
established.
(2) No premium or other periodic charge on
any policy of insurance, health care service contract, or medical or hospital
service contract shall be paid from available medical assistance funds unless
the insurer or contractor issuing such policy or contract is by law authorized
to transact business as an insurance company, health care service contractor or
hospital association in this state. [1967 c.502 §10; 1975 c.509 §6; 1991 c.66 §18]
414.135
Contracts relating to direct providers of care and services. The Department of Human Services may enter
into nonexclusive contracts under which funds available for medical assistance
may be administered and disbursed by the contractor to direct providers of
medical and remedial care and services available under medical assistance in
consideration of services rendered and supplies furnished by them in accordance
with the provisions of this chapter. Payment shall be made according to the
rules of the department pursuant to the number of days and the fees, charges
and costs established under ORS 414.065. The contractor must guarantee the
department by written acknowledgment:
(1) To make all payments under this
chapter promptly but not later than 30 days after receipt of the proper
evidence establishing the validity of the providers claim.
(2) To provide such data, records and
reports to the department as may be required by the department. [1967 c.502 §11;
1991 c.66 §19]
414.145
Implementation of ORS 414.115, 414.125 or 414.135. (1) The provisions of ORS 414.115, 414.125
or 414.135 shall be implemented whenever it appears to the Department of Human
Services that such implementation will provide comparable benefits at equal or
less cost than provision thereof by direct payments by the department to the
providers of medical assistance, but in no case greater than the legislatively
approved budgeted cost per eligible recipient at the time of contracting.
(2) When determining comparable benefits
at equal or less cost as provided in subsection (1) of this section, the
department must take into consideration the recipients need for reasonable
access to preventive and remedial care, and the contractors ability to assure
continuous quality delivery of both routine and emergency services. [1967 c.502
§11a; 1975 c.401 §3; 1983 c.590 §9; 1985 c.747 §12a; 1991 c.66 §20]
STATE AND
LOCAL PUBLIC HEALTH PARTNERSHIP
414.150
Purpose of ORS 414.150 to 414.153. It is the purpose of ORS 414.150 to 414.153 to take advantage of
opportunities to:
(1) Enhance the state and local public
health partnership;
(2) Improve the access to care and health
status of women and children; and
(3) Strengthen public health programs and
services at the county health department level. [1991 c.337 §1]
Note: 414.150 to 414.153 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 by legislative action. See Preface to Oregon Revised Statutes for further
explanation.
414.151
Enrollment of poverty level medical assistance program clients; agreements with
local governments. The
Department of Human Services shall endeavor to develop agreements with local
governments to facilitate the enrollment of poverty level medical assistance
program clients. Subject to the availability of funds therefor, the agreement
shall be structured to allow flexibility by the state and local governments and
may allow any of the following options for enrolling clients in poverty level
medical assistance programs:
(1) Initial processing shall be done at
the county health department by employees of the county, with eligibility
determination completed at the local office of the Department of Human
Services;
(2) Initial processing and eligibility
determination shall be done at the county health department by employees of the
local health department; or
(3) Application forms shall be made
available at the county health department with initial processing and eligibility
determination shall be done at the local office of the Department of Human
Services. [1991 c.337 §2; 1993 c.18 §100; 2001 c.900 §101]
Note: See note under 414.150.
414.152
Duties of state agencies. To
capitalize on the successful public health programs provided by county health
departments and the sizable investment by state and local governments in the
public health system, state agencies shall encourage agreements that allow
county health departments and other publicly supported programs to continue to
be the providers of those prevention and health promotion services now
available, plus other maternal and child health services such as prenatal
outreach and care, child health services and family planning services to women
and children who become eligible for poverty level medical assistance program
benefits pursuant to ORS 414.153. [1991 c.337 §3]
Note: See note under 414.150.
414.153
Authorization for payment for certain services. In order to make advantageous use of the
system of public health services available through county health departments
and other publicly supported programs and to insure access to public health
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 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 to receive from fee-for-service providers:
(a) Family planning services;
(b) Human immunodeficiency virus and
acquired immune deficiency syndrome prevention services; and
(c) Maternity case management if the
Department of Human Services determines that a prepaid plan cannot adequately
provide the services;
(3) Encourage and approve agreements
between prepaid health plans 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 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. [1991 c.337 §4; 1993 c.592 §1]
Note: See note under 414.150.
414.205 [1967 c.502 §18; 1981 c.825 §1; repealed by
1995 c.727 §48]
414.210 [1957 c.692 §1; repealed by 1963 c.631 §2]
ADVISORY
COMMITTEES
414.211
Medicaid Advisory Committee.
(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 Human Services or
designee;
(e) Health care providers;
(f) Persons associated with health care
organizations, including but not limited to managed care plans 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 Public Welfare Account. [1995 c.727 §43;
2007 c.70 §192]
Note: 414.211 and 414.221 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.215 [1967 c.502 §19; 1991 c.66 §21; repealed by
1995 c.727 §48]
414.220 [1957 c.692 §2; repealed by 1963 c.631 §2]
414.221
Duties of committee. The
Medicaid Advisory Committee shall advise the Administrator of the Office for
Oregon Health Policy and Research and the Director of Human Services on:
(1) Medical care, including mental health
and alcohol and drug treatment and remedial care to be provided under ORS
chapter 414; and
(2) The operation and administration of
programs provided under ORS chapter 414. [1995 c.727 §44; 2003 c.784 §7; 2007
c.697 §16]
Note: See note under 414.211.
414.225
Department to consult with committee. The Department of Human Services shall consult with the Medicaid
Advisory Committee concerning the determinations required under ORS 414.065. [1967
c.502 §20; 1991 c.66 §22; 1995 c.727 §46; 2003 c.784 §8]
414.227
Application of public meetings law to advisory committees. (1) ORS 192.610 to 192.690 apply to any
meeting of an advisory committee with the authority to make decisions for,
conduct policy research for or make recommendations to the Department of Human
Services on administration or policy related to the medical assistance program
operated under this chapter.
(2) Subsection (1) of this section applies
only to advisory committee meetings attended by two or more advisory committee
members who are not employed by a public body. [2001 c.353 §2]
414.230 [1957 c.692 §5; repealed by 1963 c.631 §2]
414.240 [1957 c.692 §3; repealed by 1963 c.631 §2]
414.250 [1957 c.692 §4; repealed by 1963 c.631 §2]
414.260 [1957 c.692 §6; repealed by 1963 c.631 §2]
414.270 [1957 c.692 §7(1); repealed by 1963 c.631 §2]
414.280 [1957 c.692 §7(2); repealed by 1963 c.631 §2]
414.290 [1957 c.692 §7(3); repealed by 1963 c.631 §2]
414.300 [1957 c.692 §8; repealed by 1963 c.631 §2]
414.305 [1969 c.507 §3; 1971 c.33 §1; 1977 c.384 §5;
1991 c.66 §23; 2001 c.900 §102; renumbered 414.028 in 2001]
414.310 [1957 c.692 §9; 1961 c.130 §2; repealed by
1963 c.631 §2]
PRESCRIPTION
DRUGS
(
414.312
(a) Pharmacy benefit manager means an
entity that, in addition to being a prescription drug claims processor,
negotiates and executes contracts with pharmacies, manages preferred drug
lists, negotiates rebates with prescription drug manufacturers and serves as an
intermediary between the Oregon Prescription Drug Program, prescription drug
manufacturers and pharmacies.
(b) Prescription drug claims processor
means an entity that processes and pays prescription drug claims, adjudicates
pharmacy claims, transmits prescription drug prices and claims data between
pharmacies and the Oregon Prescription Drug Program and processes related
payments to pharmacies.
(c) Program price means the reimbursement
rates and prescription drug prices established by the administrator of the
Oregon Prescription Drug Program.
(2) The Oregon Prescription Drug Program
is established in the Department of Human Services. The purpose of the program
is to:
(a) Purchase prescription drugs or
reimburse pharmacies for prescription drugs in order to receive discounted
prices and rebates;
(b) Make prescription drugs available at
the lowest possible cost to participants in the program; and
(c) Maintain a list of prescription drugs
recommended as the most effective prescription drugs available at the best
possible prices.
(3) The Director of Human Services shall
appoint an administrator of the Oregon Prescription Drug Program. The
administrator shall:
(a) Negotiate price discounts and rebates
on prescription drugs with prescription drug manufacturers;
(b) Purchase prescription drugs on behalf
of individuals and entities that participate in the program;
(c) Contract with a prescription drug
claims processor to adjudicate pharmacy claims and transmit program prices to
pharmacies;
(d) Determine program prices and reimburse
pharmacies for prescription drugs;
(e) Adopt and implement a preferred drug
list for the program;
(f) Develop a system for allocating and
distributing the operational costs of the program and any rebates obtained to
participants of the program; and
(g) Cooperate with other states or
regional consortia in the bulk purchase of prescription drugs.
(4) The following individuals or entities
may participate in the program:
(a) Public Employees Benefit Board;
(b) Local governments as defined in ORS
174.116 and special government bodies as defined in ORS 174.117 that directly
or indirectly purchase prescription drugs;
(c) Enrollees in the Senior Prescription
Drug Assistance Program created under ORS 414.342;
(d) Oregon Health and
(e) State agencies that directly or
indirectly purchase prescription drugs, including agencies that dispense
prescription drugs directly to persons in state-operated facilities;
(f) Residents of this state who lack or
are underinsured for prescription drug coverage;
(g) Private entities; and
(h) Labor organizations.
(5) The state agency that receives federal
Medicaid funds and is responsible for implementing the states medical
assistance program may not participate in the program.
(6) The administrator may establish
different reimbursement rates or prescription drug prices for pharmacies in
rural areas to maintain statewide access to the program.
(7) The administrator shall establish the
terms and conditions for a pharmacy to enroll in the program. A licensed
pharmacy that is willing to accept the terms and conditions established by the
administrator may apply to enroll in the program.
(8) Except as provided in subsection (9)
of this section, the administrator may not:
(a) Contract with a pharmacy benefit
manager;
(b) Establish a state-managed wholesale or
retail drug distribution or dispensing system; or
(c) Require pharmacies to maintain or
allocate separate inventories for prescription drugs dispensed through the
program.
(9) The administrator shall contract with
one or more entities to provide the functions of a prescription drug claims
processor. The administrator may also contract with a pharmacy benefit manager
to negotiate with prescription drug manufacturers on behalf of the
administrator.
(10) Notwithstanding subsection (4)(f) of
this section, individuals who are eligible for Medicare Part D prescription
drug coverage may participate in the program. [2003 c.714 §1; 2007 c.2 §1; 2007
c.67 §1; 2007 c.697 §17]
Note: 414.312 to 414.320 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.314
Application and participation in
(2) The department shall provide a
mechanism to calculate and transmit the program prices for prescription drugs
to a pharmacy. The pharmacy shall charge the participant the program price for
a prescription drug.
(3) A pharmacy may charge the participant
the professional dispensing fee set by the department.
(4) Prescription drug identification cards
issued under this section must contain the information necessary for proper
claims adjudication or transmission of price data. [2003 c.714 §2; 2007 c.67 §2;
2007 c.697 §18]
Note: See note under 414.312.
414.316
Preferred drug list for
Note: See note under 414.312.
414.318
Prescription Drug Purchasing Fund. The Prescription Drug Purchasing Fund is established separate and
distinct from the General Fund. The Prescription Drug Purchasing Fund shall
consist of moneys appropriated to the fund by the Legislative Assembly and
moneys received by the Department of Human Services for the purposes
established in this section in the form of gifts, grants, bequests, endowments
or donations. The moneys in the Prescription Drug Purchasing Fund are
continuously appropriated to the department and shall be used to purchase
prescription drugs, reimburse pharmacies for prescription drugs and reimburse
the department for the costs of administering the Oregon Prescription Drug
Program, including contracted services costs, computer costs, professional dispensing
fees paid to retail pharmacies and other reasonable program costs. Interest
earned on the fund shall be credited to the fund. [2003 c.714 §4; 2007 c.697 §20]
Note: See note under 414.312.
414.320
Rules. The Department of
Human Services shall adopt rules to implement and administer ORS 414.312 to
414.318. The rules shall include but are not limited to establishing procedures
for:
(1) Issuing prescription drug
identification cards to individuals and entities that participate in the Oregon
Prescription Drug Program; and
(2) Enrolling pharmacies in the program. [2003
c.714 §5; 2007 c.697 §21]
Note: See note under 414.312.
(Prescription
Drug Coverage by Medical Assistance)
414.325
Prescription drugs; use of legend or generic drugs; prior authorization; rules. (1) As used in this section, legend drug
means any drug requiring a prescription by a practitioner, as defined in ORS
689.005.
(2) A licensed practitioner may prescribe
such drugs under this chapter as the practitioner in the exercise of
professional judgment considers appropriate for the diagnosis or treatment of
the patient in the practitioners care and within the scope of practice.
Prescriptions shall be dispensed in the generic form pursuant to ORS 689.515
and pursuant to rules of the Department of Human Services unless the
practitioner prescribes otherwise and an exception is granted by the
department.
(3) Except as provided in subsections (4)
and (5) of this section, the department shall place no limit on the type of
legend drug that may be prescribed by a practitioner, but the department shall
pay only for drugs in the generic form unless an exception has been granted by
the department.
(4) Notwithstanding subsection (3) of this
section, an exception must be applied for and granted before the department is
required to pay for minor tranquilizers and amphetamines and amphetamine
derivatives, as defined by rule of the department.
(5)(a) Notwithstanding subsections (1) to
(4) of this section and except as provided in paragraph (b) of this subsection,
the department is authorized to:
(A) Withhold payment for a legend drug
when federal financial participation is not available; and
(B) Require prior authorization of payment
for drugs that the department has determined should be limited to those
conditions generally recognized as appropriate by the medical profession.
(b) The department may not require prior
authorization for therapeutic classes of nonsedating antihistamines and nasal
inhalers, as defined by rule by the department, when prescribed by an allergist
for treatment of any of the following conditions, as described by the Health
Services Commission on the funded portion of its prioritized list of services:
(A) Asthma;
(B) Sinusitis;
(C) Rhinitis; or
(D) Allergies.
(6)(a) The department shall pay a rural
health clinic for a legend drug prescribed and dispensed under this chapter by
a licensed practitioner at the rural health clinic for an urgent medical
condition if:
(A) There is not a pharmacy within 15
miles of the clinic;
(B) The prescription is dispensed for a
patient outside of the normal business hours of any pharmacy within 15 miles of
the clinic; or
(C) No pharmacy within 15 miles of the
clinic dispenses legend drugs under this chapter.
(b) As used in this subsection, urgent
medical condition means a medical condition that arises suddenly, is not
life-threatening and requires prompt treatment to avoid the development of more
serious medical problems.
(7) Notwithstanding ORS 414.334, the
department may conduct prospective drug utilization review prior to payment for
drugs for a patient whose prescription drug use exceeded 15 drugs in the
preceding six-month period.
(8) Notwithstanding subsection (3) of this
section, the department may pay a pharmacy for a particular brand name drug
rather than the generic version of the drug after notifying the pharmacy that
the cost of the particular brand name drug, after receiving discounted prices
and rebates, is equal to or less than the cost of the generic version of the drug.
[1977 c.818 §§2,3; 1979 c.777 §45; 1979 c.785 §3; 1983 c.608 §2; 1999 c.529 §1;
2001 c.897 §§5,6; 2003 c.14 §§190,191; 2003 c.91 §§1,2; 2003 c.810 §§20,21;
2005 c.692 §§8,9]
414.327
Electronically transmitted prescriptions; federal waiver; rules. (1) The Department of Human Services shall
seek a waiver from the federal Centers for Medicare and Medicaid Services to
allow the department to communicate prescription drug orders by electronic
means from a practitioner authorized to prescribe drugs directly to the
dispensing pharmacist.
(2) The Department of Human Services shall
adopt rules permitting the department to communicate prescription drug orders
by electronic means from a practitioner authorized to prescribe drugs directly
to the dispensing pharmacist. [2001 c.623 §8; 2003 c.14 §192]
Note: 414.327 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.329
Prescription drug benefits for certain persons who are eligible for Medicare
Part D prescription drug coverage; rules. (1) Notwithstanding ORS 414.705 to 414.750, the Department of Human
Services shall adopt rules modifying the prescription drug benefits for persons
who are eligible for Medicare Part D prescription drug coverage and who receive
prescription drug benefits under the state medical assistance program or Title
XIX of the Social Security Act. The rules shall include but need not be limited
to:
(a) Identification of the Part D classes
of drugs for which federal financial participation is not available and that
are not covered classes of drugs;
(b) Identification of the Part D classes
of drugs for which federal financial participation is not available and that
are covered classes of drugs;
(c) Identification of the classes of drugs
not covered under Medicare Part D prescription drug coverage for which federal
financial participation is available and that are covered classes of drugs; and
(d) Cost-sharing obligations related to
the provision of Part D classes of drugs for which federal financial
participation is not available.
(2) As used in this section, covered
classes of drugs means classes of prescription drugs provided to persons
eligible for prescription drug coverage under the state medical assistance
program or Title XIX of the Social Security Act. [2005 c.754 §1]
Note: 414.329 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
(Practitioner-Managed
Prescription Drug Plan)
414.330
Legislative findings on prescription drugs. The Legislative Assembly finds that:
(1) The cost of prescription drugs in the
Oregon Health Plan is growing and will soon be unsustainable;
(2) The benefit of prescription drugs when
appropriately used decreases the need for other expensive treatments and
improves the health of Oregonians; and
(3) Providing the most effective drugs in
the most cost-effective manner will benefit both patients and taxpayers. [2001
c.897 §1]
Note: 414.330 to 414.334 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.332
Policy for Practitioner-Managed Prescription Drug Plan. It is the policy of the State of
(1) Oregonians have access to the most
effective prescription drugs appropriate for their clinical conditions;
(2) Decisions concerning the clinical
effectiveness of prescription drugs are made by licensed health practitioners,
are informed by the latest peer-reviewed research and consider the health
condition of a patient or characteristics of a patient, including the patients
gender, race or ethnicity; and
(3) The cost of prescription drugs in the
Oregon Health Plan is managed through market competition among pharmaceutical
manufacturers by publicly considering, first, the effectiveness of a given drug
and, second, its relative cost. [2001 c.897 §2]
Note: See note under 414.330.
414.334
Practitioner-Managed Prescription Drug Plan for
(2) Before adopting the plan, the
department shall conduct public meetings and consult with the Health Resources
Commission.
(3) The department shall consult with
representatives of the regulatory boards and associations representing
practitioners who are prescribers under the Oregon Health Plan and ensure that
practitioners receive educational materials and have access to training on the
Practitioner-Managed Prescription Drug Plan.
(4) Notwithstanding the
Practitioner-Managed Prescription Drug Plan adopted by the department, a
practitioner may prescribe any drug that the practitioner indicates is
medically necessary for an enrollee as being the most effective available.
(5) An enrollee may appeal to the
department a decision of a practitioner or the department to not provide a
prescription drug requested by the enrollee.
(6) This section does not limit the
decision of a practitioner as to the scope and duration of treatment of chronic
conditions, including but not limited to arthritis, diabetes and asthma. [2001
c.897 §3]
Note: See note under 414.330.
414.336
Limitation on rules regarding Practitioner-Managed Prescription Drug Plan. The Department of Human Services may not
adopt or amend any rule that requires a prescribing practitioner to contact the
department to request an exception for a medically appropriate or medically
necessary drug that is not listed on the Practitioner-Managed Prescription Drug
Plan drug list for that class of drugs adopted under ORS 414.334, unless
otherwise authorized by enabling legislation setting forth the requirement for
prior authorization. [2003 c.810 §22]
Note: 414.336 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
(Patient
Prescription Drug Assistance Program)
414.338
Patient Prescription Drug Assistance Program;
(2) The program shall:
(a) Provide information on:
(A) Eligibility requirements and coverage
provided by publicly funded prescription drug benefit programs administered by
the Department of Human Services; and
(B) The process for applying to receive
publicly funded prescription drug benefits;
(b) Assist a patient in applying to
pharmaceutical companies for free or discounted prescription drug medications
if the patient is not eligible for any publicly funded prescription drug
benefit program;
(c) Provide information, in an organized
and easily understood manner, to patients, physicians, pharmacists and
pharmacies regarding patient qualifications for prescription drug assistance
programs;
(d) Increase awareness of the various
prescription drug assistance programs offered by pharmaceutical companies; and
(e) Establish a toll-free hotline and
Internet website to increase public awareness of the Patient Prescription Drug
Assistance Program and to provide public access to the information and services
provided through the program.
(3)(a) The
(b) For periods on or after July 1, 2003,
the Department of Human Services may contract with any pharmacy provider to
operate the Patient Prescription Drug Assistance Program. [2001 c.869 §1]
Note: 414.338 to 414.348 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
(Senior
Prescription Drug Assistance Program)
414.340
Definitions for ORS 414.340, 414.342 and 414.348. As used in this section and ORS 414.342 and
414.348:
(1) Eligible person means a resident of
this state who:
(a) Is 65 years of age or older;
(b) Has a gross annual income that does
not exceed the lesser of the maximum amount established by the Department of
Human Services by rule or 185 percent of the federal poverty guidelines;
(c) Has not been covered under any public
or private prescription drug benefit program for the previous six months; and
(d) Has less than $2,000 in resources.
(2) Enrollee means a person who has been
found to be eligible for the Senior Prescription Drug Assistance Program, who
has paid an enrollment fee of up to $50 and who has a Senior Prescription Drug
Assistance Program enrollment card issued by the Department of Human Services.
(3) Federal poverty guidelines means the
most recent poverty guidelines as published annually in the Federal Register by
the United States Department of Health and Human Services.
(4) Income has the meaning given that
term in ORS 411.704.
(5) Resources includes but is not
limited to cash, checking and savings accounts, certificates of deposit, money
market funds, stocks and bonds. Resources does not include the primary
residence or car of an eligible person.
(6) Senior Prescription Drug Assistance
Program price means the price of a prescription drug paid by an enrollee that
is equal to or less than the Medicaid price. [2001 c.869 §3; 2005 c.381 §15]
Note: See note under 414.338.
414.342
Senior Prescription Drug Assistance Program; application and enrollment;
enrollment fee; critical access pharmacies; rules. (1) The Senior Prescription Drug Assistance
Program is created in the Department of Human Services. The purpose of the
program is to provide financial assistance to eligible persons for the purchase
of prescription drugs.
(2) A pharmacy shall charge an enrollee
the Senior Prescription Drug Assistance Program price for a prescription drug
upon presentation of a Senior Prescription Drug Assistance Program enrollment
card.
(3) A pharmacy may charge the enrollee an
amount established by the Department of Human Services to cover the professional
dispensing fee, which may not exceed the fee paid by the state Medicaid
program.
(4) This section does not apply to
over-the-counter medications.
(5) The department shall provide a
mechanism to calculate and transmit the Senior Prescription Drug Assistance
Program price to the pharmacy.
(6) A person seeking to participate in the
Senior Prescription Drug Assistance Program shall apply annually by completing
and mailing a one-page application and including payment of an enrollment fee
established by the department, not to exceed $50. The department shall issue an
enrollment card annually to enrollees of the program. Each individuals
application shall be considered separately, regardless of the number of persons
in the individuals household.
(7) The maximum prescription drug
assistance available annually to an enrollee is $2,000.
(8) Subject to funds available, the
Department of Human Services may adjust the Senior Prescription Drug Assistance
Program price to subsidize up to 50 percent of the Medicaid price of the
prescription drug, using a sliding scale based on the income and resources of
an enrollee.
(9)(a) The department shall adopt rules
that:
(A) Identify critical access pharmacies;
and
(B) Provide for additional reimbursement
to critical access pharmacies that participate in the Senior Prescription Drug
Assistance Program.
(b) In addition, a critical access
pharmacy may charge an enrollee a fee of not more than $2 per prescription. The
$2 charge shall be annually adjusted for inflation using the U.S. City Average
Consumer Price Index, as defined in ORS 316.037. [2001 c.869 §4]
Note: See note under 414.338.
414.344
Contracts to provide services under Senior Prescription Drug Assistance
Program. The Department of
Human Services may contract with a pharmacy provider or a pharmacy benefits
manager to provide services under the Senior Prescription Drug Assistance
Program established under ORS 414.342. [2001 c.869 §10]
Note: See note under 414.338.
414.346
Rules. The Department of Human
Services shall adopt rules necessary to implement ORS 414.342. [2001 c.869 §8]
Note: See note under 414.338.
414.348
Senior Prescription Drug Assistance Fund. The Senior Prescription Drug Assistance Fund is established separate
and distinct from the General Fund. The Senior Prescription Drug Assistance
Fund may receive any appropriations, allocations, federal moneys or gifts
designated for the Senior Prescription Drug Assistance Program. The moneys in
the Senior Prescription Drug Assistance Fund are continuously appropriated to
the Department of Human Services and shall be used to reimburse retail
pharmacies for subsidized prices provided to enrollees and to reimburse the
department for the costs of administering the program, including contracted services
costs, computer costs, professional fees paid to retail pharmacies and other
reasonable program costs. Interest earned on the fund accrues to the fund. [2001
c.869 §6; 2005 c.22 §285]
Note: See note under 414.338.
DRUG USE
REVIEW BOARD
414.350
Definitions for ORS 414.350 to 414.415. As used in ORS 414.350 to 414.415:
(1) Appropriate and medically necessary
use means drug prescribing, drug dispensing and patient medication usage in
conformity with the criteria and standards developed under ORS 414.350 to
414.415.
(2) Board means the Drug Use Review
Board created under ORS 414.355.
(3) Compendia means those resources
widely accepted by the medical profession in the efficacious use of drugs,
including the following sources:
(a) The American Hospital Formulary
Services drug information.
(b) The United States Pharmacopeia drug
information.
(c) The American Medical Association drug
evaluations.
(d) The peer-reviewed medical literature.
(e) Drug therapy information provided by
manufacturers of drug products consistent with the federal Food and Drug
Administration requirements.
(4) Counseling means the effective
communication of information by a pharmacist, as defined by rules of the State
Board of Pharmacy.
(5) Criteria means the predetermined and
explicitly accepted elements based on the compendia that are used to measure
drug use on an ongoing basis to determine if the use is appropriate, medically
necessary and not likely to result in adverse medical outcomes.
(6) Drug-disease contraindication means
the potential for, or the occurrence of, an undesirable alteration of the
therapeutic effect of a given prescription because of the presence, in the
patient for whom it is prescribed, of a disease condition or the potential for,
or the occurrence of, a clinically significant adverse effect of the drug on
the patients disease condition.
(7) Drug-drug interaction means the
pharmacological or clinical response to the administration of at least two
drugs different from that response anticipated from the known effects of the
two drugs when given alone, which may manifest clinically as antagonism,
synergism or idiosyncrasy. Such interactions have the potential to have an
adverse effect on the individual or lead to a clinically significant adverse
reaction, or both, that:
(a) Is characteristic of one or any of the
drugs present; or
(b) Leads to interference with the
absorption, distribution, metabolizing, excretion or therapeutic efficacy of
one or any of the drugs.
(8) Drug use review means the programs
designed to measure and assess on a retrospective and a prospective basis,
through an evaluation of claims data, the proper utilization, quantity,
appropriateness as therapy and medical necessity of prescribed medication in
the medical assistance program.
(9) Intervention means an action taken
by the Department of Human Services with a prescriber or pharmacist to inform
about or to influence prescribing or dispensing practices or utilization of
drugs.
(10) Overutilization means the use of a
drug in quantities or for durations that put the recipient at risk of an
adverse medical result.
(11) Pharmacist means an individual who
is licensed as a pharmacist under ORS chapter 689.
(12) Prescriber means any person
authorized by law to prescribe drugs.
(13) Prospective program means the
prospective drug use review program described in ORS 414.375.
(14) Retrospective program means the
retrospective drug use review program described in ORS 414.380.
(15) Standards means the acceptable
prescribing and dispensing methods determined by the compendia, in accordance
with local standards of medical practice for health care providers.
(16) Therapeutic appropriateness means
drug prescribing based on scientifically based and clinically relevant drug
therapy that is consistent with the criteria and standards developed under ORS
414.350 to 414.415.
(17) Therapeutic duplication means the
prescribing and dispensing of two or more drugs from the same therapeutic class
such that the combined daily dose puts the recipient at risk of an adverse
medical result or incurs additional program costs without additional
therapeutic benefits.
(18) Underutilization means that a drug
is used by a recipient in insufficient quantity to achieve a desired therapeutic
goal. [1993 c.578 §1]
Note: 414.350 to 414.415 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.355
Drug Use Review Board created; duties; members; term; qualifications. (1) There is created a 12-member Drug Use
Review Board responsible for advising the Department of Human Services on the
implementation of the retrospective and prospective drug utilization review
programs.
(2) The members of the board shall be
appointed by the Director of Human Services and shall serve a term of two
years. An individual appointed to the board may be reappointed upon completion
of the individuals term. The membership of the board shall be composed of the
following:
(a) Four persons licensed as physicians
and actively engaged in the practice of medicine or osteopathic medicine in
Oregon, who may be from among persons recommended by the Oregon Medical
Association, the Osteopathic Physicians and Surgeons of Oregon or other
organization representing physicians;
(b) One person licensed as a physician in
(c) Three persons licensed and actively practicing
pharmacy in Oregon who may be from among persons recommended by the Oregon
State Pharmacists Association, the National Association of Chain Drug Stores,
the Oregon Society of Hospital Pharmacists, the Oregon Society of Consultant
Pharmacists or other organizations representing pharmacists whether affiliated
or unaffiliated with any association;
(d) One person licensed as a pharmacist in
(e) Two persons who shall represent
persons receiving medical assistance; and
(f) One person licensed and actively
practicing dentistry in Oregon who may be from among persons recommended by the
Oregon Dental Association or other organizations representing dentists.
(3) Board members must have expertise in
one or more of the following:
(a) Clinically appropriate prescribing of
outpatient drugs covered by the medical assistance program.
(b) Clinically appropriate dispensing and
monitoring of outpatient drugs covered by the medical assistance program.
(c) Drug use review, evaluation and
intervention.
(d) Medical quality assurance.
(4) The director shall fill a vacancy on
the board by appointing a new member to serve the remainder of the unexpired
term based upon qualifications described in subsections (2) and (3) of this
section.
(5) A board member may be removed only by
a vote of eight members of the board and the removal must be approved by the
director. The director may remove a member, without board action, if a member
fails to attend two consecutive meetings unless such member is prevented from
attending by serious illness of the member or in the members family. [1993
c.578 §2]
Note: See note under 414.350.
414.360
Duties of board regarding retrospective and prospective drug use review
programs; rules. (1) The
Drug Use Review Board shall advise the Department of Human Services on:
(a) Adoption of rules to implement ORS
414.350 to 414.415 in accordance with the provisions of ORS 183.710 to 183.725,
183.745 and 183.750 and ORS chapter 183.
(b) Implementation of the medical
assistance program retrospective and prospective programs as described in ORS
414.350 to 414.415, including the type of software programs to be used by the
pharmacist for prospective drug use review and the provisions of the contractual
agreement between the state and any entity involved in the retrospective drug
use review program.
(c) Development of and application of the
criteria and standards to be used in retrospective and prospective drug
utilization review in a manner that insures that such criteria and standards
are based on the compendia, relevant guidelines obtained from professional
groups through consensus-driven processes, the experience of practitioners with
expertise in drug therapy, data and experience obtained from drug utilization
review program operations. The board shall have an open professional consensus
process for establishing and revising criteria and standards. Criteria and
standards shall be available to the public. In developing recommendations for
criteria and standards, the board shall establish an explicit ongoing process
for soliciting and considering input from interested parties. The board shall
make timely revisions to the criteria and standards based upon this input in
addition to revisions based upon scheduled review of the criteria and
standards. Further, the drug utilization review standards shall reflect the
local practices of prescribers in order to monitor:
(A) Therapeutic appropriateness.
(B) Overutilization or underutilization.
(C) Therapeutic duplication.
(D) Drug-disease contraindications.
(E) Drug-drug interactions.
(F) Incorrect drug dosage or drug
treatment duration.
(G) Clinical abuse or misuse.
(H) Drug allergies.
(d) Development, selection and application
of and assessment for interventions for medical assistance program prescribers,
dispensers and patients that are educational and not punitive in nature.
(2) In reviewing retrospective and
prospective drug use, the board may consider only drugs that have received
final approval from the federal Food and Drug Administration. [1993 c.578 §6;
2003 c.70 §1]
Note: See note under 414.350.
414.365
Educational and informational duties of board; procedures to insure
confidentiality. In addition
to advising the Department of Human Services, the Drug Use Review Board shall
do the following subject to the approval of the Director of Human Services:
(1) Publish an annual report, as described
in ORS 414.415.
(2) Publish and disseminate educational
information to prescribers and pharmacists regarding the board and the drug use
review programs, including information on the following:
(a) Identifying and reducing the frequency
of patterns of fraud, abuse or inappropriate or medically unnecessary care
among prescribers, pharmacists and recipients.
(b) Potential or actual severe or adverse
reactions to drugs.
(c) Therapeutic appropriateness.
(d) Overutilization or underutilization.
(e) Appropriate use of generic products.
(f) Therapeutic duplication.
(g) Drug-disease contraindications.
(h) Drug-drug interactions.
(i) Drug allergy interactions.
(j) Clinical abuse and misuse.
(3) Adopt and implement procedures
designed to insure the confidentiality of any information collected, stored,
retrieved, assessed or analyzed by the board, staff of the board or contractors
to the drug use review programs that identifies individual prescribers,
pharmacists or recipients. [1993 c.578 §7]
Note: See note under 414.350.
414.370
Authorized intervention procedures. In appropriate instances, interventions developed under ORS 414.360
(1)(d) may include the following:
(1) Information disseminated to
prescribers and pharmacists to insure that they are aware of the duties and
powers of the Drug Use Review Board.
(2) Written, oral or electronic reminders of
recipient-specific or drug-specific information that are designed to insure
recipient, prescriber and pharmacist confidentiality, and suggested changes in
the prescribing or dispensing practices designed to improve the quality of
care.
(3) Face-to-face discussions between
experts in drug therapy and the prescriber or pharmacist who has been targeted
for educational intervention.
(4) Intensified reviews or monitoring of
selected prescribers or pharmacists.
(5) Educational outreach through the
retrospective program focusing on improvement of prescribing and dispensing
practices.
(6) The timely evaluation of interventions
to determine if the interventions have improved the quality of care.
(7) The review of case profiles before the
conducting of an intervention. [1993 c.578 §8; 2003 c.70 §2]
Note: See note under 414.350.
414.375
Standards for prospective drug use review program. The prospective drug use review program must
be based on the guidelines established by the Department of Human Services in consultation
with the Drug Use Review Board. The program must provide that prior to the
prescription being filled or delivered a review will be conducted by the
pharmacist at the point of sale to screen for potential drug therapy problems
resulting from the following:
(1) Therapeutic duplication.
(2) Drug-drug interactions, including
serious interactions with nonprescription or over-the-counter drugs.
(3) Incorrect dosage and duration of
treatment.
(4) Drug-allergy interactions.
(5) Clinical abuse and misuse.
(6) Drug-disease contraindications. [1993
c.578 §13]
Note: See note under 414.350.
414.380
Standards for retrospective drug use review program. The retrospective drug use review program
must:
(1) Be based on the guidelines established
by the Department of Human Services in consultation with the Drug Use Review
Board; and
(2) Use the mechanized drug claims
processing and information retrieval system to analyze claims data on drug use
against explicit predetermined standards that are based on the compendia and
other sources to monitor the following:
(a) Therapeutic appropriateness.
(b) Overutilization or underutilization.
(c) Fraud and abuse.
(d) Therapeutic duplication.
(e) Drug-disease contraindications.
(f) Drug-drug interactions.
(g) Incorrect drug dosage or duration of
drug treatment.
(h) Clinical abuse and misuse. [1993 c.578
§12]
Note: See note under 414.350.
414.385
Compliance with Omnibus Budget Reconciliation Act of 1990. The Drug Use Review Board, retrospective and
prospective programs, and related educational programs shall be operated in
accordance with the requirements of the Omnibus Budget Reconciliation Act of
1990 (P.L. 101-508). [1993 c.578 §11]
Note: See note under 414.350.
414.390
Unauthorized disclosure of information prohibited; staff access to information. (1) Information collected under ORS 414.350
to 414.415 that identifies an individual is confidential and shall not be
disclosed by the Drug Use Review Board, the retrospective drug use review
program, or the Department of Human Services to any person other than a health
care provider appearing on a recipients medication profile.
(2) The staff of the board may have access
to identifying information for purposes of carrying out intervention
activities. The identifying information shall not be released to anyone other
than a staff member of the board, retrospective drug use review program,
Department of Human Services, or to any health care provider appearing on a
recipients medication profile or, for purposes of investigating potential
fraud in programs administered by the Department of Human Services, to the
Department of Justice.
(3) The board may release cumulative,
nonidentifying information for the purposes of legitimate research and for
educational purposes. [1993 c.578 §10]
Note: See note under 414.350.
414.395
When executive session authorized; public testimony. (1) Notwithstanding ORS 192.660, the Drug
Use Review Board may meet in an executive session for purposes of reviewing the
prescribing or dispensing practices of individual physicians or pharmacists or
to discuss drug use review data pertaining to individual physicians or
pharmacists or to review profiles of individual clients. The meeting is subject
to the requirements of ORS 192.650 (2).
(2) The board shall provide appropriate
opportunity for public testimony at the regularly scheduled board meetings. [1993
c.578 §14]
Note: See note under 414.350.
414.400
Board subject to public record laws; chairperson; expenses; quorum; advisory
committees. (1) The Drug Use
Review Board shall operate in accordance with ORS chapter 192. The board shall
annually elect a chairperson from the members of the board.
(2) Each board member is entitled to
reimbursement for actual and necessary travel expenses incurred in connection
with the members duties, pursuant to ORS 292.495.
(3) A quorum consists of eight members of
the board.
(4) The board may establish advisory
committees to assist in carrying out the boards duties under ORS 414.350 to
414.415 with approval of the Director of Human Services. [1993 c.578 §4; 2001
c.900 §103]
Note: See note under 414.350.
414.410
Staff. The Department of
Human Services shall provide staff to the Drug Use Review Board. [1993 c.578 §5]
Note: See note under 414.350.
414.415
Contents of annual report; public comment. (1) The annual report under ORS 414.365 (1) shall be subject to public
comments prior to its submission to the Director of Human Services. Copies of
the annual report shall also be submitted to the President of the Senate, the
Speaker of the House of Representatives and other persons who request copies of
the report.
(2) The annual report must include
information on the following:
(a) An overview of the activities of the
Drug Use Review Board and the prospective and retrospective programs;
(b) A summary of interventions made,
including the number of cases brought before the board, and the number of
interventions made;
(c) An assessment of the impact of the
interventions, criteria and standards used, including an overall assessment of
the impact of the educational programs and interventions on prescribing and
dispensing patterns;
(d) An assessment of the impact of these
criteria, standards and educational interventions on quality of care; and
(e) An estimate of the cost savings
generated as a result of the prospective and retrospective programs, including
an overview of the fiscal impact of the programs to other areas of the medical
assistance program such as hospitalization or long term care costs. This
analysis should include a cost-benefit analysis of both the prospective and
retrospective programs and should take into account the administrative costs of
the drug utilization review program. [1993 c.578 §9]
Note: See note under 414.350.
MEDICAL ASSISTANCE
FOR CERTAIN INDIVIDUALS
414.420
Suspension of medical assistance for pregnant women who are incarcerated. (1) When a woman who is enrolled in the
Oregon Health Plan as a pregnant woman becomes an inmate residing in a public
institution, the Department of Human Services shall suspend medical assistance
under the plan.
(2) The department shall continue to
determine the eligibility of the pregnant woman as categorically needy as
defined in ORS 414.025.
(3) Upon notification that a pregnant
woman described under subsection (1) of this section is no longer an inmate
residing in a public institution, the department shall reinstate medical
assistance under the plan if the woman is otherwise eligible for medical
assistance. [Formerly 414.026]
414.422
Conditions for coverage for pregnant women who are incarcerated. ORS 414.420 does not extend eligibility to
an otherwise ineligible individual or extend medical assistance to an
individual if matching federal funds are not available to pay for medical assistance.
[Formerly 414.027]
414.424
Suspension of medical assistance of persons with serious mental illness under
certain circumstances. (1)
As used in this section:
(a) Person with a serious mental illness
means a person who is diagnosed by a psychiatrist, a licensed clinical
psychologist or a certified nonmedical examiner as having dementia,
schizophrenia, bipolar disorder, major depression or other affective disorder
or psychotic mental disorder other than a disorder caused primarily by
substance abuse.
(b) Public institution means:
(A) A state hospital as defined in ORS
162.135;
(B) A local correctional facility as
defined in ORS 169.005;
(C) A Department of Corrections
institution as defined in ORS 421.005; or
(D) A youth correction facility as defined
in ORS 162.135.
(2) Except as provided in subsection (6)
of this section, the Department of Human Services shall suspend the medical
assistance of a person with a serious mental illness when:
(a) The person receives medical assistance
because of a serious mental illness; and
(b) The person becomes an inmate residing
in a public institution.
(3) The department shall continue to
determine the eligibility of the person as categorically needy as defined in
ORS 414.025.
(4) Upon notification that a person
described in subsection (2) of this section is no longer an inmate residing in
a public institution, the department shall reinstate the persons medical
assistance if the person is otherwise eligible for medical assistance.
(5) This section does not extend
eligibility to an otherwise ineligible person or extend medical assistance to a
person if matching federal funds are not available to pay for medical
assistance.
(6) Subsection (2) of this section does
not apply to a person with a serious mental illness residing in a state
hospital as defined in ORS 162.135 who is under 22 years of age or who is 65
years of age or older. [2005 c.494 §2; 2007 c.70 §193]
414.426
Payment of cost of medical care for institutionalized persons. The Department of Human Services 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]
Note: 414.426 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.428
Coverage for American Indian and Alaskan Native beneficiaries. (1) An individual described in ORS 414.025
(2)(r) 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 414.835 if:
(a) The Department of Human Services
receives 100 percent federal medical assistance percentage for payments made by
the department for the health care services provided as part of the benefit
package described in ORS 414.835 that are not included in the benefit package
described in ORS 414.834; or
(b) The department 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. [Formerly
414.029; 2007 c.861 §22]
Note: 414.428 becomes operative the day after the
date the Department of Human Services receives approval from the federal
Centers for Medicare and Medicaid Services to amend
Note: 414.428 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
Note: 414.834 and 414.835 were repealed by section
5, chapter 735, Oregon Laws 2003. The text of 414.428 was not amended by
enactment of the Legislative Assembly to reflect the repeal. Editorial
adjustment of 414.428 for the repeal of 414.834 and 414.835 has not been made.
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]
Note: 414.500 to 414.530 were enacted into law by the Legislative Assembly
but were not added to or made a part of ORS chapter 414 by legislative action.
See Preface to Oregon Revised Statutes for further explanation.
414.510
Definitions. (1) Eligible
individual means a resident of the State of
(2) Hemophilia services means a program
for medical care, including the cost of blood transfusions and the use of blood
derivatives. [1975 c.513 §2]
Note: See note under 414.500.
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]
Note: See note under 414.500.
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]
Note: See note under 414.500.
414.532
Definitions for ORS 414.534 to 414.538. As used in ORS 414.534 to 414.538:
(1) Medical assistance has the meaning
given that term in ORS 414.025.
(2) Provider has the meaning given that
term in ORS 743.801. [2001 c.902 §1]
Note: 414.532 to 414.540 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.534
Treatment for breast or cervical cancer; eligibility criteria for medical
assistance. (1) The
Department of Human Services shall provide medical assistance to a woman who:
(a) Is screened for breast or cervical
cancer through the Oregon Breast and Cervical Cancer Program operated by the
department;
(b) As a result of a screening in
accordance with paragraph (a) of this subsection, is found by a provider to be
in need of treatment for breast or cervical cancer;
(c) Does not otherwise have creditable
coverage, as defined in 42 U.S.C. 300gg(c); and
(d) Is 64 years of age or younger.
(2) The period of time a woman can receive
medical assistance based on the eligibility criteria of subsection (1) of this
section:
(a) Begins:
(A) On the date the department makes a
formal determination that the woman is eligible for medical assistance in
accordance with subsection (1) of this section; or
(B) Up to three months prior to the month
in which the woman applied for medical assistance if on the earlier date the
woman met the eligibility criteria of subsection (1) of this section.
(b) Ends when:
(A) The woman is no longer in need of
treatment; or
(B) The department determines the woman no
longer meets the eligibility criteria of subsection (1) of this section. [2001
c.902 §2]
Note: See note under 414.532.
414.536
Presumptive eligibility for medical assistance for treatment of breast or
cervical cancer. (1) The
Department of Human Services shall provide medical assistance to a woman whom
the department determines is presumptively eligible for medical assistance. As
used in this section, a woman is presumptively eligible for medical assistance
if the department determines that the woman likely is eligible for medical
assistance under ORS 414.534.
(2) The period of time a woman may receive
medical assistance based on presumptive eligibility is limited. The period of
time:
(a) Begins on the date that the department
determines the woman likely meets the eligibility criteria under ORS 414.534;
and
(b) Ends on the earlier of the following
dates:
(A) If the woman applies for medical
assistance following the determination by the department that the woman is
presumptively eligible for medical assistance, the date on which a formal
determination on eligibility is made by the department in accordance with ORS
414.534; or
(B) If the woman does not apply for
medical assistance following the determination by the department that the woman
is presumptively eligible for medical assistance, the last day of the month
following the month in which presumptive eligibility begins. [2001 c.902 §3]
Note: See note under 414.532.
414.538
Prohibition on coverage limitations; priority to low-income women. (1) The Department of Human Services shall
provide medical assistance under ORS 414.534 or 414.536 to a woman who meets
general coverage requirements applicable to recipients of medical assistance.
The department 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.
(2) In providing medical assistance under
ORS 414.534 or 414.536, the Department of Human Services shall give priority to
low-income women. [2001 c.902 §4]
Note: See note under 414.532.
414.540
Rules. The Department of
Human Services shall adopt rules necessary for the implementation and
administration of ORS 414.534 to 414.538. [2001 c.902 §5]
Note: See note under 414.532.
414.550
Definitions for ORS 414.550 to 414.565. As used in ORS 414.550 to 414.565:
(1) Cystic fibrosis services means a
program for medical care, including the cost of prescribed medications and
equipment, respiratory therapy, physical therapy, counseling services that
pertain directly to cystic fibrosis related health needs and outpatient
services including physicians fees, X-rays and necessary clinical tests to
insure proper ongoing monitoring and maintenance of the patients health.
(2) Eligible individual means a resident
of the State of
Note: 414.550 to 414.565 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 by legislative action. See Preface to Oregon Revised Statutes for further
explanation.
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]
Note: See note under 414.550.
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.
(2) No member of the review committee
shall be held criminally or civilly liable for actions pursuant to this section
provided the member acts in good faith, on probable cause and without malice. [1985
c.532 §3; 1989 c.224 §83]
Note: See note under 414.550.
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]
Note: See note under 414.550.
414.610
Legislative intent. It is
the intent of the Legislative Assembly to develop and implement new strategies
for persons eligible to receive medical assistance that promote and change the
incentive structure in the delivery and financing of medical care, that
encourage cost consciousness on the part of the users and providers while
maintaining quality medical care and that strive to make state payments for
such medical care sufficient to compensate providers adequately for the
reasonable costs of such care in order to minimize inappropriate cost shifts
onto other health care payers. [1983 c.590 §1; 1985 c.747 §8]
414.620
System established. There is
established the Oregon Health Care Cost Containment 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
414.630
Prepaid capitated health care service contracts; when fee for services to be
paid. (1) The Department of
Human Services shall 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 Department of Human Services and shall not thereby be
considered to be transacting insurance.
(3) In the event that there is an
insufficient number of qualified bids for prepaid capitated health services
contracts for hospital or physician medical care, or both, in some areas of the
state, the department 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. [1983 c.590 §3; 1991 c.66 §24;
2003 c.794 §275]
414.640
Selection of providers; reimbursement for services not covered; actions as
trade practice; actions not insurance; rules. (1) Eligible persons shall select, to the extent practicable as
determined by the Department of Human Services, from among available providers
participating in the program.
(2) The department by rule shall define
the circumstances under which it may choose to reimburse for any medical
services not covered under the prepaid capitation or costs of related services
provided by or under referral from any physician participating in the program
in which the eligible person is enrolled.
(3) The department shall establish
requirements as to the minimum time period that an eligible person is assigned
to specific providers in the system.
(4) Actions taken by providers, potential
providers, contractors and bidders in specific accordance with this chapter in
forming consortiums or in otherwise entering into contracts to provide medical
care shall be considered to be conducted at the direction of this state, shall
be considered to be lawful trade practices and shall not be considered to be
the transaction of insurance for purposes of ORS 279A.025, 279A.140, 414.145
and 414.610 to 414.640. [1983 c.590 §4; 1991 c.66 §25; 2003 c.794 §276]
414.650 [1983 c.590 §7; 1987 c.660 §19; 1989 c.513 §1;
1991 c.66 §26; repealed by 1995 c.727 §48]
414.660
Demonstration projects for medical service contracts. The Department of Human Services shall
pursue demonstration projects for medical service contracts in at least the
four standard metropolitan statistical areas in this state and is authorized to
seek the necessary federal waivers in order to accomplish such contracts including
but not limited to:
(1) Limiting the scope of the system to
selected geographic areas;
(2) Allowing participating health plans to
offer benefit enhancements;
(3) Limiting the choice of eligible
persons to those providers affiliated with a participating health plan;
(4) Allowing primary care providers access
to data concerning clients utilization of service from other providers; and
(5) Allowing the department the
reimbursement flexibility necessary to implement a prospective reimbursement
system for hospital care. [1983 c.590 §5; 1985 c.747 §3; 1991 c.66 §27]
414.670
Phasing in eligible clients.
For the purpose of insuring that a maximum number of eligible persons are
served by the Oregon Health Care Cost Containment System through prepaid capitated
provider contracts, the Department of Human Services is directed to phase
eligible clients into the newly formed systems as rapidly as possible. [1983
c.590 §6; 1985 c.747 §3a; 1991 c.66 §28]
SCOPE OF
COVERED HEALTH SERVICES
414.705
Definitions for ORS 414.705 to 414.750. (1) As used in ORS 414.705 to 414.750, health services means at
least so much of each of the following as are approved and funded by the
Legislative Assembly:
(a) Services required by federal law to be
included in the states 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 practitioners practice as
defined by state law, and ambulance services;
(c) Prescription drugs;
(d) Laboratory and X-ray services;
(e) Medical 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 states medical assistance
program;
(k) Emergency hospital services;
(L) Outpatient hospital services; and
(m) Inpatient hospital services.
(2) Health services approved and funded
under subsection (1) of this section are subject to the prioritized list of
health services required in ORS 414.720. [1989 c.836 §2; 1991 c.753 §4; 2003
c.735 §1; 2003 c.810 §7]
Note: 414.705 to 414.750 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.706
Legislative approval and funding of health services to certain persons. The Legislative Assembly shall approve and
fund health services to the following persons:
(1) Persons who are categorically needy as
described in ORS 414.025 (2)(n) and (o);
(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. [2003 c.735 §3]
Note: 414.706 to 414.709 were added to and made a
part of 414.705 to 414.750 by legislative action but were not added to any
smaller series therein. See Preface to Oregon Revised Statutes for further
explanation.
414.707
Level of health services provided to certain persons. (1) Subject to funds available:
(a) Persons who are categorically needy as
described in ORS 414.025 (2)(n) and (o), and persons under 19 years of age and
pregnant women who are eligible to receive health services under ORS 414.706,
are eligible to receive all the health services approved and funded by the
Legislative Assembly.
(b) Persons described in ORS 414.708 are
eligible to receive the health services described in ORS 414.705 (1)(c), (f)
and (g).
(c) Persons 19 years of age and older who
are eligible to receive health services under ORS 414.706 are eligible to
receive the health services described in ORS 414.705 (1)(b) to (m).
(2) Persons who are categorically needy as
described in ORS 414.025 (2)(n) and (o), and persons under 19 years of age and
pregnant women who are eligible to receive health services under ORS 414.706,
must be provided, at a minimum, the health services described in ORS 414.705
(1)(a) to (g).
(3) Persons 19 years of age and older who
are eligible to receive health services under ORS 414.706 must be provided, at
a minimum, health services described in ORS 414.705 (1)(b) to (h).
(4) Persons described in ORS 414.708 must
be provided, at a minimum, the health services described in ORS 414.705 (1)(c).
(5) The Department of Human Services
shall:
(a) Develop at least three benefit
packages of provider services to be offered under ORS 414.705 (1)(j); and
(b) Define by rule the services to be
offered under ORS 414.705 (1)(k).
(6) Notwithstanding ORS 414.735, the
Legislative Assembly shall adjust health services funded under ORS 414.705 (1)
by increasing or reducing benefit packages or health services and, subject to
ORS 414.709, by increasing or reducing the population of eligible persons. [2003
c.735 §4]
Note: See note under 414.706.
414.708
Conditions for coverage for certain elderly persons, blind persons or persons who
have disabilities. (1) A
person is eligible to receive the health services described in ORS 414.707
(1)(b) when the person is a resident of this state who:
(a) Is 65 years of age or older, or is
blind or has a disability as those terms are defined in ORS 411.704;
(b) Has a gross annual income that does
not exceed the standard established by the Department of Human Services; and
(c) Is not covered under any public or
private prescription drug benefit program.
(2) A person receiving prescription drug
services under ORS 414.707 (1)(b) shall pay up to a percentage of the Medicaid
price of the prescription drug established by the department by rule and the
dispensing fee. [2003 c.735 §11; 2005 c.381 §16; 2007 c.70 §194]
Note: See note under 414.706.
414.709
Adjustment of population of eligible persons in event of insufficient
resources. (1) Except as
provided in subsection (2) of this section, if insufficient resources are
available during a biennium, the population of eligible persons receiving
health services may not be reduced below the population of eligible persons
approved and funded in the legislatively adopted budget for the Department of
Human Services for the biennium.
(2) The Department of Human Services may
periodically limit enrollment of persons described in ORS 414.708 in order to
stay within the legislatively adopted budget for the department. [2003 c.735 §4a]
Note: See note under 414.706.
414.710
Services available to certain eligible persons. The following services are available to
persons eligible for services under ORS 414.025, 414.036, 414.042, 414.065 and
414.705 to 414.750 but such services are not subject to ORS 414.720:
(1) Nursing facilities and home- and
community-based waivered services funded through the Department of Human
Services;
(2) Medical assistance to eligible persons
who receive assistance under ORS 411.706 or to children described in ORS
414.025 (2)(f), (i), (j), (k) and (m), 418.001 to 418.034, 418.189 to 418.970
and 657A.020 to 657A.460;
(3) Institutional, home- and
community-based waivered services or community mental health program care for
persons with mental retardation, developmental disabilities or severe mental
illness and for the treatment of alcohol and drug dependent persons; and
(4) Services to children who are wards of
the Department of Human Services by order of the juvenile court and services to
children and families for health care or mental health care through the
department. [1989 c.836 §3; 1991 c.67 §107; 1991 c.753 §5; 1993 c.815 §17; 1997
c.581 §25; 1999 c.1084 §52; 2005 c.381 §17; 2007 c.70 §195]
Note: See note under 414.705.
414.712
Medical assistance for certain eligible persons. The Department of Human Services shall
provide medical assistance under ORS 414.705 to 414.750 to eligible persons who
receive assistance under ORS 411.706 and to children described in ORS 414.025
(2)(f), (i), (j), (k) and (m), 418.001 to 418.034, 418.189 to 418.970 and
657A.020 to 657A.460 and those mental health and chemical dependency services
recommended according to standards of medical assistance and according to the
schedule of implementation established by the Legislative Assembly. In
providing medical assistance services described in ORS 414.018 to 414.024,
414.042, 414.107, 414.710, 414.720 and 735.712, the Department of Human
Services shall also provide the following:
(1) Ombudsman services for eligible
persons who receive assistance under ORS 411.706. With the concurrence of the
Governor, the Director of Human Services shall appoint ombudsmen and may
terminate an ombudsman. Ombudsmen are under the supervision and control of the
director. An ombudsman shall serve as a patients advocate whenever the patient
or a physician or other medical personnel serving the patient is reasonably
concerned about access to, quality of or limitations on the care being provided
by a health care provider. Patients shall be informed of the availability of an
ombudsman. Ombudsmen shall report to the Governor 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 ombudsmans recommendations for improving
ombudsman services and access to or quality of care provided to eligible
persons by health care providers.
(2) Case management services in each
health care provider organization for those eligible persons 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 who receive assistance under ORS 411.706. Case managers shall
be reasonably available to assist patients served by the organization with the
coordination of the patients health care services at the reasonable request of
the patient or a physician or other medical personnel serving the patient.
Patients 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 patients
medical needs require swift resolution of a dispute. [1991 c.753 §14; 1993
c.815 §18; 1997 c.581 §26; 1999 c.547 §7; 1999 c.1084 §53; 2003 c.14 §§193,193a;
2003 c.591 §§1,2; 2005 c.381 §18]
Note: See note under 414.705.
414.715
Health Services Commission; confirmation; qualifications; terms; expenses;
subcommittees. (1) The
Health Services Commission is established, consisting of 11 members appointed
by the Governor and confirmed by the Senate. Five members shall be physicians
licensed to practice medicine in this state who have clinical expertise in the
general areas of obstetrics, perinatal, pediatrics, adult medicine, mental
health and chemical dependency, disabilities, geriatrics or public health. One
of the physicians shall be a doctor of osteopathy. Other members shall include
a public health nurse, a social services worker and four consumers of health
care. In making the appointments, the Governor shall consult with professional
and other interested organizations.
(2) Members of the Health Services
Commission shall serve for a term of four years, at the pleasure of the
Governor.
(3) Members 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.
(4) The commission may establish such
subcommittees of its members and other medical, economic or health services
advisers as it determines to be necessary to assist the commission in the
performance of its duties. [1989 c.836 §4; 1991 c.753 §12]
Note: See note under 414.705.
414.720
Public hearings; public involvement; biennial reports on health services
priorities; funding. (1) The
Health Services Commission shall conduct public hearings prior to making the
report described in subsection (3) of this section. The commission shall
solicit testimony and information from advocates representing seniors, persons
with disabilities, mental health services consumers and low-income Oregonians,
representatives of commercial carriers, representatives of small and large
Oregon employers and providers of health care, including but not limited to
physicians licensed to practice medicine, dentists, oral surgeons,
chiropractors, naturopaths, hospitals, clinics, pharmacists, nurses and allied
health professionals.
(2) The commission shall actively solicit
public involvement in a community meeting process to build a consensus on the
values to be used to guide health resource allocation decisions.
(3) The commission shall report to the
Governor a list of health services ranked by priority, from the most important
to the least important, representing the comparative benefits of each service
to the entire population to be served. The list submitted by the commission
pursuant to this subsection is not subject to alteration by any other state
agency. The recommendation may include practice guidelines reviewed and adopted
by the commission pursuant to subsection (4) of this section.
(4) In order to encourage effective and
efficient medical evaluation and treatment, the commission:
(a) May include clinical practice
guidelines in its prioritized list of services. The commission shall actively
solicit testimony and information from the medical community and the public to
build a consensus on clinical practice guidelines developed by the commission.
(b) Shall consider both the clinical
effectiveness and cost-effectiveness of health services in determining their
relative importance using peer-reviewed medical literature as defined in ORS
743A.060.
(5) The commission shall make its report
by July 1 of the year preceding each regular session of the Legislative
Assembly and shall submit a copy of its report to the Governor, the Speaker of
the House of Representatives and the President of the Senate.
(6) The commission may alter the list
during interim only under the following conditions:
(a) Technical changes due to errors and
omissions; and
(b) Changes due to advancements in medical
technology or new data regarding health outcomes.
(7) If a service is deleted or added and
no new funding is required, the commission shall report to the Speaker of the
House of Representatives and the President of the Senate. However, if a service
to be added requires increased funding to avoid discontinuing another service,
the commission must report to the Emergency Board to request the funding.
(8) The report listing services to be
provided pursuant to ORS 414.036, 414.042, 414.065, 414.107, 414.705 to 414.725
and 414.735 to 414.750 shall remain in effect from October 1 of the
odd-numbered year through September 30 of the next odd-numbered year. [1989
c.836 §4a; 1991 c.753 §6; 1991 c.916 §2a; 1993 c.754 §1; 1993 c.815 §19; 1997
c.245 §2; 2003 c.735 §10; 2003 c.810 §8]
Note: 414.720 was added to and made a part of ORS
chapter 414 by legislative action but was not added to any smaller series
therein. See Preface to Oregon Revised Statutes for further explanation.
414.725
Prepaid managed care health services contracts; financial reporting; rules. (1)(a) Pursuant to rules adopted by the
Department of Human Services, the department shall execute prepaid managed care
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 Commissions 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 department shall establish timelines for
executing the contracts described in this paragraph.
(b) It is the intent of ORS 414.705 to
414.750 that the state use, to the greatest extent possible, prepaid managed
care health services organizations to provide physical health, dental, mental
health and chemical dependency services under ORS 414.705 to 414.750.
(c) The department 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 department may
not discriminate against any contractors that offer services within their
providers lawful scopes of practice.
(d) The department shall establish annual
financial reporting requirements for prepaid managed care health services
organizations. The department shall prescribe a reporting procedure that
elicits sufficiently detailed information for the department to assess the
financial condition of each prepaid managed care health services organization
and that includes information on the three highest executive salary and benefit
packages of each prepaid managed care health services organization.
(e) The department shall require
compliance with the provisions of paragraph (d) of this subsection as a
condition of entering into a contract with a prepaid managed care health
services organization.
(2) The department 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 department may make other special
arrangements as necessary to increase the interest of providers in
participation in the states 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.
(3) As provided in subsections (1) and (2)
of this section, the aggregate expenditures by the department 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 same or similar
community would do so under the same or similar circumstances.
(6) A prepaid managed care health services
organization shall provide information on contacting available providers to an
enrollee in writing within 30 days of assignment to the health services
organization.
(7) Each prepaid managed care health
services organization shall provide upon the request of an enrollee or
prospective enrollee annual summaries of the organizations aggregate data
regarding:
(a) Grievances and appeals; and
(b) Availability and accessibility of
services provided to enrollees.
(8) A prepaid managed care health services
organization may not limit enrollment in a designated area based on the zip
code of an enrollee or prospective enrollee. [1989 c.836 §6; 1991 c.753 §8;
2003 c.14 §194; 2003 c.735 §13; 2003 c.794 §277; 2003 c.810 §4; 2005 c.806 §8;
2007 c.458 §1]
Note: See note under 414.705.
414.727
Reimbursement of rural hospitals by prepaid managed care health services organization. (1) A prepaid managed care health services
organization, as defined in ORS 414.736, that contracts with the Department of
Human Services under ORS 414.725 (1) to provide prepaid managed care health
services, including hospital services, 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 cost-to-charge ratio used for each hospital in
setting the capitation rates paid to the prepaid managed care health services
organization for the contract period.
(2) The department shall base the
capitation rates described in subsection (1) of this section on the most recent
audited Medicare cost report for
(3) This section may not be construed to
prohibit a prepaid managed care health services organization and a hospital
from mutually agreeing to reimbursement other than the reimbursement specified
in subsection (1) of this section.
(4) Hospitals reimbursed under subsection
(1) of this section are not entitled to any additional reimbursement for
services provided. [1997 c.642 §2; 1999 c.546 §2; 2005 c.806 §2]
Note: See note under 414.705.
414.728
Reimbursement of rural hospitals by Department of Human Services. For services provided 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 Department of Human Services 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. [2005
c.806 §4]
Note: See note under 414.705.
414.730
Subcommittee on Mental Health Care and Chemical Dependency. The Health Services Commission shall
establish a Subcommittee on Mental Health Care and Chemical Dependency to
assist the commission in determining priorities for mental health care and
chemical dependency. The subcommittee shall include mental health and chemical
dependency professionals who provide inpatient and outpatient mental health and
chemical dependency care. [1989 c.836 §7; 1995 c.79 §209; 2005 c.22 §286]
Note: See note under 414.705.
414.735
Adjustment of reimbursement in event of insufficient resources; approval of
Legislative Assembly or Emergency Board; notice to providers. (1) If insufficient resources are available
during a contract period:
(a) The population of eligible persons
determined by law shall not be reduced.
(b) The reimbursement rate for providers
and plans established under the contractual agreement shall not be reduced.
(2) In the circumstances described in
subsection (1) of this section, reimbursement shall be adjusted by reducing the
health services for the eligible population by eliminating services in the
order of priority recommended by the Health Services Commission, starting with
the least important and progressing toward the most important.
(3) The Department of Human Services shall
obtain the approval of the Legislative Assembly or Emergency Board, if the
Legislative Assembly is not in session, before instituting the reductions. In
addition, providers contracting to provide health services under ORS 414.705 to
414.750 must be notified at least two weeks prior to any legislative
consideration of such reductions. Any reductions made under this section shall
take effect no sooner than 60 days following final legislative action approving
the reductions. [1989 c.836 §8; 1991 c.753 §9; 2003 c.14 §195]
Note: See note under 414.705.
414.736
Definitions. As used in this
section and ORS 414.725, 414.737, 414.738, 414.739, 414.740, 414.741, 414.742,
414.743 and 414.744:
(1) Designated area means a geographic
area of the state defined by the Department of Human Services 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 Department of Human Services on a prepaid
capitated basis under ORS 414.725 to provide an adequate network of providers
to ensure that the health services provided under the contract are reasonably
accessible to enrollees.
(3) Physician care organization means an
organization that contracts with the Department of Human Services on a prepaid
capitated basis under ORS 414.725 to provide an adequate network of providers
to ensure that the health services described in ORS 414.705 (1)(b), (c), (d),
(e), (g) and (j) are reasonably accessible to enrollees. A physician care
organization may also contract with the department on a prepaid capitated basis
to provide the health services described in ORS 414.705 (1)(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 Department of Human
Services on a prepaid capitated basis under ORS 414.725. 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. [2003 c.810 §2]
Note: 414.736 to 414.744 were added to and made a
part of 414.705 to 414.750 by legislative action but were not added to any
smaller series therein. See Preface to Oregon Revised Statutes for further
explanation.
414.737
Mandatory enrollment in prepaid managed care health services organization. (1) Except as provided in subsections (2)
and (3) of this section, a person who is eligible for or receiving physical
health, dental, mental health or chemical dependency services under ORS 414.705
to 414.750 must be enrolled in the prepaid managed care health services
organizations to receive the health services for which the person is eligible.
(2) Subsection (1) of this section does
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) A person whom the department 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; 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.
(4) 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. [2003
c.810 §3]
Note: The amendments to 414.737 by section 8,
chapter 751, Oregon Laws 2007, become operative upon receipt of necessary
federal approval. See section 9, chapter 751, Oregon Laws 2007. The text that
is operative on and after receipt of federal approval is set forth for the users
convenience.
414.737. (1) Except as provided in subsections (2)
and (3) of this section, a person who is eligible for or receiving physical
health, dental, mental health or chemical dependency services under ORS 414.705
to 414.750 must be enrolled in the prepaid managed care health services
organizations to receive the health services for which the person is eligible.
(2) Subsection (1) of this section does
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) A person whom the department 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.
(4) 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.
Note: See note under 414.736.
414.738
Use of physician care organizations. (1) If the Department of Human Services has not been able to contract
with the fully capitated health plan or plans in a designated area, the
department may contract with a physician care organization in the designated
area.
(2) The Office for Oregon Health Policy
and Research shall develop criteria that the department shall consider when
determining the circumstances under which the department may contract with a
physician care organization. The criteria developed by the office shall include
but not be limited to the following:
(a) The physician care organization must
be able to assign an enrollee to a person or entity that is primarily
responsible for coordinating the physical health services provided to the
enrollee;
(b) The contract with a physician care
organization does not threaten the financial viability of other fully capitated
health plans in the designated area; and
(c) The contract with a physician care
organization must be consistent with the legislative intent of using prepaid
managed care health services organizations to provide services under ORS
414.705 to 414.750. [2003 c.810 §5]
Note: See note under 414.736.
414.739
Circumstances under which fully capitated health plan may contract as physician
care organization. (1) A
fully capitated health plan may apply to the Department of Human Services to
contract with the department as a physician care organization rather than as a
fully capitated health plan to provide services under ORS 414.705 to 414.750.
(2) The Office for Oregon Health Policy
and Research shall develop the criteria that the department must use to
determine the circumstances under which the department may accept an application
by a fully capitated health plan to contract as a physician care organization.
The criteria developed by the office shall include but not be limited to the
following:
(a) The fully capitated health plan must
show documented losses due to hospital risk and must show due diligence in
managing those risks; and
(b) Contracting as a physician care
organization is financially viable for the fully capitated health plan. [2003
c.810 §5a]
Note: See note under 414.736.
414.740
Contracts with certain prepaid group practice health plan. (1) Notwithstanding ORS 414.738 (1), the
Department of Human Services shall contract under ORS 414.725 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), (c), (d), (e), (g) and (j).
A health plan may also contract with the Department of Human Services on a
prepaid capitated basis to provide the health services described in ORS 414.705
(1)(k) and (L). The Department of Human Services may accept financial
contributions from any public or private entity to help implement and
administer the contract. The Department of Human Services 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 Department of Human
Services shall contract with prepaid managed care health services organizations
to provide health services under ORS 414.705 to 414.750. [2003 c.810 §6]
Note: See note under 414.736.
414.741
Determination of benchmarks for setting per capita rates. (1) The Health Services Commission shall
retain an actuary to determine the benchmark for setting per capita rates
necessary to reimburse prepaid managed care health services organizations and
fee-for-service providers for the cost of providing health services under ORS
414.705 to 414.750.
(2) The actuary retained by the commission
shall use the following information to determine the benchmark for setting per
capita rates:
(a) For hospital services, the most
recently available Medicare cost reports for
(b) For services of physicians licensed
under ORS chapter 677 and other health professionals using procedure codes, the
Medicare Resource Based Relative Value system conversion rates for Oregon;
(c) For prescription drugs, the most recent
payment methodologies in the fee-for-service payment system for the Oregon
Health Plan;
(d) For durable medical equipment and
supplies, 80 percent of the Medicare allowable charge for purchases and
rentals;
(e) For dental services, the most recent
payment rates obtained from dental care organization encounter data; and
(f) For all other services not listed in
paragraphs (a) to (e) of this subsection:
(A) The Medicare maximum allowable charge,
if available; or
(B) The most recent payment rates obtained
from the data available under subsection (3) of this section.
(3) The actuary shall use the most current
encounter data and the most current fee-for-service data that is available,
reasonable trends for utilization and cost changes to the midpoint of the next
biennium, appropriate differences in utilization and cost based on geography,
state and federal mandates and other factors that, in the professional judgment
of the actuary, are relevant to the fair and reasonable estimation of costs.
The Department of Human Services shall provide the actuary with the data and
information in the possession of the department or contractors of the
department reasonably necessary to develop a benchmark for setting per capita
rates.
(4) The commission shall report the benchmark
per capita rates developed under this section to the Director of the Oregon
Department of Administrative Services, the Director of Human Services and the
Legislative Fiscal Officer no later than August 1 of every even-numbered year.
(5) The Department of Human Services shall
retain an actuary to determine:
(a) Per capita rates for health services
that the department shall use to develop the departments proposed biennial
budget; and
(b) Capitation rates to reimburse
physician care organizations for the cost of providing health services under
ORS 414.705 to 414.750 using the same methodologies used to develop capitation
rates for fully capitated health plans. The rates may not advantage or
disadvantage fully capitated health plans for similar services.
(6) The Department of Human Services shall
submit to the Legislative Assembly no later than February 1 of every
odd-numbered year a report comparing the per capita rates for health services
on which the proposed budget of the department is based with the rates
developed by the actuary retained by the Health Services Commission. If the
rates differ, the department shall disclose, by provider categories described
in subsection (2) of this section, the amount of and reason for each variance. [2003
c.810 §9]
Note: See note under 414.736.
414.742
Payment for mental health drugs. The Department of Human Services may not establish capitation rates
that include payment for mental health drugs. The department shall reimburse
pharmacy providers for mental health drugs only on a fee-for-service payment
basis. [2003 c.810 §11]
Note: See note under 414.736.
414.743
Payment to noncontracting hospital by fully capitated health plan; rules. (1) As used in this section, fully
capitated health plan means an organization that contracts with the Department
of Human Services on a prepaid capitated basis under ORS 414.725 to provide an
adequate network of providers to ensure that all health services described in
ORS 414.705 are reasonably accessible to enrollees.
(2) A fully capitated health plan that
does not have a contract with a hospital to provide inpatient or outpatient
hospital services under ORS 414.705 to 414.750 must pay for hospital services
at 80 percent of the Medicare rate for the noncontracting hospital.
(3) A hospital that does not have a
contract with a fully capitated health plan to provide inpatient or outpatient
hospital services under ORS 414.705 to 414.750 must accept as payment in full
the rates described in subsection (2) of this section.
(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.
(5) The Department of Human Services shall
adopt rules to implement and administer this section. [Subsection (1) of 2003
Edition enacted as 2003 c.735 §16(1); subsections (2) to (5) of 2003 Edition
enacted as 2003 c.735 §16(2) to (5) and 2003 c.810 §12(1) to (4); 2007 c.886 §1]
Note: The amendments to 414.743 by section 2,
chapter 886,
414.743. (1) As used in this section, fully
capitated health plan means an organization that contracts with the Department
of Human Services on a prepaid capitated basis under ORS 414.725 to provide an
adequate network of providers to ensure that all health services described in
ORS 414.705 are reasonably accessible to enrollees.
(2) A fully capitated health plan that
does not have a contract with a hospital to provide inpatient or outpatient
hospital services under ORS 414.705 to 414.750 must pay for hospital services
as follows:
(a) For inpatient hospital services, based
on the capitation rates developed for the budget period, at the level of the
statewide average unit cost, multiplied by the geographic factor, the payment
discount factor and an adjustment factor of 0.925.
(b) For outpatient hospital services,
based on the capitation rates developed for the budget period, at the level of
charges multiplied by the statewide average cost-to-charge ratio, the
geographic factor, the payment discount factor and an adjustment factor of
0.925.
(3) A hospital that does not have a contract
with a fully capitated health plan to provide inpatient or outpatient hospital
services under ORS 414.705 to 414.750 must accept as payment in full for
hospital services, rates:
(a) For inpatient hospital services, based
on the capitation rates developed for the budget period, at the level of the
statewide average unit cost, multiplied by the geographic factor, the payment
discount factor and an adjustment factor of 0.925.
(b) For outpatient hospital services,
based on the capitation rates developed for the budget period, at the level of
charges multiplied by the statewide average cost-to-charge ratio, the
geographic factor, the payment discount factor and an adjustment factor of
0.925.
(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.
(5) The Department of Human Services shall
adopt rules to implement and administer this section.
Note: See note under 414.736.
414.744
Pharmacy benefit manager to manage prescription drug benefits. (1) Subject to the provisions of subsection
(4) of this section, the Department of Human Services shall contract with a
pharmacy benefit manager to manage prescription drug benefits for the medical
assistance program. The pharmacy benefit manager shall purchase prescription
drugs in bulk or reimburse pharmacies for prescription drugs prescribed for
eligible persons in the medical assistance program.
(2) The pharmacy benefit manager shall
establish two programs for the medical assistance program. One program shall
purchase prescription drugs for or reimburse fully capitated health plans that
use the pharmacy benefit manager under contract with the department. The second
program shall reimburse fee-for-service pharmacy providers directly or provide
for payment by the Department of Human Services.
(3) Fully capitated health plans may use
the pharmacy benefit manager under contract with the department under
subsection (1) of this section.
(4) In awarding a contract under this
section, the department must ensure that the contractor has the capacity and
competence to administer the services and that the contract is cost-neutral to
the department.
(5) ORS 414.325 and 414.334 apply to the
management of prescription drug benefits under this section. [2003 c.810 §13]
Note: 414.744 becomes operative the day after the
date the Department of Human Services receives the necessary waivers from the
Centers for Medicare and Medicaid Services. See section 18, chapter 810, Oregon
Laws 2003.
Note: See note under 414.736.
414.745
Liability of health care providers and plans. Any health care provider or plan contracting to provide services to
the eligible population under ORS 414.705 to 414.750 shall not be subject to
criminal prosecution, civil liability or professional disciplinary action for
failing to provide a service which the Legislative Assembly has not funded or
has eliminated from its funding pursuant to ORS 414.735. [1989 c.836 §10; 1991
c.753 §10]
Note: See note under 414.705.
414.747
Supplemental rebates from pharmaceutical manufacturers. (1) The Department of Human Services shall
negotiate and enter into agreements with pharmaceutical manufacturers for
supplemental rebates that are in addition to the discount required under
federal law to participate in the medical assistance program.
(2) The department may participate in a
multistate prescription drug purchasing pool for the purpose of negotiating
supplemental rebates.
(3) ORS 414.325 and 414.334 apply to
prescription drugs purchased for the medical assistance program under this
section. [2003 c.810 §15]
Note: 414.747 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.750
Authority of Legislative Assembly to authorize services for other persons. Nothing in ORS 414.036 and 414.705 to
414.750 is intended to limit the authority of the Legislative Assembly to
authorize services for persons whose income exceeds 100 percent of the federal
poverty level for whom federal medical assistance matching funds are available
if state funds are available therefor. [1989 c.836 §18; 1991 c.753 §11]
Note: See note under 414.705.
414.751
Office for
(a) Representatives of managed care health
services organizations under contract with the Department of Human Services
pursuant to ORS 414.725 and serving primarily rural areas of the state;
(b) Representatives of managed care health
services organizations under contract with the Department of Human Services
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 organizations pursuant to ORS 414.725 who serve patients
in both rural and urban areas of the state;
(d) One representative from Type A
hospitals and one representative from Type B hospitals; and
(e) Representatives of the Department of
Human Services.
(2) Members of the advisory committee
shall not be entitled to compensation or per diem. [1997 c.683 §35; 2001 c.69 §2]
Note: 414.751 was enacted into law by the
Legislative Assembly but was not added to or made a part of ORS chapter 414 or
any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
PAYMENT OF
MEDICAL EXPENSES OF PERSON IN CUSTODY OF LAW ENFORCEMENT OFFICER
414.805
Liability of individual for medical services received while in custody of law
enforcement officer. (1) An
individual who receives medical services while in the custody of a law
enforcement officer is liable:
(a) To the provider of the medical
services for the charges and expenses therefor; and
(b) To the Department of Human Services
for any charges or expenses paid by the Department of Human Services out of the
Law Enforcement Medical Liability Account for the medical services.
(2) A person providing medical services to
an individual described in subsection (1)(a) of this section shall first make
reasonable efforts to collect the charges and expenses thereof from the
individual before seeking to collect them from the Department of Human Services
out of the Law Enforcement Medical Liability Account.
(3)(a) If the provider has not been paid
within 45 days of the date of the billing, the provider may bill the Department
of Human Services who shall pay the account out of the Law Enforcement Medical
Liability Account.
(b) A bill submitted to the Department of
Human Services under this subsection must be accompanied by evidence
documenting that:
(A) The provider has billed the individual
or the individuals insurer or health care service contractor for the charges
or expenses owed to the provider; and
(B) The provider has made a reasonable
effort to collect from the individual or the individuals insurer or health
care service contractor the charges and expenses owed to the provider.
(c) If the provider receives payment from
the individual or the insurer or health care service contractor after receiving
payment from the Department of Human Services, the provider shall repay the
department the amount received from the public agency less any difference
between payment received from the individual, insurer or contractor and the
amount of the billing.
(4) As used in this section:
(a) Law enforcement officer means an
officer who is commissioned and employed by a public agency as a peace officer
to enforce the criminal laws of this state or laws or ordinances of a public
agency.
(b) Public agency means the state, a
city, port, school district, mass transit district or county. [1991 c.778 §7;
2007 c.71 §105]
Note: 414.805 to 414.815 were enacted into law by
the Legislative Assembly but were not added to or made a part of ORS chapter
414 or any series therein by legislative action. See Preface to Oregon Revised
Statutes for further explanation.
414.807
Department to pay for medical services related to law enforcement activity;
certification of injury.
(1)(a) When charges and expenses are incurred for medical services provided to
an individual for injuries related to law enforcement activity and subject to
the availability of funds in the account, the cost of such services shall be
paid by the Department of Human Services out of the Law Enforcement Medical
Liability Account established in ORS 414.815 if the provider of the medical
services has made all reasonable efforts to collect the amount, or any part
thereof, from the individual who received the services.
(b) When a law enforcement agency involved
with an injury certifies that the injury is related to law enforcement
activity, the Department of Human Services shall pay the provider:
(A) If the provider is a hospital, in
accordance with current fee schedules established by the Director of the
Department of Consumer and Business Services for purposes of workers
compensation under ORS 656.248; or
(B) If the provider is other than a
hospital, 75 percent of the customary and usual rates for the services.
(2) After the injured person is
incarcerated and throughout the period of incarceration, the Department of
Human Services shall continue to pay, out of the Law Enforcement Medical
Liability Account, charges and expenses for injuries related to law enforcement
activities as provided in subsection (1) of this section. Upon release of the
injured person from actual physical custody, the Law Enforcement Medical
Liability Account is no longer liable for the payment of medical expenses of
the injured person.
(3) If the provider of medical services
has filed a medical services lien as provided in ORS 87.555, the Department of
Human Services shall be subrogated to the rights of the provider to the extent
of payments made by the Department of Human Services to the provider for the
medical services. The Department of Human Services may foreclose the lien as
provided in ORS 87.585.
(4) The Department of Human Services shall
deposit in the Law Enforcement Medical Liability Account all moneys received by
the department from:
(a) Providers of medical services as
repayment;
(b) Individuals whose medical expenses
were paid by the department under this section; and
(c) Foreclosure of a lien as provided in
subsection (3) of this section.
(5) As used in this section:
(a) Injuries related to law enforcement
activity means injuries sustained prior to booking, citation in lieu of arrest
or release instead of booking that occur during and as a result of efforts by a
law enforcement officer to restrain or detain, or to take or retain custody of,
the individual.
(b) Law enforcement officer has the
meaning given that term in ORS 414.805. [1991 c.778 §2; 1993 c.196 §9]
Note: See note under 414.805.
414.810 [Formerly 414.040; renumbered 566.310]
414.815
Law Enforcement Medical Liability Account; limited liability; rules; report. (1) The Law Enforcement Medical Liability
Account is established separate and distinct from the General Fund. Interest
earned, if any, shall inure to the benefit of the account. The moneys in the
Law Enforcement Medical Liability Account are appropriated continuously to the
Department of Human Services to pay expenses in administering the account and
paying claims out of the account as provided in ORS 414.807.
(2) The liability of the Law Enforcement
Medical Liability Account is limited to funds accrued to the account from
assessments collected under ORS 137.309 (6), (8) or (9), or collected from
individuals under ORS 414.805.
(3) The Department of Human Services may
contract with persons experienced in medical claims processing to provide
claims processing for the account.
(4) The Department of Human Services shall
adopt rules to implement administration of the Law Enforcement Medical
Liability Account including, but not limited to, rules that establish
reasonable deadlines for submission of claims.
(5) Each biennium, the Department of Human
Services shall submit a report to the Legislative Assembly regarding the status
of the Law Enforcement Medical Liability Account. Within 30 days of the
convening of each regular legislative session, the department shall submit the
report to the chair of the Senate Judiciary Committee and the chair of the
House Judiciary Committee. The report shall include, but is not limited to, the
number of claims submitted and paid during the biennium and the amount of money
in the fund at the time of the report. [1991 c.778 §1; 1993 c.196 §10; 1999
c.1051 §256; 2005 c.804 §8]
Note: See note under 414.805.
414.820 [Formerly 414.050; renumbered 566.320]
EXPANSION OF
414.821 [2001 c.898 §1; 2003 c.14 §196; repealed by
2003 c.735 §5]
414.823 [2001 c.898 §2; 2003 c.14 §197; repealed by
2003 c.735 §5]
414.825
Policy. It is the policy of
the State of
(1) The state, in partnership with the
private sector, move toward providing affordable access to basic health care
services for Oregons low-income, uninsured children and families;
(2) Subject to funds available, the state
provide subsidies to low-income Oregonians, using federal and state resources,
to make health care services affordable to Oregons low-income, uninsured
children and families and that those subsidies should encourage the shared
responsibility of employers and individuals in a public-private partnership;
(3) The respective roles and
responsibilities of government, employers, providers, individuals and the
health care delivery system be clearly defined;
(4) All public subsidies be clearly
defined and based on an individuals ability to pay, not exceeding the cost of
purchasing a basic package of health care services, except for those
individuals with the greatest medical needs; and
(5) The health care delivery system
encourage the use of evidence-based health care services, including appropriate
education, early intervention and prevention, and procedures that are effective
and appropriate in producing good health. [2001 c.898 §3; 2003 c.14 §198]
Note: 414.825, 414.831 and 431.839 were enacted
into law by the Legislative Assembly but were not added to or made a part of
ORS chapter 414 or any series therein by legislative action. See Preface to
Oregon Revised Statutes for further explanation.
414.827 [2001 c.898 §4; 2003 c.14 §199; repealed by
2003 c.735 §5]
414.829 [2001 c.898 §5; 2003 c.14 §200; repealed by
2003 c.684 §13 and 2003 c.735 §5]
414.830 [Formerly 414.060; renumbered 566.330]
414.831
Family Health Insurance Assistance Program. The Office of Private Health Partnerships shall focus on expanding
group coverage provided by the Family Health Insurance Assistance Program. [2001
c.898 §5a; 2003 c.14 §201; 2003 c.684 §6; 2005 c.744 §37]
Note: See note under 414.825.
414.833 [2001 c.898 §6; 2003 c.14 §202; repealed by
2003 c.735 §5]
414.834 [2001 c.898 §7; 2003 c.14 §203; repealed by
2003 c.735 §5]
414.835 [2001 c.898 §8; 2003 c.14 §204; repealed by
2003 c.735 §5]
414.837 [2001 c.898 §10; 2003 c.14 §205; repealed by
2003 c.735 §5]
414.839
Subsidies for health insurance coverage. (1) Subject to funds available, the Department of Human Services may
provide public subsidies for the purchase of health insurance coverage provided
by public programs or private insurance, including but not limited to the
Family Health Insurance Assistance Program, for currently uninsured individuals
based on incomes up to 200 percent of the federal poverty level. The objective
is to create a transition from dependence on public programs to privately
financed health insurance.
(2) Public subsidies shall apply only to
health benefit plans that meet or exceed the basic benchmark health benefit
plan or plans established under ORS 735.733.
(3) Cost sharing shall be permitted and
structured in such a manner to encourage appropriate use of preventive care and
avoidance of unnecessary services.
(4) Cost sharing shall be based on an
individuals ability to pay and may not exceed the cost of purchasing a plan.
(5) The state may pay a portion of the
cost of the subsidy, based on the individuals income and other resources. [2001
c.898 §11; 2003 c.14 §206; 2003 c.684 §7; 2003 c.735 §9]
Note: See note under 414.825.
(Temporary
provisions relating to Healthy Oregon Act)
Note: Sections 1 to 13 and 27, chapter 697, Oregon
Laws 2007, provide:
Sec.
1. Sections 2 to 13 of this
2007 Act shall be known and may be cited as the Healthy Oregon Act. [2007 c.697
§1]
Sec.
2. As used in sections 2 to
13 of this 2007 Act, except as otherwise specifically provided or unless the
context requires otherwise:
(1) Accountable health plan means a
prepaid managed care health services organization described in ORS 414.725 or
an entity that contracts with the Oregon Health Fund Board to provide a health
benefit plan, as defined in ORS 743.730, through the Oregon Health Fund
program.
(2) Core health care safety net provider
means a safety net provider that is especially adept at serving persons who
experience significant barriers to accessing health care, including
homelessness, language and cultural barriers, geographic isolation, mental
illness, lack of health insurance and financial barriers, and that has a
mission or mandate to deliver services to persons who experience barriers to
accessing care and serves a substantial share of persons without health
insurance and persons who are enrolled in Medicaid or Medicare, as well as
other vulnerable or special populations.
(3) Defined set of essential health
services means the services:
(a) Identified by the Health Services
Commission using the methodology in ORS 414.720 or an alternative methodology
developed pursuant to section 9 (3)(c) of this 2007 Act; and
(b) Approved by the
(4) Employer has the meaning given that
term in ORS 657.025.
(5) Oregon Health Card means the card
issued by the Oregon Health Fund Board that verifies the eligibility of the
holder to participate in the Oregon Health Fund program.
(6) Oregon Health Fund means the fund
established in section 8 of this 2007 Act.
(7) Oregon Health Fund Board means the
board established in section 5 of this 2007 Act.
(8) Safety net provider means providers
that deliver health services to persons experiencing cultural, linguistic,
geographic, financial or other barriers to accessing appropriate, timely,
affordable and continuous health care services. Safety net providers includes
health care safety net providers, core health care safety net providers, tribal
and federal health care organizations and local nonprofit organizations,
government agencies, hospitals and individual providers. [2007 c.697 §2]
Sec.
3. The Oregon Health Fund
program shall be based on the following principles:
(1) Expanding access. The state Medicaid
program, the Oregon State Childrens Health Insurance Program and the Family
Health Insurance Assistance Program must be expanded to include the current
uninsured population in
(2) Equity. All individuals must be
eligible for and have timely access to at least the same set of essential and
effective health services.
(3) Financing of the health care system
must be equitable, broadly based and affordable.
(4) Population benefit. The public must
set priorities to optimize the health of Oregonians.
(5) Responsibility for optimizing health
must be shared by individuals, employers, health care systems and communities.
(6) Education is a powerful tool for
health promotion. The health care system, health plans, providers and
government must promote and engage in education activities for individuals,
communities and providers.
(7) Effectiveness. The relationship
between specific health interventions and their desired health outcomes must be
backed by unbiased, objective medical evidence.
(8) Efficiency. The administration and
delivery of health services must use the fewest resources necessary to produce
the most effective health outcome.
(9) Explicit decision-making.
Decision-making will be clearly defined and accessible to the public, including
lines of accountability, opportunities for public engagement and how public
input will be used in decision-making.
(10) Transparency. The evidence used to
support decisions must be clear, understandable and observable to the public.
(11) Economic sustainability. Health
service expenditures must be managed to ensure long-term sustainability, using
efficient planning, budgeting and coordination of resources and reserves, based
on public values and recognizing the impact that public and private health
expenditures have on each other.
(12) Aligned financial incentives.
Financial incentives must be aligned to support and invest in activities that
will achieve the goals of the Oregon Health Fund program.
(13) Wellness. Health and wellness
promotion efforts must be emphasized and strengthened.
(14) Community-based. The delivery of care
and distribution of resources must be organized to take place at the community
level to meet the needs of the local population, unless outcomes or cost can be
improved at regional or statewide levels.
(15) Coordination. Collaboration,
coordination and integration of care and resources must be emphasized
throughout the health care system.
(16) The health care safety net is a key
delivery system element for the protection of the health of Oregonians and the
delivery of community-based care. [2007 c.697 §3]
Sec.
4. The intent of the Healthy
Oregon Act is to develop an Oregon Health Fund program comprehensive plan,
based upon the principles set forth in section 3 of this 2007 Act, that meets
the intended goals of the program to:
(1) As a primary goal, cover the current
uninsured population in
(2) Reform the health care delivery system
to maximize federal and other public resources without compromising proven
programs supported by federal law that ensure to vulnerable populations access
to efficient and high quality care;
(3) Ensure that all Oregonians have timely
access to and participate in a health benefit plan that provides high quality,
effective, safe, patient-centered, evidence-based and affordable health care
delivered at the lowest cost;
(4) Develop a method to finance the
coverage of a defined set of essential health services for Oregonians that is
not necessarily tied directly to employment;
(5) Allow the potential for employees,
employers, individuals and unions to participate in the program, or to purchase
primary coverage or offer, purchase or bargain for coverage of benefits beyond
the defined set of essential health services;
(6) Allow for a system of public and
private health care partnerships that integrate public involvement and
oversight, consumer choice and competition within the health care market;
(7) Use proven models of health care
benefits, service delivery and payments that control costs and overutilization,
with emphasis on preventive care and chronic disease management using
evidence-based outcomes and a health benefit model that promotes a primary care
medical home;
(8) Provide services for dignified
end-of-life care;
(9) Restructure the health care system so
that payments for services are fair and proportionate among various
populations, health care programs and providers;
(10) Fund a high quality and transparent
health care delivery system that will be held to high standards of transparency
and accountability and allows users and purchasers to know what they are
receiving for their money;
(11) Ensure that funding for health care
is equitable and affordable for all
(12) Ensure, to the greatest extent
possible, that annual inflation in the cost of providing access to essential
health care services does not exceed the increase in the cost of living for the
previous calendar year, based on the Portland-Salem, OR-WA, Consumer Price
Index for All Urban Consumers for All Items, as published by the Bureau of
Labor Statistics of the United States Department of Labor. [2007 c.697 §4]
Sec.
5. (1) There is established
within the Department of Human Services the Oregon Health Fund Board that shall
be responsible for developing the Oregon Health Fund program comprehensive
plan. The board shall consist of seven members appointed by the Governor,
subject to confirmation by the Senate pursuant to section 4, Article III of the
Oregon Constitution. The members of the board shall be selected based upon
their ability to represent the best interests of
(2) Each board member shall serve for a
term of four years. However, a board member shall serve until a successor has
been appointed and qualified. A member is eligible for reappointment.
(3) If there is a vacancy for any cause,
the Governor shall make an appointment to become effective immediately for the
balance of the unexpired term.
(4) The board shall select one of its
members as chairperson and another as vice chairperson, for such terms and with
duties and powers necessary for the performance of the functions of such
offices as the board determines.
(5) A majority of the members of the board
constitutes a quorum for the transaction of business.
(6) Official action by the board requires
the approval of a majority of the members of the board.
(7) A member of the board is not entitled
to compensation for services as a member, but is entitled to expenses as
provided in ORS 292.495 (2). [2007 c.697 §5]
Sec.
6. (1) Within 30 days after
the effective date of this 2007 Act [June 28, 2007], the Governor shall appoint
an executive director of the Oregon Health Fund Board who will be responsible
for establishing the administrative framework for the board.
(2) The executive director appointed under
this section may employ and shall fix the duties and amounts of compensation of
persons necessary to carry out the provisions of sections 2 to 13 of this 2007
Act. Those persons shall serve at the pleasure of the executive director.
(3) The executive director shall serve at
the pleasure of the Governor. [2007 c.697 §6]
Sec.
7. Except as otherwise
provided by law, and except for ORS 279A.250 to 279A.290, the provisions of ORS
chapters 279A, 279B and 279C do not apply to the Oregon Health Fund Board.
[2007 c.697 §7]
Sec.
8. (1) The Oregon Health
Fund is established separate and distinct from the General Fund. Interest
earned from the investment of moneys in the Oregon Health Fund shall be
credited to the fund. The Oregon Health Fund may include:
(a) Employer and employee health care
contributions.
(b) Individual health care premium
contributions.
(c) Federal funds from Title XIX or XXI of
the Social Security Act, and state matching funds, that are made available to
the fund, excluding Title XIX funds for long term care supports, services and
administration, and reimbursements for graduate medical education costs
pursuant to 42 U.S.C. 1395ww(h) and disproportionate share adjustments made
pursuant to 42 U.S.C. 1396a(a)(13)(A)(iv).
(d) Contributions from the United States
Government and its agencies for which the state is eligible provided for
purposes that are consistent with the goals of the Oregon Health Fund program.
(e) Moneys appropriated to the Oregon
Health Fund Board by the Legislative Assembly for carrying out the provisions
of the Healthy Oregon Act.
(f) Interest earnings from the investment
of moneys in the fund.
(g) Gifts, grants or contributions from
any source, whether public or private, for the purpose of carrying out the
provisions of the Healthy Oregon Act.
(2)(a) All moneys in the Oregon Health
Fund are continuously appropriated to the Oregon Health Fund Board to carry out
the provisions of the Healthy Oregon Act.
(b) The Oregon Health Fund shall be
segregated into subaccounts as required by federal law. [2007 c.697 §8]
Sec.
9. (1)(a) The Oregon Health
Fund Board shall establish a committee to examine the impact of federal law
requirements on reducing the number of Oregonians without health insurance,
improving Oregonians access to health care and achieving the goals of the
Healthy Oregon Act, focusing particularly on barriers to reducing the number of
uninsured Oregonians, including but not limited to:
(A) Medicaid requirements such as
eligibility categories and household income limits;
(B) Federal tax code policies regarding
the impact on accessing health insurance or self-insurance and the affect on
the portability of health insurance;
(C) Emergency Medical Treatment and Active
Labor Act regulations that make the delivery of health care more costly and
less efficient; and
(D) Medicare policies that result in
(b) With the approval of the Oregon Health
Fund Board, the committee shall report its findings to the
(c) The committee shall request that the
(A) Participate in at least one hearing in
each congressional district in this state on the impacts of federal policies on
health care services; and
(B) Request congressional hearings in
(2) The Oregon Health Fund Board shall
develop a comprehensive plan to achieve the Oregon Health Fund program goals
listed in section 4 of this 2007 Act. The board shall establish subcommittees,
organized to maximize efficiency and effectiveness and assisted, in the manner
the board deems appropriate, by the Oregon Health Policy Commission, the Office
for Oregon Health Policy and Research, the Health Services Commission and the Medicaid
Advisory Committee, to develop proposals for the Oregon Health Fund program
comprehensive plan. The proposals may address, but are not limited to, the
following:
(a) Financing the Oregon Health Fund
program, including but not limited to proposals for:
(A) A model for rate setting that ensures
providers will receive fair and adequate compensation for health care services.
(B) Collecting employer and employee
contributions and individual health care premium contributions, and redirecting
them to the Oregon Health Fund.
(C) Implementing a health insurance
exchange to serve as a central forum for uninsured individuals and businesses
to purchase affordable health insurance.
(D) Taking best advantage of health
savings accounts and similar vehicles for making health insurance more
accessible to uninsured individuals.
(E) Addressing the issue of medical
liability and medical errors including, but not limited to, consideration of a
patients compensation fund.
(F) Requesting federal waivers under
Titles XIX and XXI of the Social Security Act, or other federal matching funds
that may be made available to implement the comprehensive plan and increase
access to health care.
(G) Evaluating statutory and regulatory
barriers to the provision of cost-effective services, including limitations on
access to information that would enable providers to fairly evaluate contract
reimbursement, the regulatory effectiveness of the certificate of need process,
consideration of a statewide uniform credentialing process and the costs and
benefits of improving the transparency of costs of hospital services and health
benefit plans.
(b) Delivering health services in the
Oregon Health Fund program, including but not limited to proposals for:
(A) An efficient and effective delivery
system model that ensures the continued viability of existing prepaid managed
care health services organizations, as described in ORS 414.725, to serve
Medicaid populations.
(B) The design and implementation of a
program to create a public partnership with accountable health plans to
provide, through the use of an Oregon Health Card, health insurance coverage of
the defined set of essential health services that meets standards of
affordability based upon a calculation of how much individuals and families,
particularly the uninsured, can be expected to spend for health insurance and
still afford to pay for housing, food and other necessities. The proposal must
ensure that each accountable health plan:
(i) Does not deny enrollment to qualified
Oregonians eligible for Medicaid;
(ii) Provides coverage of the entire
defined set of essential health services;
(iii) Will develop an information system
to provide written information, and telephone and Internet access to
information, necessary to connect enrollees with appropriate medical and dental
services and health care advice;
(iv) Offers a simple and timely complaint
process;
(v) Provides enrollees with information
about the cost and quality of services offered by health plans and procedures
offered by medical and dental providers;
(vi) Provides advance disclosure of the
estimated out-of-pocket costs of a service or procedure;
(vii) Has contracts with a sufficient
network of providers, including but not limited to hospitals and physicians,
with the capacity to provide culturally appropriate, timely health services and
that operate during hours that allow optimal access to health services;
(viii) Ensures that all enrollees have a
primary care medical home;
(ix) Includes in its network safety net
providers and local community collaboratives;
(x) Regularly evaluates its services,
surveys patients and conducts other assessments to ensure patient satisfaction;
(xi) Has strategies to encourage enrollees
to utilize preventive services and engage in healthy behaviors;
(xii) Has simple and uniform procedures
for enrollees to report claims and for accountable health plans to make
payments to enrollees and providers;
(xiii) Provides enrollment, encounter and
outcome data for evaluation and monitoring purposes; and
(xiv) Meets established standards for loss
ratios, rating structures and profit or nonprofit status.
(C) Using information technology that is
cost-neutral or has a positive return on investment to deliver efficient, safe
and quality health care and a voluntary program to provide every Oregonian with
a personal electronic health record that is within the individuals control,
use and access and that is portable.
(D) Empowering individuals through
education as well as financial incentives to assume more personal
responsibility for their own health status through the choices they make.
(E) Establishing and maintaining a
registry of advance directives and Physician Orders for Life-Sustaining
Treatment (POLST) forms and a process for assisting a person who chooses to
execute an advance directive in accordance with ORS 127.531 or a POLST form.
(F) Designing a system for regional health
delivery.
(G) Combining, reorganizing or eliminating
state agencies involved in health planning and policy, health insurance and the
delivery of health care services and integrating and streamlining their
functions and programs to maximize their effectiveness and efficiency. The
subcommittee may consider, but is not limited to considering, the following
state agencies, functions or programs:
(i) The Health Services Commission;
(ii) The Oregon Health Policy Commission;
(iii) The Health Resources Commission;
(iv) The Medicaid Advisory Committee;
(v) The Department of Human Services,
including but not limited to the state Medicaid agency, the Office for Oregon
Health Policy and Research, offices involved in health systems planning,
offices involved in carrying out the duties of the department with respect to
certificates of need under ORS 443.305 to 443.350 and the functions of the
department under ORS chapter 430;
(vi) The Department of Consumer and
Business Services;
(vii) The Oregon Patient Safety
Commission;
(viii) The Office of Private Health
Partnerships;
(ix) The Public Employees Benefit Board;
(x) The State Accident Insurance Fund
Corporation; and
(xi) The Office of Rural Health.
(c) Establishing the defined set of
essential health services, including but not limited to proposals for a
methodology, consistent with the principles in section 3 of this 2007 Act, for
determining and continually updating the defined set of essential health
services. The Oregon Health Fund Board may delegate this function to the Health
Services Commission established under ORS 414.715.
(d) The eligibility requirements and
enrollment procedures for the Oregon Health Fund program, including, but not
limited to, proposals for:
(A) Public subsidies of premiums or other
costs under the program.
(B) Streamlined enrollment procedures,
including:
(i) A standardized application process;
(ii) Requirements to ensure that enrollees
demonstrate
(iii) A process to enable a provider to
enroll an individual in the Oregon Health Fund program at the time the
individual presents for treatment to ensure coverage as of the date of the
treatment; and
(iv) Permissible waiting periods,
preexisting condition limitations or other administrative requirements for
enrollment.
(C) A grievance and appeal process for
enrollees.
(D) Standards for disenrollment and
changing enrollment in accountable health plans.
(E) An outreach plan to educate the
general public, particularly uninsured and underinsured persons, about the
program and the programs eligibility requirements and enrollment procedures.
(F) Allowing employers to offer health
insurance coverage by insurers of the employers choice or to contract for
coverage of benefits beyond the defined set of essential health services.
(3) On the effective date of this 2007 Act
[June 28, 2007], the Oregon Health Policy Commission, the Office for Oregon
Health Policy and Research, the Health Services Commission and the Medicaid
Advisory Committee are directed to begin compiling data and conducting research
to inform the decision-making of the subcommittees when they are convened. No
later than February 1, 2008, the Oregon Health Policy Commission, the Office
for Oregon Health Policy and Research, the Health Services Commission and the
Medicaid Advisory Committee shall present reports containing data and
recommendations to the subcommittees as follows:
(a) The Oregon Health Policy Commission
shall report on the financing mechanism for the comprehensive plan;
(b) The Administrator of the Office for
Oregon Health Policy and Research shall report on the health care delivery
model of the comprehensive plan;
(c) The Health Services Commission shall
report on the methodology for establishing the defined set of essential health
services under the comprehensive plan; and
(d) The Medicaid Advisory Committee shall
report on eligibility and enrollment requirements under the comprehensive plan.
(4) The membership of the subcommittees
shall, to the extent possible, represent the geographic and ethnic diversity of
the state and include individuals with actuarial and financial management
experience, individuals who are providers of health care, including safety net
providers, and individuals who are consumers of health care, including seniors,
persons with disabilities and individuals with complex medical needs.
(5) Each subcommittee shall select one of
its members as chairperson for such terms and with such duties and powers
necessary for performance of the functions of those offices. Each chairperson
shall serve as an ex officio member of the Oregon Health Fund Board.
Chairpersons shall collaborate to integrate the committee recommendations to
the extent possible.
(6) The committee and the subcommittees
are public bodies for purposes of ORS chapter 192 and must provide reasonable
opportunity for public testimony at each meeting.
(7) All agencies of state government, as
defined in ORS 174.111, are directed to assist the committee, the subcommittees
and the Oregon Health Fund Board in the performance of their duties and, to the
extent permitted by laws relating to confidentiality, to furnish such
information and advice as the members of the committees, the subcommittees and
the Oregon Health Fund Board consider necessary to perform their duties.
(8) The Oregon Health Fund Board shall
report to the Legislative Assembly not later than February 29, 2008. The report
must describe the progress of the subcommittees and the board toward developing
a comprehensive plan to:
(a) Decrease the number of children and
adults without health insurance;
(b) Ensure universal access to health
care;
(c) Contain health care costs; and
(d) Address issues regarding the quality
of health care services.
(9) The Oregon Health Fund Board shall
present a plan to the Legislative Assembly not later than February 1, 2008, for
the design and implementation of the health insurance exchange described in
subsection (2)(a)(C) of this section. [2007 c.697 §9]
Sec.
10. The Oregon Health Fund
Board shall conduct public hearings on the draft Oregon Health Fund program
comprehensive plan developed under section 9 of this 2007 Act and solicit
testimony and input from advocates representing seniors, persons with
disabilities, tribes, consumers of mental health services, low-income
Oregonians, employers, employees, insurers, health plans and providers of
health care including, but not limited to, physicians, dentists, oral surgeons,
chiropractors, naturopaths, hospitals, clinics, pharmacists, nurses and allied
health professionals. [2007 c.697 §10]
Sec.
11. (1) The Oregon Health
Fund Board shall finalize the Oregon Health Fund program comprehensive plan developed
under section 9 of this 2007 Act with due consideration to the information
provided in the public hearings under section 10 of this 2007 Act and shall
present the finalized comprehensive plan to the Governor, the Speaker of the
House of Representatives and the President of the Senate no later than October
1, 2008. The board is authorized to submit the finalized comprehensive plan as
a measure request directly to the Legislative Counsel upon the convening of the
Seventy-fifth Legislative Assembly.
(2) Upon legislative approval of the
comprehensive plan, the board is authorized to request federal waivers deemed
necessary and appropriate to implement the comprehensive plan.
(3) Upon legislative approval of the
comprehensive plan, the board is authorized immediately to implement any
elements necessary to implement the plan that do not require legislative
changes or federal approval. [2007 c.697 §11]
Sec.
12. (1) The Oregon Health
Fund program comprehensive plan described in section 11 of this 2007 Act must
ensure, except as provided in subsection (2) of this section, that a resident
of Oregon who is not a beneficiary of a health benefit plan providing coverage
of the defined set of essential health services and who is not eligible to be
enrolled in a publicly funded medical assistance program providing primary care
and hospital services participates in the Oregon Health Fund program. A
resident of
(2)
Sec.
13. (1) The Administrator of
the Office for Oregon Health Policy and Research, in collaboration with the
Oregon Health Research and Evaluation Collaborative and other persons with
relevant expertise, shall be responsible for developing a plan for evaluating
the implementation and outcomes of the legislation described in section 11 of
this 2007 Act. The evaluation plan shall focus particularly on the individuals
receiving health care covered through the state Medicaid program, the Oregon
State Childrens Health Insurance Program and the Family Health Insurance
Assistance Program and shall include measures of:
(a) Access to care;
(b) Access to health insurance coverage;
(c) Quality of care;
(d) Consumer satisfaction;
(e) Health status;
(f) Provider capacity;
(g) Population demand;
(h) Provider and consumer participation;
(i) Utilization patterns;
(j) Health outcomes;
(k) Health disparities;
(L) Financial impacts, including impacts
on medical debt;
(m) The extent to which employers
discontinue coverage due to the availability of publicly financed coverage or
other employer responses;
(n) Impacts on the financing of health
care and uncompensated care;
(o) Adverse selection, including migration
to
(p) Use of technology;
(q) Transparency of costs; and
(r) Impact on health care costs.
(2) The administrator shall develop
recommendations for a model quality institute that shall:
(a) Develop and promote methods for
improving collection, measurement and reporting of information on quality in
health care;
(b) Provide leadership and support to
further the development of widespread and shared electronic health records;
(c) Develop the capacity of the workforce
to capitalize on health information technology;
(d) Encourage purchasers, providers and
state agencies to improve system transparency and public understanding of
quality in health care;
(e) Support the Oregon Patient Safety
Commissions efforts to increase collaboration and state leadership to improve
health care safety; and
(f) Coordinate an effort among all state
purchasers of health care and insurers to support delivery models and
reimbursement strategies that will more effectively support infrastructure
investments, integrated care and improved health outcomes. [2007 c.697 §13]
Sec.
27. Sections 1 to 13 of this
2007 Act are repealed on January 2, 2010. [2007 c.697 §27]
414.840 [Formerly 414.070; renumbered 566.340]
414.850 [Formerly 414.080; renumbered 566.350]
414.860 [Formerly 414.090; renumbered 566.360]
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