(a) Have demonstrated experience and a capacity for managing financial risk and establishing financial reserves.
(b) Meet the following minimum financial requirements:
(A) Maintain restricted reserves of $250,000 plus an amount equal to 50 percent of the coordinated care organization’s total actual or projected liabilities above $250,000.
(B) Maintain capital or surplus of not less than $2,500,000 and any additional amounts necessary to ensure the solvency of the coordinated care organization, as specified by the authority by rules that are consistent with ORS 731.554 (6), 732.225, 732.230 and 750.045.
(C) Expend a portion of the annual net income or reserves of the coordinated care organization that exceed the financial requirements specified in this paragraph on services designed to address health disparities and the social determinants of health consistent with the coordinated care organization’s community health improvement plan and transformation plan and the terms and conditions of the Medicaid demonstration project under section 1115 of the Social Security Act (42 U.S.C. 1315).
(c) Operate within a fixed global budget and, by January 1, 2023, spend on primary care, as defined in section 2, chapter 575, Oregon Laws 2015, at least 12 percent of the coordinated care organization’s total expenditures for physical and mental health care provided to members, except for expenditures on prescription drugs, vision care and dental care.
(d) Develop and implement alternative payment methodologies that are based on health care quality and improved health outcomes.
(e) Coordinate the delivery of physical health care, behavioral health care, oral health care and covered long-term care services.
(f) Engage community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the coordinated care organization’s members and in the coordinated care organization’s community.
(2) In addition to the criteria and requirements specified in subsection (1) of this section, the authority must adopt by rule requirements for coordinated care organizations contracting with the authority so that:
(a) Each member of the coordinated care organization receives integrated person centered care and services designed to provide choice, independence and dignity.
(b) Each member has a consistent and stable relationship with a care team that is responsible for comprehensive care management and service delivery.
(c) The supportive and therapeutic needs of each member are addressed in a holistic fashion, using patient centered primary care homes, behavioral health homes or other models that support patient centered primary care and behavioral health care and individualized care plans to the extent feasible.
(d) Members receive comprehensive transitional care, including appropriate follow-up, when entering and leaving an acute care facility or a long term care setting.
(e) Members are provided:
(A) Assistance in navigating the health care delivery system;
(B) Assistance in accessing community and social support services and statewide resources;
(C) Meaningful language access as required by federal and state law including, but not limited to, 42 U.S.C. 18116, Title VI of the Civil Rights Act of 1964, Title VI Guidance issued by the United States Department of Justice and the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care as issued by the United States Department of Health and Human Services; and
(D) Qualified health care interpreters or certified health care interpreters listed on the health care interpreter registry, as those terms are defined in ORS 413.550.
(f) Services and supports are geographically located as close to where members reside as possible and are, if available, offered in nontraditional settings that are accessible to families, diverse communities and underserved populations.
(g) Each coordinated care organization uses health information technology to link services and care providers across the continuum of care to the greatest extent practicable and if financially viable.
(h) Each coordinated care organization complies with the safeguards for members described in ORS 414.605.
(i) Each coordinated care organization convenes a community advisory council that meets the criteria specified in ORS 414.575.
(j) Each coordinated care organization prioritizes working with members who have high health care needs, multiple chronic conditions or behavioral health conditions and involves those members in accessing and managing appropriate preventive, health, remedial and supportive care and services, including the services described in ORS 414.766, to reduce the use of avoidable emergency room visits and hospital admissions.
(k) Members have a choice of providers within the coordinated care organization’s network and that providers participating in a coordinated care organization:
(A) Work together to develop best practices for care and service delivery to reduce waste and improve the health and well-being of members.
(B) Are educated about the integrated approach and how to access and communicate within the integrated system about a patient’s treatment plan and health history.
(C) Emphasize prevention, healthy lifestyle choices, evidence-based practices, shared decision-making and communication.
(D) Are permitted to participate in the networks of multiple coordinated care organizations.
(E) Include providers of specialty care.
(F) Are selected by coordinated care organizations using universal application and credentialing procedures and objective quality information and are removed if the providers fail to meet objective quality standards.
(G) Work together to develop best practices for culturally and linguistically appropriate care and service delivery to reduce waste, reduce health disparities and improve the health and well-being of members.
(L) Each coordinated care organization reports on outcome and quality measures adopted under ORS 414.638 and participates in the health care data reporting system established in ORS 442.372 and 442.373.
(m) Each coordinated care organization uses best practices in the management of finances, contracts, claims processing, payment functions and provider networks.
(n) Each coordinated care organization participates in the learning collaborative described in ORS 413.259 (3).
(o) Each coordinated care organization has a governing body that complies with ORS 414.584 and that includes:
(A) At least one member representing persons that share in the financial risk of the organization;
(B) A representative of a dental care organization selected by the coordinated care organization;
(C) The major components of the health care delivery system;
(D) At least two health care providers in active practice, including:
(i) A physician licensed under ORS chapter 677 or a nurse practitioner licensed under ORS 678.375, whose area of practice is primary care; and
(ii) A behavioral health provider;
(E) At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and
(F) At least two members of the community advisory council, one of whom is or was within the previous six months a recipient of medical assistance and is at least 16 years of age, or a parent, guardian or primary caregiver of an individual who is or was within the previous six months a recipient of medical assistance.
(p) Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.
(q) Each coordinated care organization publishes on a website maintained by or on behalf of the coordinated care organization, in a manner determined by the authority, a document designed to educate members about best practices, care quality expectations, screening practices, treatment options and other support resources available for members who have mental illnesses or substance use disorders.
(r) Each coordinated care organization works with the Tribal Advisory Council established in ORS 414.581 and has a dedicated tribal liaison, selected by the council, to:
(A) Facilitate a resolution of any issues that arise between the coordinated care organization and a provider of Indian health services within the area served by the coordinated care organization;
(B) Participate in the community health assessment and the development of the health improvement plan;
(C) Communicate regularly with the Tribal Advisory Council; and
(D) Be available for training by the office within the authority that is responsible for tribal affairs, any federally recognized tribe in Oregon and the urban Indian health program that is located within the area served by the coordinated care organization and operated by an urban Indian organization pursuant to 25 U.S.C. 1651.
(3) The authority shall consider the participation of area agencies and other nonprofit agencies in the configuration of coordinated care organizations.
(4) In selecting one or more coordinated care organizations to serve a geographic area, the authority shall:
(a) For members and potential members, optimize access to care and choice of providers;
(b) For providers, optimize choice in contracting with coordinated care organizations; and
(c) Allow more than one coordinated care organization to serve the geographic area if necessary to optimize access and choice under this subsection.
(5) On or before July 1, 2014, each coordinated care organization must have a formal contractual relationship with any dental care organization that serves members of the coordinated care organization in the area where they reside. [Formerly 414.625; 2021 c.453 §13]
Note 1: The amendments to 414.572 by section 13, chapter 453, Oregon Laws 2021, become operative July 1, 2022. See section 18, chapter 453, Oregon Laws 2021. The text that is operative until July 1, 2022, is set forth for the user’s convenience.
(1) The Oregon Health Authority shall adopt by rule the qualification criteria and requirements for a coordinated care organization and shall integrate the criteria and requirements into each contract with a coordinated care organization. Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two. Coordinated care organizations may contract with counties or with other public or private entities to provide services to members. The authority may not contract with only one statewide organization. A coordinated care organization may be a single corporate structure or a network of providers organized through contractual relationships. The criteria and requirements adopted by the authority under this section must include, but are not limited to, a requirement that the coordinated care organization:
(a) Have demonstrated experience and a capacity for managing financial risk and establishing financial reserves.
(b) Meet the following minimum financial requirements:
(A) Maintain restricted reserves of $250,000 plus an amount equal to 50 percent of the coordinated care organization’s total actual or projected liabilities above $250,000.
(B) Maintain capital or surplus of not less than $2,500,000 and any additional amounts necessary to ensure the solvency of the coordinated care organization, as specified by the authority by rules that are consistent with ORS 731.554 (6), 732.225, 732.230 and 750.045.
(C) Expend a portion of the annual net income or reserves of the coordinated care organization that exceed the financial requirements specified in this paragraph on services designed to address health disparities and the social determinants of health consistent with the coordinated care organization’s community health improvement plan and transformation plan and the terms and conditions of the Medicaid demonstration project under section 1115 of the Social Security Act (42 U.S.C. 1315).
(c) Operate within a fixed global budget and, by January 1, 2023, spend on primary care, as defined in section 2, chapter 575, Oregon Laws 2015, at least 12 percent of the coordinated care organization’s total expenditures for physical and mental health care provided to members, except for expenditures on prescription drugs, vision care and dental care.
(d) Develop and implement alternative payment methodologies that are based on health care quality and improved health outcomes.
(e) Coordinate the delivery of physical health care, mental health and chemical dependency services, oral health care and covered long-term care services.
(f) Engage community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the coordinated care organization’s members and in the coordinated care organization’s community.
(2) In addition to the criteria and requirements specified in subsection (1) of this section, the authority must adopt by rule requirements for coordinated care organizations contracting with the authority so that:
(a) Each member of the coordinated care organization receives integrated person centered care and services designed to provide choice, independence and dignity.
(b) Each member has a consistent and stable relationship with a care team that is responsible for comprehensive care management and service delivery.
(c) The supportive and therapeutic needs of each member are addressed in a holistic fashion, using patient centered primary care homes, behavioral health homes or other models that support patient centered primary care and behavioral health care and individualized care plans to the extent feasible.
(d) Members receive comprehensive transitional care, including appropriate follow-up, when entering and leaving an acute care facility or a long term care setting.
(e) Members receive assistance in navigating the health care delivery system and in accessing community and social support services and statewide resources, including through the use of certified health care interpreters and qualified health care interpreters, as those terms are defined in ORS 413.550.
(f) Services and supports are geographically located as close to where members reside as possible and are, if available, offered in nontraditional settings that are accessible to families, diverse communities and underserved populations.
(g) Each coordinated care organization uses health information technology to link services and care providers across the continuum of care to the greatest extent practicable and if financially viable.
(h) Each coordinated care organization complies with the safeguards for members described in ORS 414.605.
(i) Each coordinated care organization convenes a community advisory council that meets the criteria specified in ORS 414.575.
(j) Each coordinated care organization prioritizes working with members who have high health care needs, multiple chronic conditions, mental illness or chemical dependency and involves those members in accessing and managing appropriate preventive, health, remedial and supportive care and services, including the services described in ORS 414.766, to reduce the use of avoidable emergency room visits and hospital admissions.
(k) Members have a choice of providers within the coordinated care organization’s network and that providers participating in a coordinated care organization:
(A) Work together to develop best practices for care and service delivery to reduce waste and improve the health and well-being of members.
(B) Are educated about the integrated approach and how to access and communicate within the integrated system about a patient’s treatment plan and health history.
(C) Emphasize prevention, healthy lifestyle choices, evidence-based practices, shared decision-making and communication.
(D) Are permitted to participate in the networks of multiple coordinated care organizations.
(E) Include providers of specialty care.
(F) Are selected by coordinated care organizations using universal application and credentialing procedures and objective quality information and are removed if the providers fail to meet objective quality standards.
(G) Work together to develop best practices for culturally appropriate care and service delivery to reduce waste, reduce health disparities and improve the health and well-being of members.
(L) Each coordinated care organization reports on outcome and quality measures adopted under ORS 414.638 and participates in the health care data reporting system established in ORS 442.372 and 442.373.
(m) Each coordinated care organization uses best practices in the management of finances, contracts, claims processing, payment functions and provider networks.
(n) Each coordinated care organization participates in the learning collaborative described in ORS 413.259 (3).
(o) Each coordinated care organization has a governing body that complies with ORS 414.584 and that includes:
(A) At least one member representing persons that share in the financial risk of the organization;
(B) A representative of a dental care organization selected by the coordinated care organization;
(C) The major components of the health care delivery system;
(D) At least two health care providers in active practice, including:
(i) A physician licensed under ORS chapter 677 or a nurse practitioner licensed under ORS 678.375, whose area of practice is primary care; and
(ii) A mental health or chemical dependency treatment provider;
(E) At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and
(F) At least two members of the community advisory council, one of whom is or was within the previous six months a recipient of medical assistance and is at least 16 years of age, or a parent, guardian or primary caregiver of an individual who is or was within the previous six months a recipient of medical assistance.
(p) Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.
(q) Each coordinated care organization publishes on a website maintained by or on behalf of the coordinated care organization, in a manner determined by the authority, a document designed to educate members about best practices, care quality expectations, screening practices, treatment options and other support resources available for members who have mental illnesses or substance use disorders.
(r) Each coordinated care organization works with the Tribal Advisory Council established in ORS 414.581 and has a dedicated tribal liaison, selected by the council, to:
(A) Facilitate a resolution of any issues that arise between the coordinated care organization and a provider of Indian health services within the area served by the coordinated care organization;
(B) Participate in the community health assessment and the development of the health improvement plan;
(C) Communicate regularly with the Tribal Advisory Council; and
(D) Be available for training by the office within the authority that is responsible for tribal affairs, any federally recognized tribe in Oregon and the urban Indian health program that is located within the area served by the coordinated care organization and operated by an urban Indian organization pursuant to 25 U.S.C. 1651.
(3) The authority shall consider the participation of area agencies and other nonprofit agencies in the configuration of coordinated care organizations.
(4) In selecting one or more coordinated care organizations to serve a geographic area, the authority shall:
(a) For members and potential members, optimize access to care and choice of providers;
(b) For providers, optimize choice in contracting with coordinated care organizations; and
(c) Allow more than one coordinated care organization to serve the geographic area if necessary to optimize access and choice under this subsection.
(5) On or before July 1, 2014, each coordinated care organization must have a formal contractual relationship with any dental care organization that serves members of the coordinated care organization in the area where they reside.
Note 2: The amendments to 414.572 (formerly 414.625) by section 14, chapter 489, Oregon Laws 2017, become operative January 1, 2023. See section 20, chapter 489, Oregon Laws 2017. The text that is operative on and after January 1, 2023, including amendments by section 4, chapter 49, Oregon Laws 2018, section 8, chapter 358, Oregon Laws 2019, section 2, chapter 364, Oregon Laws 2019, section 58, chapter 478, Oregon Laws 2019, section 7, chapter 529, Oregon Laws 2019, and section 14, chapter 453, Oregon Laws 2021, is set forth for the user’s convenience. (1) The Oregon Health Authority shall adopt by rule the qualification criteria and requirements for a coordinated care organization and shall integrate the criteria and requirements into each contract with a coordinated care organization. Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two. Coordinated care organizations may contract with counties or with other public or private entities to provide services to members. The authority may not contract with only one statewide organization. A coordinated care organization may be a single corporate structure or a network of providers organized through contractual relationships. The criteria and requirements adopted by the authority under this section must include, but are not limited to, a requirement that the coordinated care organization:
(a) Have demonstrated experience and a capacity for managing financial risk and establishing financial reserves.
(b) Meet the following minimum financial requirements:
(A) Maintain restricted reserves of $250,000 plus an amount equal to 50 percent of the coordinated care organization’s total actual or projected liabilities above $250,000.
(B) Maintain capital or surplus of not less than $2,500,000 and any additional amounts necessary to ensure the solvency of the coordinated care organization, as specified by the authority by rules that are consistent with ORS 731.554 (6), 732.225, 732.230 and 750.045.
(C) Expend a portion of the annual net income or reserves of the coordinated care organization that exceed the financial requirements specified in this paragraph on services designed to address health disparities and the social determinants of health consistent with the coordinated care organization’s community health improvement plan and transformation plan and the terms and conditions of the Medicaid demonstration project under section 1115 of the Social Security Act (42 U.S.C. 1315).
(c) Operate within a fixed global budget and spend on primary care, as defined by the authority by rule, at least 12 percent of the coordinated care organization’s total expenditures for physical and mental health care provided to members, except for expenditures on prescription drugs, vision care and dental care.
(d) Develop and implement alternative payment methodologies that are based on health care quality and improved health outcomes.
(e) Coordinate the delivery of physical health care, behavioral health care, oral health care and covered long-term care services.
(f) Engage community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the coordinated care organization’s members and in the coordinated care organization’s community.
(2) In addition to the criteria and requirements specified in subsection (1) of this section, the authority must adopt by rule requirements for coordinated care organizations contracting with the authority so that:
(a) Each member of the coordinated care organization receives integrated person centered care and services designed to provide choice, independence and dignity.
(b) Each member has a consistent and stable relationship with a care team that is responsible for comprehensive care management and service delivery.
(c) The supportive and therapeutic needs of each member are addressed in a holistic fashion, using patient centered primary care homes, behavioral health homes or other models that support patient centered primary care and behavioral health care and individualized care plans to the extent feasible.
(d) Members receive comprehensive transitional care, including appropriate follow-up, when entering and leaving an acute care facility or a long term care setting.
(e) Members are provided:
(A) Assistance in navigating the health care delivery system;
(B) Assistance in accessing community and social support services and statewide resources;
(C) Meaningful language access as required by federal and state law including, but not limited to, 42 U.S.C. 18116, Title VI of the Civil Rights Act of 1964, Title VI Guidance issued by the United States Department of Justice and the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care as issued by the United States Department of Health and Human Services; and
(D) Qualified health care interpreters or certified health care interpreters listed on the health care interpreter registry, as those terms are defined in ORS 413.550.
(f) Services and supports are geographically located as close to where members reside as possible and are, if available, offered in nontraditional settings that are accessible to families, diverse communities and underserved populations.
(g) Each coordinated care organization uses health information technology to link services and care providers across the continuum of care to the greatest extent practicable and if financially viable.
(h) Each coordinated care organization complies with the safeguards for members described in ORS 414.605.
(i) Each coordinated care organization convenes a community advisory council that meets the criteria specified in ORS 414.575.
(j) Each coordinated care organization prioritizes working with members who have high health care needs, multiple chronic conditions or behavioral health conditions and involves those members in accessing and managing appropriate preventive, health, remedial and supportive care and services, including the services described in ORS 414.766, to reduce the use of avoidable emergency room visits and hospital admissions.
(k) Members have a choice of providers within the coordinated care organization’s network and that providers participating in a coordinated care organization:
(A) Work together to develop best practices for care and service delivery to reduce waste and improve the health and well-being of members.
(B) Are educated about the integrated approach and how to access and communicate within the integrated system about a patient’s treatment plan and health history.
(C) Emphasize prevention, healthy lifestyle choices, evidence-based practices, shared decision-making and communication.
(D) Are permitted to participate in the networks of multiple coordinated care organizations.
(E) Include providers of specialty care.
(F) Are selected by coordinated care organizations using universal application and credentialing procedures and objective quality information and are removed if the providers fail to meet objective quality standards.
(G) Work together to develop best practices for culturally and linguistically appropriate care and service delivery to reduce waste, reduce health disparities and improve the health and well-being of members.
(L) Each coordinated care organization reports on outcome and quality measures adopted under ORS 414.638 and participates in the health care data reporting system established in ORS 442.372 and 442.373.
(m) Each coordinated care organization uses best practices in the management of finances, contracts, claims processing, payment functions and provider networks.
(n) Each coordinated care organization participates in the learning collaborative described in ORS 413.259 (3).
(o) Each coordinated care organization has a governing body that complies with ORS 414.584 and that includes:
(A) At least one member representing persons that share in the financial risk of the organization;
(B) A representative of a dental care organization selected by the coordinated care organization;
(C) The major components of the health care delivery system;
(D) At least two health care providers in active practice, including:
(i) A physician licensed under ORS chapter 677 or a nurse practitioner licensed under ORS 678.375, whose area of practice is primary care; and
(ii) A behavioral health provider;
(E) At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and
(F) At least two members of the community advisory council, one of whom is or was within the previous six months a recipient of medical assistance and is at least 16 years of age or a parent, guardian or primary caregiver of an individual who is or was within the previous six months a recipient of medical assistance.
(p) Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.
(q) Each coordinated care organization publishes on a website maintained by or on behalf of the coordinated care organization, in a manner determined by the authority, a document designed to educate members about best practices, care quality expectations, screening practices, treatment options and other support resources available for members who have mental illnesses or substance use disorders.
(r) Each coordinated care organization works with the Tribal Advisory Council established in ORS 414.581 and has a dedicated tribal liaison, selected by the council, to:
(A) Facilitate a resolution of any issues that arise between the coordinated care organization and a provider of Indian health services within the area served by the coordinated care organization;
(B) Participate in the community health assessment and the development of the health improvement plan;
(C) Communicate regularly with the Tribal Advisory Council; and
(D) Be available for training by the office within the authority that is responsible for tribal affairs, any federally recognized tribe in Oregon and the urban Indian health program that is located within the area served by the coordinated care organization and operated by an urban Indian organization pursuant to 25 U.S.C. 1651.
(3) The authority shall consider the participation of area agencies and other nonprofit agencies in the configuration of coordinated care organizations.
(4) In selecting one or more coordinated care organizations to serve a geographic area, the authority shall:
(a) For members and potential members, optimize access to care and choice of providers;
(b) For providers, optimize choice in contracting with coordinated care organizations; and
(c) Allow more than one coordinated care organization to serve the geographic area if necessary to optimize access and choice under this subsection.
(5) On or before July 1, 2014, each coordinated care organization must have a formal contractual relationship with any dental care organization that serves members of the coordinated care organization in the area where they reside.