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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 

DIVISION 500
RURAL MEDICAL PRACTITIONERS INSURANCE
SUBSIDY PROGRAM
410-500-0000
Purpose
(1)
Effective retroactive to January 1, 2012, the Rural Medical Practitioners Insurance
Subsidy Program (Program) has been established in the Oregon Health Authority (Authority).
(2)
The purpose of the Program is to provide payments from the Rural Medical Liability
Subsidy Fund to authorized medical professional liability insurance carriers to
subsidize the cost of premiums charged by carriers to qualified practitioners for
policies issued, in force, or renewed on or after January 1, 2012, in the manner
provided in these rules.
(3)
These rules govern the Authority’s payment of premium subsidies under this
Program. The Authority may not accept or pay for any claims involving a carrier
or a practitioner, or disputes between them.
Stat.
Auth.: ORS 413.042 & 676.550 -556
Stats.
Implemented: ORS 413.042
Hist.:
DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12; DMAP 36-2012, f. 7-27-12,
cert. ef. 7-28-12
410-500-0010
Definitions
For
the purposes of OAR 410-500-0000 through 410-500-0060, the following definitions
shall apply:
(1)
“Carrier” means a medical professional liability insurer holding a valid
certificate of authority from the Director of the Department of Consumer and Business
Services (DCBS) that authorizes the transaction of insurance as defined in ORS 731.066(1)
and 731.072(1), and does not include DCBS listed insurers pursuant to 735.300 to
735.365 and 735.400 to 735.495.
(2)
“Medical assistance” has the same meaning given that term in ORS 414.025.
(3)
“Medicare” means medical coverage provided under Title XVIII of the
Social Security Act.
(4)
“Office of Rural Health” (Office) has the same meaning given that term
in ORS 442.475.
(5)
“Practitioner” means a physician licensed under ORS chapter 677 or a
nurse practitioner certified under ORS 678.375 who has a rural practice that meets
criteria established by the Office that applied as of January 1, 2004, for the purposes
of ORS 315.613. Practitioner does not include a physician or nurse practitioner
located in an urbanized area of Jackson County, as defined by the United States
Census Bureau according to the most recent federal decennial census taken pursuant
to the authority of the United States Department of Commerce under 13 U.S.C. 141(a),
unless the practitioner is:
(a)
A physician who specializes in obstetrics or who specializes in family or general
practice and provides obstetrical services; or
(b)
A nurse practitioner certified for obstetric care.
(6)
“Rural Medical Liability Subsidy Fund” means a fund established in ORS
676.550 -556 to provide payments to medical professional liability insurance carriers
to subsidize the cost of premiums charged by the carriers to qualifying practitioners.
(7)
“Rural Medical Practitioner Insurance Fund Program” (Program) means
the program established by the Authority to provide payments to authorized medical
professional liability insurance carriers to subsidize the cost of premiums charged
by the carriers to qualified practitioners from the Rural Medical Liability Subsidy
Fund established in ORS 676.550 -556
Stat.
Auth.: ORS 413.042 & 676.550 -556
Stats.
Implemented: ORS 413.042
Hist.:
DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12; DMAP 36-2012, f. 7-27-12,
cert. ef. 7-28-12
410-500-0020
Eligibility
Criteria for Rural Practitioners
(1)
A practitioner who has a rural practice that meets the criteria established by the
Office for the purposes of ORS 315.613 is eligible for a subsidy under the Program,
if the practitioner:
(a)
Holds an active, unrestricted license or certification;
(b)
Is covered by a medical professional liability insurance policy issued by an authorized
carrier with minimum coverage limits coverage of $1 million per occurrence and
$1 million annual aggregate; and
(c)
Is willing to serve patients with Medicare coverage and patients receiving medical
assistance in at least the same proportion to the practitioner’s total number
of patients as the Medicare and medical assistance populations represent of the
total number of individuals determined by the Office to be in need of care in the
areas served by the practice.
(2)
A nurse practitioner employed by a licensed physician is eligible for a subsidy
if they are covered by a medical professional liability insurance policy that names
and separately calculates the premium for the nurse practitioner.
(3)
A practitioner whose medical professional liability insurance coverage is provided
through a health care facility, as defined in ORS 442.400, and also meets the requirements
of section (4) of this rule is eligible for a premium subsidy if the Office determines
that practitioner:
(a)
Is not an employee of the health care facility;
(b)
Is covered by a medical professional liability insurance policy that names the practitioner
and separately calculates the premium for the practitioner; and
(c)
Fully reimburses the health care facility for the premium calculated for the practitioner.
(4)
Eligibility by individual practitioners to participate in the Program must be requested
each year using an annual attestation administered by the Office. Consistent with
the requirements of this rule, the Office shall establish criteria and procedures
for making the eligibility determinations and for an annual attestation procedure
that practitioners must use.
(5)
The Office shall determine whether practitioners are eligible to participate in
the Program and shall provide its eligibility determination to the Authority and
the practitioner.
(a)
If a practitioner disagrees with the office’s eligibility determination for
the Program, the Office shall conduct an informal review and issue its recommendation
to the Authority.
(b)
The Authority shall make the final determination of eligibility to participate in
the Program. Appeals shall be handled in accordance with the procedure for administrative
review described in OAR 410-500-0060.
(6)
The Authority shall forward to each of the authorized carriers participating in
this Program, the list of eligible practitioners that it receives from the Office.
The list shall include the practitioner’s name, mailing address, specialty
and applicable professional license or certification number issued by either the
Board of Medical Examiners or the Board of Nursing.
Stat.
Auth.: ORS 413.042 & 676.550 -556
Stats.
Implemented: ORS 413.042
Hist.:
DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12; DMAP 36-2012, f. 7-27-12,
cert. ef. 7-28-12
410-500-0030
Determination
of Subsidy Amount
(1)
Beginning with the first calendar quarter in 2012, premium subsidy payments may
be made to carriers to subsidize the cost of premiums charged by the carrier to
eligible practitioners.
(a)
Premium subsidies paid as a percentage of the actual premium charged for medical
professional liability insurance with coverage limits of $1 million per occurrence
and up to $3 million annual aggregate.
(b)
Notwithstanding section (1)(a) of this rule, the premium subsidy for a practitioner
referred to in OAR 410-500-0030(3)(c) or (d) shall be the lesser of the percentage
of the premium due or paid for the current calendar year and the premium paid in
the previous calendar year. When determining the lesser amount, any step increases
in the premium owing to the claims-made nature of the policy may not be considered.
(2)
Within 30 days after the end of each billing period,monthly or quarterly, each
carrier must electronically, (using Microsoft Excel or similar spreadsheet application)
submit a report to the Authority showing the following information for each eligible
practitioner who has been determined eligible for a premium subsidy by the Office
in accordance with OAR 410-500-0020, as of the end of the billing quarter under
this Program.
(a)
The information must include the following:
(A)
Carrier’s name;
(B)
Practitioner’s name and, for each practitioner:
(i)
Oregon Board of Medical Examiners license number or Oregon State Board of Nursing
certification number;
(ii)
Practitioner’s specialty and specialty class;
(iii)
Insurance Services Office (ISO) code;
(iv)
Policy number and effective date;
(v)
Billing period coverage start and end dates;
(vi)
Billing frequency (annually, quarterly, monthly);
(vii)
Current in-force annual premium for coverage limits of $1 million per occurrence
and up to $3 million annual aggregate;
(viii)
Premium subsidy percentage, calculated in accordance with section (3) of this rule;
(ix)
Dollar amount of premium subsidy, calculated in accordance with these rules;
(x)
Explanation of any adjustments under this Program from previous reports;
(xi)
Policy coverage limits;
(xii)
Claims-made step of practitioner, if applicable.
(xiii)
Identification of practitioners who were not on the eligible list at the beginning
of the quarter, including all of the information in subparagraphs through this
rule for eligible practitioners;
(b)
Each January all carriers must provide the Authority with a copy of its base rates
and increased limits factors table. The carrier must also inform the Authority of
the base rates and increased limits factors table from their current rate filing
for Oregon within 30 days of any change to those rates and table.
(c)
A carrier must submit true, accurate, and complete report or rates.
(d)
Failure to make a timely submission may result in delay in processing the payment
request. The Authority shall calculate the payment of premium subsidies from the
Rural Medical Liability Subsidy Fund based on the funds available for the applicable
billing period. In the event of insufficient funds, the risk of carrier delay in
submission of a request for subsidy payment is on the carrier, because payments
shall be based on the subsidy requests received timely for each applicable billing
period.
(3)
Subject to section (4) of this rule, the amount of the premium subsidy paid shall
be calculated for eligible practitioners, as follows:
(a)
Eighty percent of the actual premium charged for physicians specializing in obstetrics
and nurse practitioners certified for obstetric care;
(b)
Sixty percent of the actual premium charged for physicians specializing in family
or general practice who provide obstetrical services;
(c)
Forty percent of the actual premium charged for physicians and nurse practitioners
engaging in one or more of the following practices:
(A)
Family practice without obstetrical services;
(B)
General practice without obstetrical services;
(C)
Internal medicine;
(D)
Geriatrics;
(E)
Pulmonary medicine;
(F)
Pediatrics;
(G)
General surgery; or
(H)
Anesthesiology;
(d)
Fifteen percent of the actual premium charged for physicians and nurse practitioners
other than those included in sections (3) (a) through (c).
(e)
Using the information timely provided by carriers provided pursuant to section (2)
of this rule, the information provided by the Office about eligible practitioners,
and the provisions of this rule describing the calculation of the premium subsidy
amounts, the Authority shall review the report for accuracy, and make the appropriate
premium subsidy payments to the authorized carriers for undisputed items to the
authorized carrier within 30 days of receipt.
(4)
All payments authorized to be made by the Authority must be made from the Rural
Medical Liability Subsidy Fund. No other funds have been established by the Legislative
Assembly to make any premium subsidy payments.
(a)
If the funds available for the Program in the Rural Medical Liability Subsidy Fund
are insufficient to provide the maximum premium subsidy for all qualifying practitioners,
the Authority shall reduce or eliminate subsidies for practitioners described in
section (3)(d).
(b)
If, after eliminating subsidies for practitioners described in section (3)(d), the
funds are insufficient to provide the maximum premium subsidies for the remaining
practitioners, the Authority shall also reduce or eliminate the subsidies for practitioners
described in section (3)(c).
(c)
If the funds are insufficient to provide the subsidies for the remaining practitioners,
the Program may not make payments that exceed the amounts remaining in the Fund.
(d)
If the Authority must take any of the actions described in this rule due to insufficient
funds to pay a premium subsidy, the Authority shall inform the affected participants
and carriers about the action.
(5)
A carrier shall reduce the premium charged to a practitioner by the amount of any
premium subsidy paid or to be paid under this Program. Each carrier must provide
its participating practitioners with the following information each quarter this
Program is in effect:
(a)
The quarterly premium due before the premium subsidy is applied;
(b)
The amount of the premium subsidy; and
(c)
The premium after the premium subsidy is applied.
(6)
The carrier shall display these three figures on each participating practitioner’s
billing statement.
Stat.
Auth.: ORS 413.042 & 676.550 -556
Stats.
Implemented: ORS 413.042
Hist.:
DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12; DMAP 36-2012, f. 7-27-12,
cert. ef. 7-28-12
410-500-0040
Authorized
Carriers
(1)
To participate in the Program carriers must provide written notice and certification
to the Authority not less than 30 days prior to the beginning date of a calendar
quarter. The initial carrier written notification and certification must be signed
by an individual authorized to represent the carrier and delivered to the Authority
at the following address: Oregon Health Authority, 500 Summer St NE, E-44, Salem,
OR 97301, and Attention: Rural Medical Practitioners Insurance Subsidy Program.
(a)
The written notification must certify that the carrier:
(A)
Is a medical professional liability insurer holding a valid certificate of authority
from the Director of DCBS that authorizes the transaction of insurance as defined
in ORS 731.066(1) and 731.072(1), and does not include DCBS listed insurers pursuant
to 735.300 to 735.365 and 735.400 to 735.495;
(B)
Understands that the Authority may confirm the representations in paragraph (A)
with DCBS, and that DCBS’ determination about whether the carrier holds a
valid certificate of authority to engage in professional liability insurance in
the state of Oregon and the other criteria in paragraph (A) shall be relied upon
by the Authority in determining whether an insurer is an authorized carrier and
(C)
That the carrier agrees to comply with the terms and conditions of the rules applicable
to this Program in effect at the time of initial certification and those rules in
effect when any request for subsidy payment is submitted to the Authority for payment.
(D)
The Authority shall confirm in writing that the carrier meets the criteria as an
authorized carrier. If the Authority determines that an entity is not eligible to
participate as a carrier, the Authority shall provide notice to the entity of its
determination and shall deny participation in the Program. The Authority shall handle
a request to appeal that determination in accordance with the procedure for administrative
review described in OAR 410-500-0060.
(b)
If an insurer fails to provide the notice and certification to the Authority within
the time established, the insurer may not submit a request for premium subsidy payment
for the next calendar quarter and insurers otherwise eligible practitioners may
not receive a premium subsidy for that quarter.
(c)
An authorized carrier must provide, and continue to provide, to the Authority accurate,
complete and truthful information concerning their qualification for participation
in the Program. A carrier must notify the Authority in writing of a material change
in any status or condition that relates to their eligibility to participate in the
Program.
(2)
If a carrier decides to discontinue participation in the Program, the carrier shall
notify the Authority at least 90 days prior to the beginning date of the next calendar
quarter. The carrier shall notify its insured participating practitioners of its
intent to not participate at least 60 days prior to the date of the next calendar
quarter.
(3)
The Authority may determine that funds available for the Program are insufficient
to provide maximum premium subsidy for all qualified practitioners, and the Authority
may reduce or eliminate subsidies. There is no guarantee of any amount of premium
subsidy that may be provided to any carrier.
Stat.
Auth.: ORS 413.042 & 676.550 -556
Stats.
Implemented: ORS 413.042
Hist.:
DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12; DMAP 36-2012, f. 7-27-12,
cert. ef. 7-28-12
410-500-0050
Program
Integrity
(1)
The Authority shall analyze and monitor the operation of the Program and audit and
verify the accuracy and appropriateness of subsidy payments, or other program integrity
actions. To promote the integrity of the administration of the program, the carrier
shall:
(a)
Develop and maintain adequate financial and other documentation, which supports
the actual premium payments and coverage records for which payment has been requested.
The Program shall make payments only for adequately documented services. Documentation
must be completed before the service is billed to the Authority. The records must
be accurate and in sufficient detail to substantiate the data reported in relation
to a request for premium subsidy payment;
(b)
Have policies and procedures to ensure the maintenance of the applicable records;
(c)
Upon written request from the Authority, the Oregon Secretary of State (Secretary),
other federal or state oversight agency or their authorized representatives, furnish
requested documentation immediately or within the time frame specified in the written
request. Copies of the documents may be furnished unless the originals are requested.
At their discretion, official representatives of the Authority, Secretary, or other
oversight agency, may review and copy the original documentation in the carrier's
place of business. Upon the written request of the carrier, the Program, Secretary,
or other oversight agency may, at their sole discretion, modify or extend the time
for provision of such records if, in the opinion of the Program or the Secretary
or other oversight agency good cause for such extension is shown;
(d)
If a carrier fails to comply with requests for documents within the specified time
frames, the Authority may consider that the requested records do not exist for purposes
of verifying appropriateness of payment. The Authority may also deny or recover
payments from the carrier, which may subject the carrier to possible denial or recovery
of payments made by the Authority or to other actions;
(e)
The Authority may communicate with and coordinate any program integrity actions
with the federal and state oversight authorities, including but not limited to DCBS
if documentation is missing or is inconsistent with claims made for payment of subsidies.
(2)
When the Authority determines that an overpayment has been made to a carrier, the
amount of overpayment is subject to recovery. The Authority may take appropriate
action to redress payment errors or false claims for payment under the Program.
(a)
If an authorized carrier determines that a subsidy payment request is incorrect,
the carrier shall submit a correction within 30 calendar days of the discovery of
the error and refund the amount of any overpayment at that time.
(b)
If the Authority determines that a carrier received a premium subsidy for an insured
eligible practitioner that exceeded the amount that should have been paid, the Authority
shall notify the carrier and require the carrier to remit the overpayment to the
Authority within 30 days of the date of the notification. Overpayment collection
repayment from a carrier does not prevent the carrier from collecting the appropriate
premium from the insured; however, the Authority’s ability to recover an overpayment
from a carrier is not limited by whether the carrier recovers any amount from its
insured.
(c)
The Authority may recover overpayments made to a carrier by direct reimbursement,
offset, civil action, or other actions authorized by law:
(A)
The carrier must make a direct reimbursement to the Authority within 30 calendar
days from the date of the notice of the overpayment;
(B)
The Authority may grant the carrier an additional period of time to reimburse the
Authority upon written request made within 30 calendar days from the date of the
notice of overpayment if the carrier provides a statement of facts and reasons sufficient
to show that repayment should be delayed pending appeal because there is a reason
to believe that the overpayment is not correct or is less than the amount in the
notice, and the carrier has timely filed a request for administrative review of
the overpayment determination, or that carrier accepts the amount of the overpayment
but is authorized in writing by the Authority to make repayment over a period of
time;
(3)
The Authority shall conduct appeals of overpayment determinations in accordance
with the procedure for administrative review described in OAR 410-500-0060.
(4)
If the carrier does not timely request an administrative review, the overpayment
is final and the amount of the overpayment shall be due and payable to the Authority.
(5)
The Authority may withhold payment on pending premium subsidy payment requests and
on subsequently received premium subsidy payment requests for the overpayment when
overpayments are not paid in accordance with the requirements of this rule;
(6)
The Authority may file a civil action in the appropriate court and exercise all
other civil remedies available to the Authority in order to recover the amount of
an overpayment.
(7)
A noncompliant carrier may be terminated from participation in the Program.
(8)
If a carrier fails to reduce the premium charged to a qualified practitioner by
the amount of the premium subsidy, or other noncompliance with Program requirements
the Authority may terminate the carrier from the Program and recover any premium
payments made to the carrier that were not expended in accordance with the requirements
of this Program, if the carrier fails to cure the deficiency within the time and
in the manner prescribed by the Authority.
Stat.
Auth.: ORS 413.042 & 676.550 -556
Stats.
Implemented: ORS 413.042
Hist.:
DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12; DMAP 36-2012, f. 7-27-12,
cert. ef. 7-28-12
410-500-0060
Appeals:
Administrative Review
(1)
Administrative review, for purposes of these rules, shall be the process for any
appeals made to the Authority. An administrative review is an appeal process that
allows an opportunity for the Administrator of the Program or designee to review
a decision. Administrative review is not a contested case.
(2)
A carrier or practitioner may request administrative review. The request must be
received by the Authority not later than 30 calendar days after the date of the
Authority’s notice.
(3)
If the request for administrative review is timely, the practitioner or the carrier
must provide the Authority with a copy of all relevant records and other materials
relevant to the appeal, not later than 10 days before the review is scheduled.
(4)
If the Administrator or designee decides that a preliminary meeting between the
practitioner or carrier and Authority staff may assist the review, the Administrator
or designee shall notify the individual requesting the review of the date, time,
and place the meeting is scheduled.
(5)
The administrative review meeting shall be conducted as follows:
(a)
Conducted by the Administrator, or designee;
(b)
No minutes or transcript of the review shall be made;
(c)
The carrier or practitioner requesting review does not have to be represented by
counsel during an administrative review meeting and shall be given ample opportunity
to present relevant information;
(d)
Authority staff shall not be available for cross-examination, but may attend and
participate in the review meeting;
(e)
Failure to appear without good cause constitutes acceptance of the Authority’s
determination;
(f)
The Administrator may combine similar administrative review proceedings and meetings
involving the same parties or similar facts, if the Administrator determines that
joint proceedings may facilitate the review;
(g)
The Administrator or designee may request the practitioner or carrier making the
appeal to submit, in writing, new information that has been presented orally. The
Authority shall establish the deadline for submission of the information. .
(6)
The results of the administrative review shall be sent to the participant involved
in the review, within 30 calendar days of the conclusion of the administrative review
meeting, or such time as may be agreed to by the participant or designated by the
Authority.
(7)
The Authority’s final decision on administrative review is the final decision
on appeal and binding on the parties. Under ORS 183.484, this decision is an order
in other than a contested case. ORS 183.484 and the procedures in OAR 137-004-0080
to 137-004-0092 apply to the Authority's final decision on administrative review.
(8)
These rules shall be construed in accordance with the laws of the State of Oregon
without regard to principles of conflicts of law. The courts of the State of Oregon
are empowered to resolve any disputes, with venue in Marion County.
Stat.
Auth.: ORS 413.042 & 676.550 -556
Stats.
Implemented: ORS 413.042
Hist.:
DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12; DMAP 36-2012, f. 7-27-12,
cert. ef. 7-28-12

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