The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS




 

DIVISION 27
PRIMARY CARE SERVICES REPORTING
409-027-0010
Purpose and Scope
These rules define primary care services
that must be reported by all Coordinated Care Organizations to the Oregon Health
Authority no later than December 31, 2015. The findings generated from these reports
will be presented to the legislature no later than February 1, 2016.
Stat. Auth: 2015 OL, Ch. 575
Stats. Implemented: 2015
OL, Ch. 575
Hist.: OHP 8-2015(Temp),
f. & cert. ef. 11-5-15 thru 5-2-16
409-027-0020
Definitions
The following definitions apply:
(1) “Authority”
means the Oregon Health Authority.
(2) “Coordinated care
organization (CCO)” has the meaning given that term in ORS 414.025.
(3) “Non-claims based
primary care expenditures” means resources given to a primary care provider
or practice for the following services or arrangements:
(a) Capitation and salaried
arrangements with primary care providers or practices not billed or captured through
claims.
(b) Risk-based reconciliation
for arrangements with primary care providers or practices not billed or captured
through claims.
(c) Payments to Patient-Centered
Primary Care Homes or Patient-Centered Medical Homes based upon that recognition
or payments for participation in proprietary or other multi-payer medical home initiatives.
(d) Retrospective incentive
payments to primary care providers or practices based on performance aimed at decreasing
cost or improving value for a defined population of patients.
(e) Prospective incentive
payments to primary care providers or practices aimed at developing capacity for
improving care for a defined population of patients.
(f) Payments for Health Information
Technology structural changes at a primary care practice such as electronic records
and data reporting capacity from those records.
(g) Workforce expenses including
payments or expenses for supplemental staff or supplemental activities integrated
into the primary care practice such as practice coaches, patient educators, patient
navigators, and nurse care managers.
(4) “Non-claims based
total health care expenditures” means resources given to a provider or practice
for the following services or arrangements:
(a) Capitation or salaried
arrangements with providers or practices not billed or captured through claims.
(b) Risk-based reconciliation
for arrangements with providers or practices not billed or captured through claims.
(c) Payments to Patient-Centered
Primary Care Homes, Patient-Centered Medical Homes, or Patient-Centered Specialty
Practices based upon that recognition or payments for participation in proprietary
or other multi-payer medical home or specialty care practice initiatives.
(d) Retrospective incentive
payments to providers or practices based on performance aimed at decreasing cost
or improving value for a defined population of patients.
(e) Prospective incentive
payments to providers or practices aimed at developing capacity for improving care
for a defined population of patients.
(f) Payments for Health Information
Technology structural changes at a practice such as electronic records and data
reporting capacity from those records.
(g) Workforce expenses including
payments or expenses for supplemental staff or supplemental activities integrated
into the practice such as practice coaches, patient educators, patient navigators,
and nurse care managers.
(5) “Patient-Centered
Medical Home (PCMH)” means a practice or provider who has been recognized
as such by the National Committee for Quality Assurance.
(6) “Patient-Centered
Primary Care Home (PCPCH)” means a health care team or clinic as defined in
ORS 414.655, meets the standards pursuant to OAR 409-055-0040, and has been recognized
through the process pursuant to OAR 409-055-0040.
(7) “Patient Centered
Specialty Practice (PCSP)” means a practice or provider who has been recognized
as such by the National Committee for Quality Assurance.
(8) “Practice”
means an individual, facility, institution, corporate entity, or other organization
which provides direct health care services or items, also termed a performing provider,
or bills, obligates and receives reimbursement on behalf of a performing provider
of services, also termed a billing provider (BP). The term provider refers to both
performing providers and BPs unless otherwise specified.
(9) “Primary care”
means family medicine, general internal medicine, naturopathic medicine, obstetrics
and gynecology, pediatrics or general psychiatry.
(10) “Primary care
provider” means:
(a) A physician, naturopath,
nurse practitioner, physician assistant or other health professional licensed or
certified in this state, whose clinical practice is in the area of primary care.
(b) A health care team or
clinic certified by the Authority as a PCPCH.
Stat. Auth: 2015 OL, Ch. 575
Stats. Implemented: 2015
OL, Ch. 575
Hist.: OHP 8-2015(Temp),
f. & cert. ef. 11-5-15 thru 5-2-16
409-027-0030
Coordinated Care Organization (CCO) Reporting
Requirements
(1) Each CCO shall submit to the Authority
no later than December 31, 2015, all non-claims based primary care expenditures
as defined in OAR 409-027-0020 for calendar year (CY) 2014 using the approved file
layout and format available at: http://www.oregon.gov/OHA/OHPR/pages/rulemaking/index.aspx.
(2) Each CCO shall submit
to the Authority no later than December 31, 2015, all non-claims based total health
care expenditures as defined in section 409-027-0020 for CY 2014 using the approved
file layout and format available at: http://www.oregon.gov/OHA/OHPR/pages/rulemaking/index.aspx.
(3) Each category included
in the approved file format is mutually exclusive; therefore, expenditures shall
only be accounted for in one category.
(4) Claims-based primary
care and total health care expenditures will be calculated for each CCO by the Authority
using data from the Authority’s All-Payer All-Claims Database.
(5) Expenditures for services
or activities outside the primary care setting, regardless of a primary care capacity
building intent, are not considered primary care expenditures for purposes of this
report.
NOTE: Other CCO rules can be
found at OAR 410-141-3000 to 410-141-3485.
Stat. Auth: 2015 OL, Ch. 575
Stats. Implemented: 2015
OL, Ch. 575
Hist.: OHP 8-2015(Temp),
f. & cert. ef. 11-5-15 thru 5-2-16






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