OAR Chapter 409 — Oregon Health Authority, Health Policy and Analytics

Division 1 PROCEDURAL RULES

Or. Admin. R. 409-001-0005 Model Rules of Procedure

The Oregon Health Authority, Health Policy and Analytics Division adopts the Attorney General’s Uniform and Model Rules of Procedure applicable to rulemaking, effective July 2016.

[ED. NOTE: The full text of the Attorney General’s Model Rules of Procedure is available from the Office of the Attorney General or the Oregon Health Authority.]

History

Statutory/Other Authority: ORS 183.341 & 413.042
Statutes/Other Implemented: ORS 183.341 & 413.042
OHP 25-2019, minor correction filed 12/27/2019, effective 12/27/2019
OHP 4-2018, amend filed 06/11/2018, effective 06/11/2018
OHP 1-2002, f. & cert. ef. 1-2-02
OHP 1-1998, f. & cert. ef. 5-6-98
OHP 1-1997, f. & cert. ef. 8-25-97
HP 1-1996, f. & cert. ef. 1-2-96
HP 1-1994, f. & cert. ef. 4-22-94
HP 1-1992, f. & cert. ef. 6-8-92
HP 6-1990, f. & cert. ef. 6-13-90
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 1-1987, f. & ef. 2-3-87
SHPD 12-1985, f. & ef. 11-15-85
SHPD 40-1983, f. & ef. 11-21-83
SHPD 8-1981, f. & ef. 11-18-81
SHPD 1-1980, f. & ef. 2-19-80
SHPD 2, f. & ef. 11-2-77
SHPD 1(Temp), f. & ef. 8-19-77

Division 15 HEALTH CARE FACILITY FINANCIAL REPORTING

Or. Admin. R. 409-015-0005 Definitions

The following definitions apply to OAR 409-015-0005 through 409-015-0040:

(1) “Authority” means the Oregon Health Authority.

(2) "Charity care" means the uncollectible value, at the hospital's full established rates, of services provided to financially indigent patients. The uncollectible portion may vary from a very small percentage of the regular charges for some patients, up to 100 percent for other patients.

(3) "Health care facility" means a hospital, including any special inpatient care facility, and an ambulatory surgical facility. The following facilities are not covered:

(a) Institutions providing only domiciliary care;

(b) Infirmaries of state institutions, colleges and universities;

(d) Long-term care facilities, or hospital-based long-term care service.

(4) "Medicare and Medicaid deductions" means the uncollectible differences between the hospital's full established charges for individual services and the rates paid by Medicare or Medicaid for composite services.

(5) "Other contractual deductions" means the uncollectible differences between full established charges for individual services and the contractual rates paid by a third-party payer for composite services, usually on a per diem, per discharge or capitation basis.

(6) "Provision for bad debts" means the estimated amount of accounts receivable expected to result in credit losses.

(7) "Unreimbursed care" means the sum of the provision for bad debts plus charity service, Medicare deductions, Medicaid deductions and contractual deductions.

History

Statutory/Other Authority: ORS 442.400 & 442.420
Statutes/Other Implemented: ORS 442.400 & 442.420
OHP 4-2016, f. & cert. ef. 3-28-16
OHP 1-2002, f. & cert. ef. 1-2-02
OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99
OHP 1-1997, f. & cert. ef. 8-25-97
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1994, f. & cert. ef. 4-22-94
HP 2-1992, f. & cert. ef. 10-19-92
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 1-1987, f. & ef. 2-3-87
SHPD 21-1983, f. & ef. 6-28-83
SHPD 9-1982(Temp), f. & ef. 12-30-82
SHPD 6-1981, f. & ef. 10-2-81
SHPD 1-1979, f. & ef. 6-1-79

Or. Admin. R. 409-015-0010 Report Forms

(1) All health care facilities shall file the required reports and data on forms provided or approved by the Authority.

(2) The Authority adopts and incorporates by reference the Patient Revenue and Unreimbursed Care form, Form FR-3.

(3) The Authority shall not accept obsolete forms.

[ED. NOTE: Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 442.405, 442.420 & 442.425
Statutes/Other Implemented: ORS 442.425
OHP 4-2016, f. & cert. ef. 3-28-16
OHP 3-2011, f. 2-8-11, cert. ef. 3-1-11
OHP 1-2002, f. & cert. ef. 1-2-02
OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99
OHP 1-1997, f. & cert. ef. 8-25-97
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1994, f. & cert. ef. 4-22-94
HP 2-1992, f. & cert. ef. 10-19-92
HP 2-1990, f. & cert. ef. 2-12-90
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 12-1986, f. & ef. 7-7-86
SHPD 18-1984, f. & ef. 12-20-84
SHPD 21-1983, f. & ef. 6-28-83
SHPD 9-1982(Temp), f. & ef. 12-30-82
SHPD 6-1981, f. & ef. 10-2-81
SHPD 1-1979, f. & ef. 6-1-79

Or. Admin. R. 409-015-0012 Filing Date

The date of filing for the Databank Monthly Data electronically, is the date of receipt by the Oregon Association of Hospitals and Health Systems. The date of filing for the Patient Revenue and Unreimbursed Care (Form FR-3) is the postmark date.

[ED. NOTE: Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 442.405, 442.420 & 442.425
Statutes/Other Implemented: ORS 442.425
OHP 5-2010, f. 9-23-10, cert. ef. 10-1-10
OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1990, f. & cert. ef. 2-12-90
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 18-1984, f. & ef. 12-20-84
SHPD 21-1983, f. & ef. 6-28-83
SHPD 9-1982(Temp), f. & ef. 12-30-82

Or. Admin. R. 409-015-0015 Reports Required

(1) Each health care facility shall file with the Authority financial statements, with attached certification of audit, not later than 120 days following the close of each fiscal year. If the financial statements of the facility are a part of the combining of a for-profit or not-for-profit corporation, the combining financial statements and attached certification of audit shall be filed.

(2) Each health care facility shall file an accurately completed Databank Monthly Data electronically with the Oregon Association of Hospitals and Health Systems (OAHHS) for receipt by OAHHS on or before the 23rd day of each month. This form will transmit data for the preceding month. The Authority may, at its discretion, exempt a special inpatient care facility, ambulatory surgical facility or other health care facility from the requirements of this section. The Authority may, by oral or written notification, require a health care facility to use an express mail service to submit the Databank Monthly Data Input Form to OAHHS.

(3) The Authority may annually require that each health care facility provide a breakdown of its unreimbursed care into bad debts, charity care, Medicare deductions, Medicaid deductions and other contractual deductions, using Form FR-3.

(4) Each health care facility may be required to annually submit to the Authority a breakdown of its gross patient service revenue into inpatient revenue and outpatient revenue, and other applicable categories specified by Form FR-3.

(5) Documents filed with the Authority under these rules are to be addressed to the Oregon Health Authority, Health Systems Research & Data, 500 Summer St. NE E-64, Salem, Oregon 97301-1079.

[ED. NOTE: Forms referenced are available from the agency.]

History

Statutory/Other Authority: ORS 442.405, 442.420 & 442.425
Statutes/Other Implemented: ORS 442.425
OHP 4-2016, f. & cert. ef. 3-28-16
OHP 5-2010, f. 9-23-10, cert. ef. 10-1-10
OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1990, f. & cert. ef. 2-12-90
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 12-1986, f. & ef. 7-7-86
SHPD 18-1984, f. & ef. 12-20-84
SHPD 21-1983, f. & ef. 6-28-83
SHPD 9-1982(Temp), f. & ef. 12-30-82
SHPD 6-1981, f. & ef. 10-2-81
SHPD 1-1979, f. & ef. 6-1-79

Or. Admin. R. 409-015-0022 Instructions to Form RR-4

Text in ORMS

History

OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99
HP 2-1990, f. & cert. ef. 2-12-90
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 18-1984, f. & ef. 12-20-84
Reverted to OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99
Sunset on 09-28-2017

Or. Admin. R. 409-015-0030 Modification of Reporting Requirements

(1) The Authority, upon request of a health care facility and for good cause, may relieve or modify the reporting requirements provided for in these rules when the reporting requirement is proven to the satisfaction of the Authority to impose an undue hardship.

(2) Unless otherwise specified by the Authority, any relief or modification granted under section (1) of this rule is restricted to the specific instance or occasion for which relief was sought, and may not be construed to relieve any other reporting requirements of the health care facility.

History

Statutory/Other Authority: ORS 442.405, 442.420 & 442.425
Statutes/Other Implemented: ORS 442.425
OHP 4-2016, f. & cert. ef. 3-28-16
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 21-1983, f. & ef. 6-28-83
SHPD 9-1982(Temp), f. & ef. 12-30-82
SHPD 6-1981, f. & ef. 10-2-81
SHPD 1-1979, f. & ef. 6-1-79

Or. Admin. R. 409-015-0035 Civil Penalties

(1) Pursuant to ORS 442.445, the Authority adopts the following schedule of civil penalties:

(a) $250.00 per day for the first five days of failure to file in accord with ORS 442.425; and

(b) $500.00 per day from the sixth day until filing in accordance with ORS 442.425 is satisfactorily accomplished.

(2) Any amount of civil penalty imposed by the Authority may not be allowed as a reimbursable cost item and may not be recoverable from any category of payment source or patient.

History

Statutory/Other Authority: ORS 442.405, 442.420 & 442.445
Statutes/Other Implemented: ORS 442.445(2)
OHP 4-2016, f. & cert. ef. 3-28-16
OHP 1-1999, f. 10-22-99, cert. ef. 10-23-99
HP 2-1991, f. & cert. ef. 11-8-91
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 21-1983, f. & ef. 6-28-83
SHPD 9-1982(Temp), f. & ef. 12-30-82
SHPD 6-1981, f. & ef. 10-2-81
SHPD 1-1979, f. & ef. 6-1-79

Division 17 DENTAL SERVICES : UNDERSERVED POPULATIONS

Or. Admin. R. 409-017-0121 Dental Therapy Definition of Underserved Populations

(1) The purpose of this rule is to define the term “underserved population” per ORS 679.624 for the Board of Dentistry Dental Therapy rules.

(2) The term “Underserved Population” refers to populations experiencing a shortage of dental health services due to systemic inequities causing an inability to pay, lack of access to culturally responsive, linguistically appropriate, and comprehensive care, or other inequities for reasons of race, ethnicity, national origin, language, disability, age, gender, gender identity, sexual orientation, socioeconomic class, religion, intersections among these communities or identities, or other socially determined circumstances. These populations include, but are not limited to:

(a) Latino/a/x populations;

(b) Black or African American populations;

(d) Asian populations;

(e) Middle Eastern and North African populations;

(f) Native Hawaiian and Pacific Islander populations;

(g) Slavic and Eastern European populations;

(h) Immigrants and Refugees;

(i) Individuals with limited English proficiency (LEP);

(j) Persons with disabilities;

(k) LGBTQ+ populations;

(L) Pregnant women, new mothers, and women with children;

(m) Individuals transitioning out of incarceration;

(n) Members of religious minorities;

(o) People experiencing unstable housing/houselessness/homelessness;

(p) Migrant and seasonal farmworkers, and related family members;

(q) Young adults and postsecondary graduating students who do not have coverage options through a parent's plan, a student plan, or an employer plan;

(r) Government program-eligible consumers, regardless of whether they are actually enrolled in the program, including those eligible for OHP, Healthier Together Oregon/Cover All Oregonians, DHS foster children;

(s) Uninsured or under-insured individuals, including those receiving coverage though community-based programs or funds;

(t) Other populations not listed above experiencing inequities.

History

Statutory/Other Authority: ORS 679.624
Statutes/Other Implemented: ORS 679.624
OHP 6-2022, adopt filed 08/30/2022, effective 08/30/2022

Division 21 ACCESS OF DATA AND FEES FOR DATA SEARCH

Or. Admin. R. 409-021-0005 Introduction

This division defines the access to the health data collected from various sources and stored at the Office for Oregon Health Policy and Research.

History

Statutory/Other Authority: ORS 442.420(3)(d)
Statutes/Other Implemented: ORS 192.410 - 192.440 & 442.420(3)(d)
OHP 1-2002, f. & cert. ef. 1-2-02
OHP 1-1997, f. & cert. ef. 8-25-97
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1994, f. & cert. ef. 4-22-94
HP 2-1992, f. & cert. ef. 10-19-92
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 5-1986, f. & ef. 1-24-86

Or. Admin. R. 409-021-0010 Definitions

As used in this division:

(1) “Computer” means a desktop personal computer physically located in the Office.

(2) “Data use agreement” means the terms, conditions, restrictions, and other rules governing the use of health data as specified in Form D-1 (Research Data Request) and in Form D-3 (OHPR Data Use Agreement).

(3) “Electronic media” means the consumer media commonly used to store and transport up to 4.7 GB of data. This includes, but is not limited to, floppy diskettes, CDs, DVDs, and other forms of removable storage media.

(4) “Format” means the way health data appears in a display, on electronic media, on printed copy, or in output or data files produced by the Office’s computer software.

(5) “Health data” means an electronic or printed copy of a document, book, paper, file, or other materials, regardless of mode received, that is filed or maintained in pursuit of law or in connection with the transaction of public business. Health data reported to the Office from hospitals and other health care facilities may include information that is protected health information when it is maintained at the hospital or health care facility. The Office obtains such information because it is required by law, and because the Office acts in the capacity of a health oversight agency. The Office is not a covered entity or a business associate of a covered entity. Health data may include, but is not limited to:

(a) The socioeconomic and demographic characteristics of a population;

(b) The incidence of specific diseases or injuries;

(d) The supply of health care services;

(e) Characteristics of the health care providers;

(f) The utilization of health care services; or

(g) Determining the need for health care services.

(6) “HIPAA” means the federal Health Insurance Portability and Accountability Act of 1996 and the regulations published Title 45, Parts 160 and 164, of the Code of Federal Regulations.

(7) “Office” means the Office for Oregon Health Policy and Research.

(8) “Person” means any natural person, corporation, partnership, firm, association or member or committee of the Legislative Assembly.

(9) “Public use health data file” means an aggregation of health data without personal identifiers that are publicly available for download, available through electronic mail, or available for delivery on electronic media, and at the Office’s discretion may require an approved data use agreement.

(10) “Requestor” means the person who:

(a) Requests to inspect health data as provided in OAR 409-021-0120.

(b) Requests one or more copies of one or more public use health data files as provided in OAR 409-021-0130.

(11) “Restricted health data set” means health data, other than routinely available public use data files, provided exclusively for purposes that are specified in an approved data use agreement. Limited data sets as defined by HIPAA shall be considered restricted health data sets.

(12) “Software” means a proprietary package of written programming language that instructs a computer to perform certain tasks.

(13) “Staff time” means the total time required by staff to complete a data request starting from initial contact to final contact with requestor, including searching for information, summarizing, duplicating, accessing the data, or any other time required by staff to complete the request.

(14) “State” means the State of Oregon.

History

Statutory/Other Authority: ORS 192.440 & 442.420(3)(d)
Statutes/Other Implemented: ORS 192.410 - 192.440 & 442.420(3)(d)
OHP 1-2007, f. 1-29-07, cert. ef. 2-1-07
OHP 1-2002, f. & cert. ef. 1-2-02
OHP 1-1997, f. & cert. ef. 8-25-97
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 5-1986, f. & ef. 1-24-86

Or. Admin. R. 409-021-0115 Calculation of Fees

The Office shall charge fees necessary to fully recover the reasonable costs of responding to data requests and requests to examine health data maintained by the Office.

(1) The costs that the Office shall recover include, but are not limited to:

(a) Cost of materials and copying as provided in OAR 409-909-0020.

(b) Cost of staff time necessary to respond to the request.

(d) Any reasonable additional costs the Office deems necessary to respond to the request.

(2) Upon receipt of a completed form D-1, the Office shall provide a written estimate of fees within a reasonable period of time, unless the complete fees for the data request are the published fees for obtaining copies of public use health data files.

(3) The Office reserves the right to discount or waive fees for State agencies or at the discretion of the Administrator of the Office.

(4) The Office may develop contractual agreements for routinely providing data to a person at a discounted fee, upon approval of the Administrator of the Office.

History

Statutory/Other Authority: ORS 192.440 & 442.420(3)(d)
Statutes/Other Implemented: ORS 192.410 - 192.440 & 442.420(3)(d)
Renumbered from 409-021-0025, OHP 1-2007, f. 1-29-07, cert. ef. 2-1-07
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 5-1986, f. & ef. 1-24-86

Or. Admin. R. 409-021-0120 Inspection of Health Data

(1) An inspection of the health data that are maintained at the Office shall be only by appointment during the normal working days and business hours of the Office.

(2) Requests to inspect health data that are maintained by the Office may, at the Office’s discretion, require an approved data use agreement as provided in OAR 409-021-0130(1).

(3) The inspection shall take place at the Office; on a case-by-case basis, other reasonable locations may be designated at the sole discretion of the Administrator of the Office.

(4) The inspection of the requested data shall be in a format commonly employed by the Office for maintaining the requested data.

(5) Recovery of fees, if any, shall take place at the time of inspection.

History

Statutory/Other Authority: ORS 192.440 & 442.420(3)(d)
Statutes/Other Implemented: ORS 192.410 - 192.440 & 442.420(3)(d)
Renumbered from 409-021-0020, OHP 1-2007, f. 1-29-07, cert. ef. 2-1-07
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 5-1986, f. & ef. 1-24-86

Or. Admin. R. 409-021-0130 Requests to Obtain Copies of Public Use Health Data Files

(1) Any requestor who wishes to obtain copies of public use health data files maintained by the Office shall provide all of the following:

(a) Form D-1 (Research Data Request).

(b) Form D-2 (Data Order Form).

(d) Full payment of fees.

(2) All requests for public use health data files require the written approval of the Research and Data Manager.

(3) Upon approval and receipt of full payment of fees, one copy of the requested public use health data file will be provided to the requestor.

(4) The Office shall respond to public use health data file requests within a reasonable period of time, except that the Office's response may be delayed so that critical operations and activities are not unduly disrupted. The Office shall notify the requestor in writing if an extensive delay is anticipated.

(5) This rule shall not apply to health data that the Office routinely makes available for direct download from the Office's web site.

(6) The public use files may not be used to identify any individual, including but not limited to patients, physicians, and other health care providers. The requestor may not use outside information to attempt to ascertain the identity of particular individuals who are the subject of public use files.

[ED. NOTE: Forms referred are available from the agency.]

History

Statutory/Other Authority: ORS 192.440 & 442.420(3)(d)
Statutes/Other Implemented: ORS 192.410 - 192.440, 192.496, 192.501 & 442.420(3)(d)
OHP 1-2013, f. 1-24-13, cert. ef. 2-1-13
Renumbered from 409-021-0015, OHP 1-2007, f. 1-29-07, cert. ef. 2-1-07
OHP 1-2002, f. & cert. ef. 1-2-02
OHP 1-1997, f. & cert. ef. 8-25-97
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1994, f. & cert. ef. 4-22-94
HP 2-1992, f. & cert. ef. 10-19-92
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 5-1986, f. & ef. 1-24-86

Or. Admin. R. 409-021-0140 Requests and Requirements to Obtain Restricted Health Data Sets

(1) The Office may authorize the disclosure of health data in accordance with an approved data use agreement entered into by both the Office and a researcher, pursuant to which the Office may disclose a restricted health data set to a researcher for research, public health, or health care operations. The intent of this rule is to generally apply the legal standard established in the HIPAA Privacy Rule applicable to limited data sets, 45 CFR 164.514(e).

(2) Any requestor who wishes to obtain restricted health data sets from the Office shall provide all of the following:

(a) Form D-1 (Research Data Request)

(b) Form D-2 (Data Order Form)

(d) Full payment of fees.

(3) All requests for restricted health data sets require the written approval of the Research and Data Manager.

(4) Upon approval and receipt of full payment of fees, the Office is authorized to provide one copy of the requested restricted health data set to the requestor.

(5) The Office shall respond to restricted health data set requests within a reasonable period of time, except that the Office’s response may be delayed so that critical operations and activities are not unduly disrupted. The Office shall notify the requestor in writing if an extensive delay is anticipated.

[ED. NOTE: Forms referred are available from the agency.]

History

Statutory/Other Authority: ORS 192.440 & 442.420(3)(d)
Statutes/Other Implemented: ORS 192.410 - 192.440 & 442.420(3)(d)
Renumbered from 409-021-0030, OHP 1-2007, f. 1-29-07, cert. ef. 2-1-07
OHP 1-2002, f. & cert. ef. 1-2-02
OHP 1-1997, f. & cert. ef. 8-25-97
HP 1-1996, f. & cert. ef. 1-2-96
HP 2-1994, f. & cert. ef. 4-22-94
HP 2-1992, f. & cert. ef. 10-19-92
HP 2-1988, f. & cert. ef. 3-25-88
SHPD 5-1986, f. & ef. 1-24-86

Or. Admin. R. 409-021-0150 Denial of Requests to Inspect or Obtain Copies of Health Data

The Office shall deny requests to inspect health data, receive copies of public use health data sets, and receive copies of restricted health data sets in order to prevent uses that are not consistent with current agreements, policies, rules, regulations, or statutes.

(1) The Office shall deny requests to examine health data or receive copies of health data for reasons that include, but are not limited to:

(a) Fulfilling the request violates one or more of the Office’s current data use agreements with one or more other persons.

(b) Fulfilling the request requires unreasonable interference with the Office’s regular discharge of duties.

(d) Fulfilling the request requires disclosures that are an unreasonable invasion of privacy. If a request is denied for this reason, the burden is on the requestor to provide the Office clear and convincing evidence that fulfilling the data request is not an unreasonable invasion of privacy and that the public interest requires disclosing the requested data.

(2) Nothing in these rules authorizes the Office to disclose health data in a form that allows easy and precise identification of individual patients or individual licensed health care professionals.

History

Statutory/Other Authority: ORS 192.440 & 442.420(3)(d)
Statutes/Other Implemented: ORS 192.410 - 192.440 & 442.420(3)(d)
OHP 1-2007, f. 1-29-07, cert. ef. 2-1-07

Division 22 HEALTH CARE FACILITY UTILIZATION AND DISCHARGE DATA SUBMISSION REQUIREMENTS

Or. Admin. R. 409-022-0010 Definitions

The following definitions apply to OAR 409-022-0010 to 409-022-0070:

(1) “Ambulatory Surgical Center” has the same meaning given that term in ORS 442.015.

(2) "Ambulatory surgical discharge data" means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a surgical or diagnostic procedure treatment in a hospital outpatient setting or an ambulatory surgical center setting into a data record.

(3) “Authority” means the Oregon Health Authority.

(4) "Emergency department discharge data" means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for treatment in a hospital emergency department for patients that were not subsequently admitted to the same hospital as an inpatient.

(5) “Health Care Facility” has the same meaning given that term in ORS 442.015.

(6) "Hospital” has the same meaning given that term in ORS 442.015.

(7) “Hospital inpatient” means acute care provided at a hospital in which the patient was formally admitted under a doctor’s order.

(8) “Hospital outpatient” means acute care provided at a hospital in which the patient is not formally admitted to the hospital under a doctor’s order.

(9) “Inpatient discharge data” means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a surgical or diagnostic procedure treatment in a hospital inpatient setting.

History

Statutory/Other Authority: ORS 442.120
Statutes/Other Implemented: ORS 442.120
OHP 1-2020, amend filed 01/10/2020, effective 01/10/2020
OHP 14-2018, amend filed 11/20/2018, effective 12/01/2018
OHP 3-2015, f. 6-30-15, cert. ef. 7-1-15
OHP 3-2006, f. 12-14-06, cert. ef. 1-1-07

Or. Admin. R. 409-022-0015 Health Care Facility Annual Reports

(1) The Authority may require an annual report from each licensed health care facility on utilization of the facility.

(2) For hospitals, the Authority adopts the American Hospital Association annual survey, as administered by the Oregon Association of Hospitals and Health Systems, as the annual report on utilization of the facility.

(3) For all other health care facilities, the Authority shall notify the health care facility of the requirement no later than December 31 of the year to be reported.¶

(4) A health care facility must submit the annual report on a form, prescribed by the Authority, no later than April 30 of the subsequent year.

(5) The Authority shall acknowledge acceptance of the annual report or inform the licensed health care facility in writing of any corrections required within 30 days of the submission of an annual report by a health care facility.

History

Statutory/Other Authority: ORS 442.420, 442.463
Statutes/Other Implemented: ORS 442.463
OHP 1-2020, amend filed 01/10/2020, effective 01/10/2020
OHP 14-2018, adopt filed 11/20/2018, effective 12/01/2018

Or. Admin. R. 409-022-0020 Hospital Reporting Requirements

(1) All hospitals must submit the following, in a form and manner prescribed by the Authority:

(a) Inpatient hospital discharge data; and

(b) Emergency department discharge data, and

(2) Inpatient hospital discharge data submitted must include the following data elements if the data elements are available:

(a) Patient name;

(b) Patient date of birth;

(d) Patient ethnicity;

(e) Patient sex;

(f) Patient residential address;

(g) Hospital identifier;

(h) Admission date and hour;

(i) Discharge date and hour;

(j) Admitting diagnosis or chief complaint;

(k) Principle diagnosis;

(L) Secondary diagnoses;

(m) Principle procedure performed;

(n) Secondary procedures performed;

(o) Dates of procedures performed;

(p) External cause of injury codes;

(q) Patient disposition or discharge status;

(r) Admission source or point of origin;

(3) Emergency department discharge data must include the following data elements if the data elements are available:

(a) Patient name;

(b) Patient date of birth;

(d) Patient ethnicity;

(e) Patient sex;

(f) Patient residential address;

(g) Hospital identifier;

(h) Admission date and hour;

(i) Discharge date and hour;

(j) Principle diagnosis;

(k) Secondary diagnoses;

(L) Procedures performed;

(m) Dates of procedures performed;

(n) External cause of injury codes;

(o) Patient disposition or discharge status;

(p) Admission source or point of origin;

(q) Admission type;

(r) Total billed charges;

(s) Revenue codes; and

(t) Units of service.

(4) Ambulatory surgical discharge data submitted for hospital outpatient services must include the following data elements if the data elements are available:

(a) Patient name;

(b) Patient date of birth;

(d) Patient ethnicity;

(e) Patient sex;

(f) Patient residential address;

(g) Hospital identifier;

(h) Admission date;

(i) Discharge date;

(j) Principle diagnosis;

(k) Secondary diagnoses;

(L) Procedures performed;

(m) Dates of procedures performed;

(n) External cause of injury codes;

(o) Patient disposition or discharge status;

(p) Admission source or point of origin;

(q) Admission type;

(r) Total billed charges;

(s) Revenue codes; and

(t) Units of service.

History

Statutory/Other Authority: ORS 442.120
Statutes/Other Implemented: ORS 442.120
OHP 1-2020, amend filed 01/10/2020, effective 01/10/2020
OHP 14-2018, amend filed 11/20/2018, effective 12/01/2018
OHP 3-2015, f. 6-30-15, cert. ef. 7-1-15
OHP 3-2006, f. 12-14-06, cert. ef. 1-1-07

Or. Admin. R. 409-022-0025 Ambulatory Surgical Centers Requirements

(1) On and after January 1, 2020, all licensed Ambulatory Surgical Centers that bill any public or private insurance on behalf of the patient must submit ambulatory surgical discharge data to the Authority, in a form and manner prescribed by the Authority.

(2) Data submitted must include the following data elements if the data elements are available:

(a) Patient name;

(b) Patient date of birth;

(d) Patient ethnicity;

(e) Patient sex;

(f) Patient residential address;

(h) Facility name;

(i) Admission date;

(j) Discharge date;

(k) Principle diagnosis;

(L) Secondary diagnoses;

(m) Procedures performed;

(n) Dates of procedures performed;

(o) External cause of injury codes;

(p) Patient disposition or discharge status;

(q) Admission source or point of origin;

(r) Admission type; and

(s) Total billed charges;

(3) Mandatory reporters shall submit data following standard file layout and data values as prescribed by the Authority.

History

Statutory/Other Authority: ORS 442.120
Statutes/Other Implemented: ORS 442.120
OHP 14-2018, adopt filed 11/20/2018, effective 12/01/2018

Or. Admin. R. 409-022-0035 Ambulatory Surgical Center Fees

(1) The Authority shall assess a fee pursuant to ORS 442.120 that shall not exceed the total cost of receiving, processing, analyzing and maintaining ambulatory surgical discharge data.

(2) The fee shall not exceed $1.75 per discharge.

(3) The fee shall be calculated by totaling the costs of receiving, processing, analyzing and maintaining the data in the previous two quarters and dividing the total by the number of records received to derive a per record fee.

(4) The Authority shall invoice ambulatory surgical centers every six months based on the calculated per record fee and the number of records submitted. Fees assessed for January 1 through June 30 shall be invoiced no later than December 1 of the same year. Fees assessed for July 1 through December 31 shall be invoiced no later than June 1 of the subsequent year.

History

Statutory/Other Authority: ORS 442.120
Statutes/Other Implemented: ORS 442.120
OHP 14-2018, adopt filed 11/20/2018, effective 12/01/2018

Or. Admin. R. 409-022-0070 Health Care Facility Utilization and Discharge Data Use and Disclosure

The Authority may use and disclose data submitted to it under these rules in accordance with ORS 442.120 and OAR 943.014.

History

Statutory/Other Authority: ORS 442.120
Statutes/Other Implemented: ORS 442.120
OHP 14-2018, amend filed 11/20/2018, effective 12/01/2018
OHP 3-2015, f. 6-30-15, cert. ef. 7-1-15
OHP 3-2006, f. 12-14-06, cert. ef. 1-1-07

Division 23 COMMUNITY BENEFIT REPORTING

Or. Admin. R. 409-023-0100 Definitions

The following definitions apply to OAR 409-023-0100 to 409-023-0115:

(1) “Affiliated clinic” or “hospital affiliated clinic” mean an outpatient clinic located in Oregon that is operating under the common control or ownership of a hospital.

(2) “Authority” means the Oregon Health Authority.

(3) “Charity care” means free or discounted health services provided to persons who cannot afford to pay and from whom a hospital has no expectation of payment. Charity care does not include bad debt, governmentally set fees, contractual allowances, or discounts for quick payment.

(4) “Community” means the geographic service area and patient population that the health care institution serves as defined by the hospital.

(5) “Community benefits” mean programs or activities that provide treatment or promote health and healing, address health disparities or address the social determinants of health in a response to identified community needs. They are not provided primarily for marketing purposes or to increase market share. Community benefit must generate a negative margin and meet at least one of the following criteria:

(a) Improve access to health services;

(b) Enhance population health or improve health disparities;

(d) Demonstrate charitable purpose; or

(e) Address social determinants of health.

(6) “Health System” means an organization that delivers health care services through hospitals, facilities, clinics, medical groups and other entities that are under common ownership or control.

(7) “Hospital” has the meaning provided in ORS 442.612.

(8) “Patient cost” has the meaning provided in ORS 442.612.

(9) “Prescreen” or “prescreening” means the process a hospital uses to proactively screen a patient for presumptive eligibility for financial assistance in accordance with ORS 442.615.

(10) “Presumptive eligibility” refers to a decision by the hospital that, based upon the hospital’s prescreening, the patient qualifies for financial assistance.

(11) “Net cost” means the total expense incurred by the hospital minus any offsetting revenue such as grants, donations, or payments for service. Net costs may be provided using either a cost-to-charge ratio methodology or a cost accounting methodology.

(12) “Social Determinants of Health” has the meaning provided in ORS 442.612.

(13) “State medical assistance program” means a program for payment of health services provided to eligible Oregonians, including Medicaid and CHIP services under the OHP Medicaid Demonstration Project and Medicaid and CHIP services under the State Plan, or Healthier Oregon, or Bridge Program, or any other programs that may be prescribed by the Authority from time to time, in accordance with ORS 414.025(17).

History

Statutory/Other Authority: ORS 442.602, 442.615, 442.618 & 442.624
Statutes/Other Implemented: ORS 442.601, 442.602 & 442.612
OHP 1-2024, amend filed 05/07/2024, effective 05/07/2024
OHP 5-2020, amend filed 12/21/2020, effective 12/21/2020
OHP 2-2008, f. & cert. ef. 7-1-08

Or. Admin. R. 409-023-0105 Community Benefit Reporting

(1) Hospital reporting required pursuant to this rule must be consistent with generally accepted accounting principles (GAAP).

(2) The hospital must submit a completed Community Benefit Report form CBR-1 to the Authority within 240 days from the close of the hospital’s fiscal year. The report will be deemed submitted as of the date the report is postmarked or electronically delivered to the Authority, whichever is first.

(3) Form CBR-1 must be completed in accordance with instructions published by the Authority in the Community Benefit Reporting Guidelines (CBR-2). The Authority has 30 days to review and request clarification or corrections to form CBR-1.

(4) No later than October 31 of each year, the Authority shall send out a summary file for hospitals to review and validate. Hospitals shall have 14 days to review the summary file and submit corrections.

(5) Hospitals that are part of a multi-hospital system may submit reports for all system hospitals in one submission, but each hospital must be separately reported and clearly identified in any submission. Nothing in this rule removes the requirement that hospitals report their individual community benefit activities.

(6) If the ownership or control of the hospital changes during the reporting year, each hospital owner or controller must submit a community benefit report for the hospital for the portion of the year it owned or controlled the hospital.

(7) The Authority shall inform each hospital subject to reporting of any changes to the Community Benefit Report (CBR-1) or Community Benefit Reporting Guidelines (CBR-2) for the subsequent year by July 1. Community Benefit Reporting Guidelines shall be posted on the Authority’s website.

(a) Hospitals may report a community benefit activity in only one of the following categories as defined by the authority’s Community Benefit Reporting Guidelines (CBR-2):

(A) Charity care;

(B) Losses related to Medicaid and State Children’s Health Insurance Program;

(D) Community health improvement services;

(E) Health professionals’ education;

(F) Subsidized health services;

(G) Research;

(H) Financial and in-kind contributions to the community;

(I) Community building activities; or

(J) Community benefit operations.

(b) Community benefit activities must be reported as net costs.

(c) Only activities that occur during the fiscal year of the report and are under the control or management of the hospital can be reported, except in the case of a large one-time expenditure.

(d) Large one-time expenditures for qualifying community benefit activity that is under the control or management of the hospital may be allocated across multiple fiscal years, provided that:

(A) The expenditure is a single-transaction contribution;

(B) The expenditure exceeds the lesser of $1 million or 0.5% of annual net patient revenue;

(C) The expenditure is made in the community benefit categories of cash and in-kind contributions, community health improvement activities, or community building activities, as defined in the Community Benefit Reporting Guidelines (CBR-2);

(D) Net costs are not allocated across more than five fiscal years; and

(E) The hospital provides the Authority with a description of the investment and a plan for allocation.

(8) In addition to the reporting requirements of sections (6) and (7), a nonprofit hospital shall submit the most recent version of its Community Health Needs Assessment and its Community Health Improvement Strategy as specified in ORS 442.630.

(9) Beginning with a hospital’s fiscal year 2022 community benefit reports, the hospital shall report additional information, as prescribed in the Community Benefit Reporting Guidelines (CBR-2), relating to:

(a) The community need or health improvement strategy the community benefit activity addresses;

(b) Entities to which the hospital gave funds, grants, or in-kind contributions; and

(10) Beginning with a hospital’s fiscal year 2022, a hospital that works with a CCO or public health agency to address community need(s) shall identify:

(a) The community partner(s), and

(b) The community health needs assessment or community health improvement plan that identifies the community need(s) on either form CBR-1 or in supplemental documentation.

(11) Any information provided to the Authority pursuant to this reporting will be publicly available and may be included in the annual report produced by the Authority.

(12) The Authority shall annually report on community benefit activity to the Oregon Health Policy Board and produce a public report detailing community benefit activities performed by individual hospitals.

(13) A hospital that fails to report as required in these rules may be subject to a civil penalty not to exceed $500 per day.

History

Statutory/Other Authority: ORS 442.602
Statutes/Other Implemented: ORS 442.630
OHP 5-2020, amend filed 12/21/2020, effective 12/21/2020
OHP 2-2008, f. & cert. ef. 7-1-08

Or. Admin. R. 409-023-0110 Community Benefit Minimum Spending Floor

(1) The community benefit minimum spending floor program is effective January 1, 2021.

(2) The Authority shall calculate community benefit minimum spending floors for each hospital and its affiliated clinics in Oregon based on the fiscal year of the hospital, with each floor effective over the next two consecutive fiscal years. The Authority shall recalculate the spending floor every two years.

(3) The Authority will collect the data and criteria enumerated in ORS 442.624 on form CBR-3, if it is not already provided by hospitals on forms CBR-1 or FR-3, and from the general public for consideration in establishing hospital minimum community benefit floors. The Authority will post the spending floors for comment from the hospitals and general public as required under OAR 409-023-0110 (9).

(4) Community benefit minimum spending floors shall apply to all community benefit net costs reported to the Authority on Community Benefit Reporting Form (CBR-1).

(5) Each hospital may select among the following methodologies, as applicable to the hospital’s organizational structure, for the purpose of applying a minimum community benefit floor:

(a) By each individual hospital and all of the hospital’s nonprofit affiliated clinics;

(b) By a hospital and a group of the hospital’s nonprofit affiliated clinics;

(c) By all hospitals that are under common ownership and control and all of the hospitals’ nonprofit affiliated clinics; or

(d) By any other grouping of hospitals and their hospital affiliated clinics that is approved by the Authority.

(6) The Authority will utilize the methodology selected by the hospital from among those listed in OAR 409-023-0110 (5) to assign each hospital’s community benefit minimum spending floor, subject to the following requirements:

(a) Hospitals shall include audited financial statements and other objective data describing the overall financial positions of the hospitals and their affiliated clinics as grouped in the selected methodology on form CBR-3, if such information is not already incorporated into the audited financial reporting of the hospitals.

(b) Hospitals shall report the community benefit net costs that occur in their affiliated clinic(s) as grouped in the selected methodology on CBR-1.

(c) Hospitals choosing methodologies with multiple groupings shall report objective financial data and community benefit net costs for each facility such that the group totals, taken together, sum to be equal to the cumulative financials and net community benefit costs of all hospitals and affiliated clinics referenced in the chosen methodology.

(d) Each hospital shall inform the Authority of its elected organization groupings on form CBR-3 and provide all information requested on CBR-3 no later than 90 days prior to the start of their fiscal year.

(e) The elected organization grouping shall be maintained for the two-year duration of the community benefit minimum spending floor assignment, unless a facility within the organizational grouping closes or undergoes a change in ownership or control.

(7) The Authority shall publish the formula used to calculate hospitals’ community benefit minimum spending floors by January 1 of every odd numbered year.

(8) The Authority shall provide a proposed community benefit spending floor applicable to a hospital and its elected organization grouping no later than 60 days prior to the start of the hospital’s fiscal year.

(9) The proposed community benefit spending floor shall be posted to the Authority’s website, and a public comment period of 30 days shall begin the day of posting. All subsequent changes or amendments to the spending floor shall also be posted to the website for comment.

(10) The hospital and its affiliates shall have 30 days from receipt of the proposed spending floor to comment or provide additional information which may be used to modify the proposed community benefit spending floor.

(11) The Authority shall notify each hospital of the final community benefit spending floor no later than the first business day of the initial fiscal year of the two-year period for which the spending floors are effective.

(12) A hospital may ask for a review of its minimum spending floor if the hospital experiences a change in circumstance outside its control that will result in serious financial harm to the hospital if the community benefit minimum spending floor remains unchanged.

(13) The authority may amend the formula, if necessary, based on review of community benefit reports and feedback from stakeholders and the general public.

History

Statutory/Other Authority: ORS 442.602 & 442.624
Statutes/Other Implemented: ORS 442.601, ORS 442.602, 442.612, 442.624 & 442.630
OHP 5-2020, adopt filed 12/21/2020, effective 12/21/2020

Or. Admin. R. 409-023-0115 Annual reports of financial assistance policies and nonprofit status

(1) For purposes of this rule:

(a) “Health care facility” means:

(A) A hospital;

(B) An ambulatory surgical center;

(D) An outpatient renal dialysis facility; or

(E) An extended stay center.

(b) “Reportable affiliated clinic” means an outpatient clinic located in Oregon that:

(A) Is operating under the common control of a hospital; or

(B) Is owned in whole or part by the hospital; or

(2) A hospital or health system designee must submit a health care facility and reportable affiliated clinic report using the Hospital Facility and Clinic Report form (form HFCR) to the Authority, annually, by June 30 of each calendar year. The report shall identify its health care facilities and reportable affiliated clinics on form HFCR and provide the following:

(a) The health care facility name and street address for the facility location;

(b) The reportable affiliated clinic name and street address for the clinic location;

(d) An attestation, signed by an officer of the hospital, that the hospital’s financial assistance policy as developed under ORS 442.614 has been posted in the health care facilities and reportable affiliated clinics, and has been made available to patients of the facility and reportable affiliated clinic.

(3) Effective for hospital fiscal years that begin on or after January 1, 2025, hospitals must submit the Hospital Financial Assistance Report form (form HFAR) no later than 150 days after the end of the hospital’s fiscal year, for certain financial assistance data from the most recently completed fiscal year. Data on form HFAR must include:

(a) Total number of financial assistance applications received in the fiscal year, and of the received applications, the number approved and denied by the following payer types:

(A) Uninsured;

(B) Medicare and Medicare Advantage;

(D) Commercial or private health insurance; and

(E) All other payers.

(b) Total number of patients who received cost adjustments based on:

(A) Completing a hospital’s financial assistance application; and

(B) Without completing a hospital’s financial assistance application, but instead as a result of the hospital’s presumptive eligibility process as specified in OAR 409-023-0120.

(d) Total number of patient accounts in which extraordinary collection activities (ECA) occurred, listed by the following categories, as described in 26 C.F.R. 1.501(r)-6(b):

(A) Selling of an individual’s debt to another party (except for those sales not considered an ECA as described in 26 C.F.R. 1.501(r)-6(b)(2));

(B) Reporting adverse information about the individual to consumer credit reporting agencies or credit bureaus;

(C) Deferring or denying, or requiring a payment before providing, medically necessary care because of an individual’s nonpayment of one or more bills for previously provided care covered under the hospital’s financial assistance policy, as described in 26 C.F.R. 1.501(r)-6(b)(iii); and

(D) Taking actions that require a legal or judicial process including, but not limited to, liens, judgements, garnishments, foreclosures, or other action related to collection of a debt owed to the hospital as described in 26 CFR 1.501(r)-6(b)(iv)(A)-(G).

(e) The average and median per person debt, as well as the total amount of debt owed to the hospital by patients whose accounts were either placed in collections or referred to a collection agency during the reporting period.

(4) The Authority shall provide the necessary data reporting templates and make them available on its website no later than September 30th of each year for the upcoming fiscal year reporting.

(5) Data collected on form HFCR and form HFAR shall be made publicly available on the Hospital Reporting Program of the Authority’s website. Prior to posting on its website, the Authority shall suppress information as necessary to protect patient confidentiality in accordance with applicable laws and regulations, as well as with the Authority’s policies regarding small number reporting.

(6) A hospital that fails to report as required in OAR 409-023-0115 may be subject to a civil penalty not to exceed $500 per day.

History

Statutory/Other Authority: ORS 442.618
Statutes/Other Implemented: ORS 442.618
OHP 1-2024, amend filed 05/07/2024, effective 05/07/2024
OHP 5-2020, adopt filed 12/21/2020, effective 12/21/2020

Or. Admin. R. 409-023-0120 Requirements for prescreening patients for presumptive eligibility for financial assistance

(1) Prescreening and presumptive eligibility rules are effective July 1, 2024.

(2) Hospitals must document their prescreening process in their financial assistance policy. Process documentation must disclose the software products and all other third-party services used to evaluate patient household income for prescreening.

(3) The prescreening process and presumptive eligibility determination is not considered an application for financial assistance and does not disqualify a patient from seeking financial assistance.

(4) The prescreening process must use the financial assistance eligibility standards published in the hospital’s financial assistance policy and in accordance with the minimum standards specified in ORS 442.614. Any adjustment to patient cost due to the prescreening process must meet the minimum standards specified in ORS 442.614.

(5) Hospitals must complete prescreening for financial assistance and make any resulting adjustments to patient cost prior to sending the patient a billing statement.

(6) Prior to taking any other prescreening actions, the hospital must determine if during the previous nine (9) month period, the patient has applied for financial assistance and the hospital has determined that the patient is eligible for financial assistance based on documentation provided by the patient. If yes, the patient must receive a patient cost adjustment in accordance with ORS 442.614, prior to receiving a billing statement.

(7) Hospitals must prescreen for presumptive eligibility for financial assistance whenever the patient meets any of the following criteria:

(a) Is uninsured; or

(b) Is enrolled in a state medical assistance program; or

(c) Will owe the hospital more than $1,500 for a single hospital encounter after all adjustments from insurance or third-party payers, if applicable, have been made.

(8) Hospitals may prescreen patients who do not meet any of the criteria in (7) above at the hospital’s discretion or as established in the hospital’s financial assistance policy.

(9) A hospital must not require a patient to present documentation or other verification related to any eligibility criteria as a condition of prescreening or a requirement for adjustment to the patient costs as a result of prescreening. A hospital may accept voluntary submission of information or documentation that would assist the hospital in the prescreening process as long as the hospital does not compel the patient to provide the information.

(10) Hospitals may use existing patient data in the prescreening process, including but not limited to:

(a) Existing patient records;

(b) Information routinely collected during patient registration or admission;

(d) Previous financial assistance adjustments; and

(e) Existing eligibility for assistance programs. Examples include, but are not limited to: Medicaid, Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Women, Infants and Children (WIC), free lunch or breakfast programs, low-income home energy assistance programs, or any other programs which are means tested and would reasonably reflect the approximate patient household income.

(f) If a hospital’s initial prescreening method fails to return information about the patient, the hospital must make a good faith effort to determine the patient's presumptive eligibility status based on other information available to the hospital.

(11) A hospital may use third-party income verification software tools or services or contract with a third party to conduct the prescreening if:

(a) The process does not cause any negative impact on the patient’s credit score;

(b) Evaluations must be based on eligibility criteria established in the hospital’s written financial assistance policy. Evaluations by non-profit hospitals must be based on household income only, and cannot consider household assets or any assessment, evaluation or score that predicts the patient’s propensity or ability to pay; and

(c) If a third-party service or software tool fails to return information about the patient, or specifies the patient’s income is unknown, the hospital make a good faith effort to determine the patient's presumptive eligibility status based on information available to the hospital.

(12) Hospitals must document methods utilized under (10) and (11) they took to prescreen the patient.

(13) A hospital must notify the patient in writing of the results of the prescreening process, regardless of outcome. The notification must meet the following standards:

(a) Be written in plain language and either the preferred language of the patient or otherwise in alignment with the translation standards specified in ORS 442.614;

(b) Delivered by a minimum of one of the following means:

(A) Letter;

(B) Email, if agreed to by the patient as an acceptable form of communication;

(D) A prominently displayed notice on the billing statement;

(E) An insert accompanying a billing statement; or

(F) In-person acknowledgement signed by the patient.

(A) Presumptively eligible for full financial assistance;

(B) Presumptively eligible for partial financial assistance;

(D) Unable to determine presumptive eligibility status.

(d) If the prescreening process determines that the patient is not presumptively eligible, or their eligibility cannot be determined, or the patient cost adjustment was less than 100% of the patient cost amount, the hospital must further state the following information:

(A) That the patient may still apply for financial assistance, or additional financial assistance, by using the standard hospital financial assistance application;

(B) How a patient may request and receive a physical application or access an online application;

(D) That the patient is eligible to apply for financial assistance for at least 240 days following the first billing statement for the services provided or at least 12 months after the patient pays for the services provided, or for any additional time period beyond these minimums as specified in the hospital’s financial assistance policies.

History

Statutory/Other Authority: ORS 442.615
Statutes/Other Implemented: ORS 442.614 & 442.615
OHP 3-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 1-2024, adopt filed 05/07/2024, effective 05/07/2024

Or. Admin. R. 409-023-0125 Requirements for a Process for Patient Appeals of Financial Assistance Determinations

(1) Requirements for patient appeals of financial assistance determination are effective January 1, 2025.

(2) Hospitals must document their financial assistance appeals process in their financial assistance policy.

(3) A patient may only appeal determinations based on applications for financial assistance.

(4) If a hospital denies an application for financial assistance, finds the application to be incomplete or missing documentation, or provides a patient cost adjustment for less than 100% of the patient costs, the hospital must, within ten (10) business days, notify the patient of their ability to take corrective action or appeal the determination. The notification must meet the following criteria:

(a) The notification must be written in plain language and either the preferred language of the patient or otherwise in alignment with the translation standards specified in ORS 442.614.

(b) The notification may be delivered by mail, email, in person, or through an online portal, if the patient is a registered user of the hospital’s portal. The notification must be delivered separately and in addition to any financial assistance statements included on billing statements.

(c) The notification must clearly specify whether the application was incomplete or if the patient was denied due to not meeting eligibility criteria.

(A) If the application is found to be incomplete, missing documentation, or containing errors, the notification must designate the application as incomplete and requiring further action by the patient. The notice must further clearly describe the deficiencies and the actions the patient can take to complete the application by correcting the deficiencies.

(B) If the application was denied based on a failure to meet eligibility criteria, the notification must specify the relevant eligibility criteria and provide contact information so that the patient can request further information about the relevant eligibility criteria and the information that was used by the hospital to reach its determination.

(d) The notification must include a clear description of how the patient may submit corrections or additional documentation and how the patient may request an appeal. At a minimum, a patient must be able to submit corrections or additional documentations and request an appeal electronically, by either email or through a secure online portal, by mail, and by in-person delivery.

(e) The notification must inform the patient that if the patient chooses to appeal, the patient may request review by the hospital’s Chief Financial Officer or a designee of the hospital’s Chief Financial Officer who has been delegated decision-making authority over the appeal.

(f) The notification must inform the patient that the patient may also submit an appeal through a written statement or other supporting documentation.

(g) The notification must provide contact information to an appropriate hospital representative who may answer questions about the appeals process or the patient’s financial assistance application.

(5) A hospital must allow a patient the remaining duration of the 240-day application period after the date of the first post-discharge billing statement for the care provided, as specified in 26 CFR 1.501(r)-1(b)(3), or 45 days from the date the patient was notified of the financial assistance determination to correct deficiencies in the application or request an appeal, whichever is greater. A hospital may conduct standard billing practices during the application period if there is not a pending appeal. However, this does not remove the hospital’s obligation to reimburse a patient if found to be eligible for financial assistance, in accordance with ORS 442.615.

(6) During the pendency of an appeal a hospital must:

(a) Suspend all collection activities if the hospital has initiated collection activities; and

(b) If the hospital has sold the debt under appeal to a collection agency or has authorized a collection agency to collect debts on behalf of the hospital, the hospital must notify the collection agency to suspend collection activities; and

(c) Provide the patient with a written statement, delivered in accordance with OAR 409-023-0125(4)(b), and any request by the patient to use a specific, permitted, different delivery method, that contains:

(A) Confirmation of receipt of the patient’s appeal request;

(B) Notice that:

(i) The hospital has suspended all collection activities that it has initiated; and

(ii) If the hospital has sold debt to a collection agency or authorized a collection agency to collect debts on behalf of the hospital, that the hospital has notified the collection agency to suspend collection activities.

(C) Information on any actions the patient may take if a patient has requested a review by the hospital’s Chief Financial Officer or a designee.

(7) If it is determined by the hospital officer with the authority to determine the appeal that the patient must provide additional information, the patient must be allowed an additional 45 days, minimum, to provide the requested information. This additional time period runs from the date the hospital officer with the authority to determine the appeal informs the patient that they must supply additional information.

(8) A hospital may allow for multiple meetings to make a decision about the appeal.

(9) A hospital must allow for a third party acting with consent and on behalf of the patient to take action on a patient’s application and/or represent the patient on appeal. A hospital may require documentation of consent to representation from the patient.

(10) A hospital must issue a written determination on the appeal within 30 days of either the date of the final appeals meeting or the date of receipt of corrections related to application deficiencies, whichever is later. The hospital must communicate its determination in accordance with plain language and preferred language requirements established in OAR 409-023-0125(4)(a) and it must be delivered in accordance with OAR 409-023-0125(4)(b), and any request by the patient to use a specific, permitted, delivery method.

(a) If the final determination results in a denial of financial assistance, the hospital must also notify the patient of the date on which suspended collection activities, if any, will resume.

(b) A hospital may not resume suspended collection activities until a patient is notified of the final determination.

(11) A patient who has taken corrective action on an application that was determined to have deficiencies may request an appeal if the application is subsequently denied based on a failure to meet the hospital’s eligibility criteria.

History

Statutory/Other Authority: ORS 442.615
Statutes/Other Implemented: ORS 442.614 & 442.615
OHP 1-2024, adopt filed 05/07/2024, effective 05/07/2024

Division 24 CAPITAL PROJECT REPORTING PROGRAM

Or. Admin. R. 409-024-0000 Definitions

The following definitions apply to OAR 409-024-0000 to 409-024-0130:

(1) “Authority” means the Oregon Health Authority.

(2) “Capital project” has the meaning described in ORS 442.361.

(3) “Community benefits” mean programs or activities that provide treatment or promote health and healing as a response to identified community needs and are not provided primarily for marketing purposes or to increase market share.

(4) “Reporting entity” includes the following if licensed pursuant to ORS 441.015:

(a) A type A hospital as described in ORS 442.470.

(b) A type B hospital as described in ORS 442.470.

(d) An ambulatory surgical center as defined in ORS 442.015.

(e) Any Type A, Type B, or DRG hospital as defined in (4)(a) through (c) above that is certified as a Critical Access Hospital by the Centers for Medicare and Medicaid Services.

History

Statutory/Other Authority: ORS 442.362
Statutes/Other Implemented: ORS 442. 361 & 442.362
OHP 7-2015, f. & cert. ef. 9-24-15
OHP 3-2010, f. 6-24-10, cert. ef. 7-1-10

Or. Admin. R. 409-024-0110 Capital Project Report

(1) Each reporting entity must submit to the Authority a report of pending or proposed capital projects using a Capital Project Reporting Form CPR-1 as defined by the Authority. The report must be completed in accordance with instructions in the capital project reporting guidelines published on the Authority’s website.

(2) The Capital Project Reporting Form CPR-1 shall include but is not limited to:

(a) A summary of the information posted by the reporting entity under ORS 442.362.

(b) The procedure that the reporting entity used to collect public comment.

(d) The estimated cost of the project.

(3) Capital project reports must be submitted to the Authority no later than 30 days after financing for a project that has been approved for ambulatory surgical centers or within 30 days after the project has been approved by the hospital’s board of directors or other governing body for hospitals. The report shall be considered submitted on the date the report is postmarked or electronically delivered to the Authority, whichever is first.

(4) The Authority shall maintain on its website a publicly available resource to enable interested parties to view capital project reports filed with the Authority.

History

Statutory/Other Authority: ORS 442.362
Statutes/Other Implemented: ORS 442.361 & 442.362
OHP 7-2015, f. & cert. ef. 9-24-15
OHP 3-2010, f. 6-24-10, cert. ef. 7-1-10

Or. Admin. R. 409-024-0120 Public Comments

(1) Each reporting entity must make available a means for interested persons to submit public comments on the capital project either on their website or by posting public notice in a major newspaper for a period of no less than seven days. Comments must be collected for a period of no less than 30 days and made available for public review.

(2) The hospital or ambulatory care center shall then notify the Authority after the 30 day public comment if the hospital or ambulatory care center chooses to complete the project as is or if the project has changed and an expected completion date. The Authority shall post this update on its website for 30 days.

History

Statutory/Other Authority: ORS 442.362
Statutes/Other Implemented: ORS 442.361 & 442.362
OHP 7-2015, f. & cert. ef. 9-24-15
OHP 3-2010, f. 6-24-10, cert. ef. 7-1-10

Or. Admin. R. 409-024-0130 Civil Penalties

(1) If the Authority learns that any reporting entity has failed to file a capital project report, the Authority shall contact the reporting entity by certified mail requesting the unfiled report. If the reporting entity fails to reply within 30 calendar days or continues to be non-compliant with the reporting requirements, the Authority shall assess a civil penalty pursuant to the following schedule:

(a) $250 per day for the first five days of failure to file in accordance with ORS 442.991; and

(b) $500 per day from the sixth day until filing in accordance with ORS 442.991 is completed.

(2) Any amount of civil penalty assessed by the Authority may not be allowed as a reimbursable cost item and may not be recoverable from any category of payment source or patient.

History

Statutory/Other Authority: ORS 442.362
Statutes/Other Implemented: ORS 442.361, 442.362 & 442.991
OHP 7-2015, f. & cert. ef. 9-24-15
OHP 3-2010, f. 6-24-10, cert. ef. 7-1-10

Division 25 ALL PAYER ALL CLAIMS DATA REPORTING PROGRAM

Or. Admin. R. 409-025-0100 Definitions

The following definitions apply to OAR 409-025-0100 to 409-025-0190

(1) “Accident policy” means an insurance policy that provides benefits only for a loss due to accidental bodily injury.

(2) “Allowed amount” means the actual amount of charges for healthcare services, equipment, or supplies that are covered expenses under the terms of an insurance policy or health benefits plan.

(3) “APAC” means all payer all claims.

(4) “Association” means any organization, including a labor union, that has an active existence for at least one year, that has a constitution and bylaws and that has been organized and is maintained in good faith primarily for purposes other than that of obtaining insurance.

(5) “Attending provider” means the individual health care provider who delivered the health care services, equipment, or supplies specified on a health care claim.

(6) “Authority” means the Oregon Health Authority.

(7) “Billing provider” means the individual or entity that submits claims for health care services, equipment, or supplies delivered by an attending provider.

(8) “Capitated services” means services rendered by a provider through a contract in which payments are based upon a fixed monthly dollar amount for each enrollee.

(9) “Carrier” shall have the meaning given that term in ORS 743B.005.

(10) “Certificate of authority” shall have the meaning given that term in ORS 731.072.

(11) “Charges” means the actual dollar amount charged on the claim.

(12) “Claim” means an encounter or request for payment under the terms of an insurance policy, health benefits plan, Medicare, or Medicaid.

(13) "Coinsurance" means the percentage an enrollee pays toward the cost of a covered service.

(14) “Control totals file” means a data set containing summary information on medical, pharmacy and dental claims, members, providers, and premiums used to validate the detailed files submitted.

(15) “Coordinated Care Organization (CCO)” shall have the meaning given that term in ORS 414.025.

(16) "Copayment" means the fixed dollar amount an enrollee pays to a health care provider at the time a covered service is provided or the full cost of a service when that is less than the fixed dollar amount.

(17) “Data file” means electronic health information including medical claims files, enrollment files, medical provider files, pharmacy claims files, dental claims files, control totals files, subscriber-billed premiums files, payment arrangement files and any other related information specified in these rules.

(18) “Data set” means a collection of individual data records, whether in electronic or manual files.

(19) “Data vendor” means the entity under contract with the Authority to administer in whole or in part the all payer all claims database and related functions.

(20) “DCBS” means the Oregon Department of Consumer and Business Services.

(21) “Deductible” means the total dollar amount an enrollee pays toward the cost of covered services over an established period before the carrier or third-party administrator makes any payments under an insurance policy or health benefit plan.

(22) “De-identified health information” means health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual.

(23) “Dental carrier” means an insurer or other entity that offers a policy, certificate of insurance or other contract that provides dental benefits, either standalone or in conjunction with other health insurance.

(24) “Dental claims file” means a data set comprised of dental health care service level remittance information for all adjudicated claims for each billed service including but not limited to provider information, charge and payment information, and clinical diagnosis and procedure codes for an Oregon resident as defined in ORS 803.355 or a non-resident who is a member of a PEBB or OEBB group health insurance plan.

(25) “Direct personal identifier” means information relating to an individual patient or enrollee that contains primary or obvious identifiers, including:

(a) Names;

(b) Business names when that name would serve to identify a person;

(d) Specific latitude and longitude or other geographic information that would be used to derive postal address;

(e) Telephone and fax numbers;

(f) Electronic mail addresses;

(g) Social security numbers;

(h) Vehicle identifiers and serial numbers, including license plate numbers;

(i) Medical record numbers;

(j) Health plan beneficiary numbers;

(k) Certificate and license numbers;

(l) Internet protocol (IP) addresses and uniform resource locators (URL) that identify a business that would serve to identify a person;

(m) Biometric identifiers, including finger and voice prints; and

(n) Personal photographic images.

(26) “Disability policy” means an insurance policy that provides benefits for losses due to a covered illness or disability.

(27) “Disclosure” means the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.

(28) “DRC” means Data Review Committee.

(29) “Dual eligible special needs plan” means a special needs plan that enrolls beneficiaries entitled to both Medicare and Medicaid.

(30) “Enrollment file” means a data set containing demographic information for each individual enrollee eligible for medical benefits for one or more days of coverage at any time during a calendar month for an Oregon resident as defined in ORS 803.355 or a non-Oregon resident who is a member of a PEBB or OEBB group health insurance plan.

(31) “Eligible employee” shall have the meaning given that term in ORS 743B.005.

(32) “Employee” shall have the meaning given that term in ORS 654.005.

(33) “Employer” shall have the meaning given that term in ORS 654.005.

(34) “Encrypted identifier” means a code or other means of identification to allow individual patients or enrollees to be tracked across data sets without revealing their identity.

(35) "Encryption" means a method by which the true value of data has been disguised to prevent the identification of individual patients or enrollees and does not provide the means for recovering the true value of the data.

(36) “Enrollee” means enrollee as defined in ORS 743B.005.

(37) “ERISA” means the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001.

(38) “Exemption” means a requested variance from a validation rule on data format or quality threshold.

(39) “Extension” means a requested variance from the Data Submission schedule incorporated by reference under OAR 409-025-0120 and 409-025-0125.

(40) “Facility” means a health care facility as defined in ORS 442.015.

(41) “Genetic test” shall have the meaning given that term in ORS 192.531.

(42) “Group health insurance” shall have the meaning given that term in ORS 731.098.

(43) “Health benefit plan” shall have the meaning given that term in ORS 743B.005.

(44) “Health care” shall have the meaning given that term in ORS 192.556.

(45) “Health care operations” means certain administrative, financial, legal, and quality improvement activities that are necessary to run programs including, but not limited to, conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, case management and care coordination, evaluating practitioner, provider, or health plan performance, and underwriting, enrollment, premium rating and other activities related to creation, renewal, or replacement of a health insurance contract.

(46) “Health care provider” shall have the meaning given that term in ORS 192.556.

(47) “Health information” shall have the meaning given that term in ORS 192.556.

(48) “Health insurance exchange” shall have the meaning given that term in ORS 741.300.

(49) “Healthcare Common Procedure Coding System (HCPCS)” means a medical code set, maintained by the United States Department of Health and Human Services, that identifies health care procedures, equipment, and supplies for claim submission purposes.

(50) “HIPAA” means Title II, Subtitle F of the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d, et seq. and the federal regulations adopted to implement the Act.

(51) “Hospital indemnity policy” means an insurance policy that provides benefits only for covered hospital stays.

(52) “Indirect personal identifier” means information relating to an individual patient or enrollees that a person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods could apply to render such information individually identifiable by using such information alone or in combination with other reasonably available information.

(53) “Individual”, when used in a list of required lines of business, means individual health benefit plans.

(54) “Individually identifiable health information” shall have the meaning given that term in ORS 192.556.

(55) “Insurance” shall have the meaning given that term in ORS 731.102.

(56) “Labor union” means any organization which is constituted for the purpose, in whole or in part, of collective bargaining or dealing with employers concerning grievances, terms or conditions of employment or of other mutual aid or protection in connection with employees.

(57) “Large group” means health benefit plans for employers with more than 50 employees.

(58) “Long-term care insurance” shall have the meaning given that term in ORS 743.652.

(59) “Mandatory reporter” means any organization defined as a mandatory reporter in OAR 409-025-0110.

(60) “Medicaid” means medical assistance provided under 42 U.S.C. section 1396a (section 1902 of the Social Security Act) or Children’s Health Insurance Program (CHIP) medical assistance provided under 42 U.S.C section 1397aa-mm (section 2103 of the Social Security Act), as administered by the Division of Medical Assistance Programs.

(61) “Medicaid fee-for-service” (Medicaid FFS) means that portion of Medicaid where a health care provider is paid a fee for each covered health care service delivered to an eligible Medicaid patient.

(62) “Medical claims file” means a data set composed of health care service level remittance information for all adjudicated claims for each billed service including but not limited to provider information, charge and payment information, and clinical diagnosis and procedure codes for an Oregon resident as defined in ORS 803.355 or a non-Oregon resident who is a member of a PEBB or OEBB group health insurance plan.

(63) “Medicare” means coverage under Part A, Part B, Part C, or Part D of Title XVIII of the Social Security Act, 42 U.S.C. 135 et seq., as amended.

(64) “Non-claims based primary care expenditures” means resources given to a primary care provider or practice for services and are not otherwise in a fee-for-service arrangement.

(65) “OEBB” means the Oregon Educators Benefit Board.

(66) “Paid amount” means the actual dollar amount paid for claims.

(67) “Patient” means any person in the data set who is the subject of the activities of the claim performed by the health care provider.

(68) “Patient-Centered Primary Care Home” or “PCPCH” means a health care team or clinic as defined in ORS 414.655 that meets the standards pursuant to OAR 409-055-0040, and has been recognized through the process pursuant to OAR 409-055-0040.

(69) “Payment arrangement file” means a data set composed of total and primary care-related dollars disbursed, by payment arrangement and line of business.

(70) “PEBB” means the Oregon Public Employees’ Benefit Board.

(71) “Person” shall have the meaning given that term in ORS 731.116.

(72) “Pharmacy benefit manager (PBM)” means a person or entity that performs pharmacy benefit management, including a person or entity in a contractual or employment relationship with a person or entity performing pharmacy benefit management for a health benefits plan.

(73) “Pharmacy claims file” means a data set containing service level remittance information from all adjudicated claims including, but not limited to provider information, charge and payment information, and national drug codes for an Oregon resident as defined in ORS 803.355 or a non-Oregon resident who is a member of a PEBB or OEBB group health insurance plan.

(74) “Policy” shall have the meaning given that term in ORS 731.122.

(75) "Prepaid amount" means the fee for the service equivalent that would have been paid for a specific service if the service had not been capitated.

(76) “Premium” shall have the meaning given that term in ORS 743B.005.

(77) “Primary care” means family medicine, general internal medicine, naturopathic medicine, obstetrics and gynecology, pediatrics or general psychiatry.

(78) “Primary care provider” means:

(a) A physician, naturopath, nurse practitioner, physician associate 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.

(79) “Principal investigator (PI)” means the person in charge of a research project that makes use of limited data sets. The PI is the custodian of the data and shall comply with all state and federal restrictions, limitations, and conditions of use associated with the data release.

(80) “Protected health information” shall have the meaning given that term in ORS 192.556.

(81) “Provider file” means a data set containing information about health care providers providing health.

(82) “Public health authority” means the Public Health Division of the Authority or local public health authority as defined in ORS 431A.005.

(83) “Public health purposes” means the activities of a public health authority for preventing or controlling disease, injury, or disability including, but not limited to, the reporting of disease, injury, vital events such as birth or death, and the conduct of public health surveillance, investigations, and interventions.

(84) “Registered entity” means any person required to register with DCBS under ORS 744.714.

(85) “Research” means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalized knowledge.

(86) “Self-insured plan” means any plan, program, contract, or any other arrangement under which one or more employers, unions, or other organizations provide health care services or benefits to their employees or members in this state, either directly or indirectly through a trust or third-party administrator.

(87) “Small employer health insurance” means health benefit plans for employers whose workforce consists of at least two but not more than 50 eligible employees.

(88) “Special Needs Plan” means a Medicare health benefit plan created by the Medicare Modernization Act that is specifically designed to provide targeted care to individuals with special needs.

(89) “Specific disease policy” means an insurance policy that provides benefits only for a loss due to a covered disease.

(90) “Strongly-encrypted” means an encryption method that uses a cryptographic key with many random keyboard characters.

(91) “Subscriber” means the individual responsible for payment of premiums or whose employment is the basis for eligibility for membership in a health benefit plan.

(92) “Subscriber-billed Premium File” means the data set that includes premium information at the subscriber level for medical, pharmacy and dental insurance.

(93) “Summarized data” means data aggregated by one or more categories. Summarized data created from protected health information may not contain direct or indirect identifiers.

(94) “Third-party administrator (TPA)” means any person who directly or indirectly solicits or effects coverage of, underwrites, collects charges or premiums from, or adjusts or settles claims on, residents of Oregon or residents of another state from offices in Oregon, in connection with life insurance or health insurance coverage; or any person or entity who must otherwise be licensed under ORS 744.702.

(95) “Transact insurance” shall have the meaning given that term in ORS 731.146.

(96) “Trust” means a fund established by two or more employers in the same or related industry or by one or more labor unions or by one or more employers and one or more labor unions or by an association.

(97) “Vision policy” means a health benefits plan covering only vision health care.

(98) “Voluntary reporter” means any registered organization, other than a mandatory reporter, that voluntarily elects to comply with the reporting requirements in OAR 409-025-0100 to 409-025-0170.

(99) “Waiver” means an approved variance from the types of files submitted under OAR 409-025-0120 and 409-025-0125.

History

Statutory/Other Authority: ORS 443.373
Statutes/Other Implemented: ORS 442.372 & 443.373
OHP 2-2025, amend filed 10/24/2025, effective 10/24/2025
OHP 3-2024, minor correction filed 06/06/2024, effective 06/06/2024
OHP 8-2022, amend filed 12/01/2022, effective 12/01/2022
OHP 3-2021, amend filed 09/02/2021, effective 09/02/2021
OHP 1-2019, amend filed 05/30/2019, effective 07/01/2019
OHP 9-2018, amend filed 07/02/2018, effective 01/01/2019
OHP 7-2018, amend filed 06/29/2018, effective 01/01/2019
OHP 2-2017, f. 6-23-17, cert. ef. 1-1-18
OHP 10-2016, f. 6-22-16, cert. ef. 1-1-17
OHP 1-2016, f. & cert. ef. 1-5-16
OHP 6-2012, f. 6-26-12, cert. ef. 7-9-12
OHP 5-2012(Temp), f. 6-23-12, cert. ef. 6-1-12 thru 11-15-12
OHP 4-2012, f. 5-23-12, cert. ef. 6-1-12
OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10

Or. Admin. R. 409-025-0110 General Reporting Requirements

(1) Determination of “mandatory reporter”:

(a) For carriers, dental carriers and licensed third-party administrators, the Authority shall identify mandatory reporters using information collected by DCBS including, but not limited to, data from the Health Insurance Member Enrollment Report.

(A) The Authority shall aggregate the most recent four quarters of data.

(B) The Authority shall calculate the mean total lives for each carrier and licensed third-party administrator. Mean total lives shall be calculated by using the total covered lives in the following lines of business for each carrier, dental carrier and licensed third-party administrator:

(i) Large group;

(ii) Small group;

(iii) Individual market;

(iv) dental;

(v) Medicare Advantage; and

(vi) Self-insured.

(C) All carriers, dental carriers and licensed third-party administrators with calculated mean total lives of 5,000 or higher shall be mandatory reporters.

(b) All PBMs shall be mandatory reporters.

(d) All reporting entities with Dual Eligible Special Needs Plans in Oregon shall be mandatory reporters.

(e) All insurers providing coverage funded under Part D of Medicare shall be mandatory reporters.

(f) All insurers offering a health benefits plan in Oregon’s health insurance exchange shall be mandatory reporters.

(g) All insurers providing group health insurance plans to PEBB and OEBB members shall be mandatory reporters.

(2) If an organization believes a determination by the Authority of its mandatory status to be in error, the organization must contact the Authority to contest the determination as described in the notice no later than 90 days prior to the first scheduled date of submission of production files.

(3) Any carrier or licensed third-party administrator who has been identified as a mandatory reporter and believes their entity has fewer than 5,000 mean total lives due to ERISA self-insured shall notify the Authority by filing a request for waiver under OAR 409-025-0140.

(4) An organization may elect to participate as a voluntary reporter by notifying the Authority in writing.

(5) Mandatory and voluntary reporters shall submit data files for all required lines of business. They may submit data files for the voluntary lines of business and may not submit data files for any excluded lines of business.

(a) Required lines of business include:

(A) Medicare Advantage Part C and Medicare Part D;

(B) Medicaid;

(D) Small employer health insurance;

(E) Large group;

(F) Associations and trusts;

(G) PEBB and OEBB group health insurance plans;

(H) Self-insured plans not subject to ERISA; and

(I) Dental insurance.

(b) Voluntary lines of business include self-insured plans subject to ERISA.

(A) Accident policy;

(B) Disability policy;

(D) Long-term care insurance;

(E) Medicare supplemental insurance;

(F) Specific disease policy;

(G) Stop-loss plans;

(H) Student health policy;

(I) Supplemental insurance that pays deductibles, copays or coinsurance;

(J) Vision-only insurance; and

(K) Workers compensation.

(d) A mandatory reporter that contracts with another entity remains responsible for reporting all required lines of business. If the mandatory reporter elects to have the data reported by a contracted entity, the mandatory reporter shall notify the Authority and provide contact information for the contracted entity.

(6) Mandatory and voluntary reporters shall comply with data file layout, format, and coding requirements in OAR 409-025-0120.

(7) Mandatory and voluntary reporters shall comply with data submission requirements in OAR 409-025-0130.

(8) A mandatory reporter who plans to withhold data must submit a waiver of reporting in compliance with OAR 409-025-0140. If the mandatory reporter believes that the data are prohibited from disclosure under state or federal statutes, regulations or rules, then the waiver request must state the data prohibited from disclosure and the statute, regulation or rule that requires withholding the data.

(9) The Authority shall provide written notification by July 1 of each year to all mandatory reporter’s subject to the reporting requirements of OAR 409-025-0100 to 409-025-0150 for the following calendar year.

(10) New mandatory reporters submitting for the first time, or mandatory reporters that did not submit data in the previous year, shall submit test files before production files are due. The mandatory reporters shall submit test files no later than 60 days before the first scheduled date of submission of production files.

History

Statutory/Other Authority: ORS 442.466
Statutes/Other Implemented: ORS 442.464 & 442.466
OHP 2-2025, amend filed 10/24/2025, effective 10/24/2025
OHP 8-2022, amend filed 12/01/2022, effective 12/01/2022
OHP 2-2019, amend filed 05/30/2019, effective 01/01/2020
OHP 7-2018, amend filed 06/29/2018, effective 01/01/2019
OHP 2-2017, f. 6-23-17, cert. ef. 1-1-18
OHP 10-2016, f. 6-22-16, cert. ef. 1-1-17
OHP 1-2016, f. & cert. ef. 1-5-16
OHP 6-2012, f. 6-26-12, cert. ef. 7-9-12
OHP 5-2012(Temp), f. 6-23-12, cert. ef. 6-1-12 thru 11-15-12
OHP 4-2012, f. 5-23-12, cert. ef. 6-1-12
OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10

Or. Admin. R. 409-025-0120 Data File Layout, Format, and Coding Requirements

(1) All mandatory reporters shall submit claims-based data for all claims where the subscriber’s residence is in Oregon or the subscriber is enrolled in a plan for which the State of Oregon is the payer.

(2) Claims-based data files shall include:

(a) Enrollment;

(b) Medical claims;

(d) Dental claims;

(e) Provider;

(f) Subscriber-billed premiums; and

(g) Control totals files.

(3) Mandatory reporters must include plan-specific identifiers for members, subscribers, providers and contracts in required files. Mandatory reporters authorized by the Centers for Medicare and Medicaid Services or contracted through an insurer must provide the member’s identifier for those organizations in addition to the mandatory reporters’ member specific identifier. All identifiers must be:

(a) Sufficient length to be unique within the mandatory reporters’ solution;

(b) Assigned to a single individual, entity or contract;

(d) Persistent over time unless change in identifier is required due to change in coverage or contract.

(4) The enrollment file shall be submitted by all mandatory reporters using the approved layout, format, and coding described in Appendix A, Enrollment.

(a) Mandatory reporters shall report race and ethnicity data as outlined in Appendix A, Enrollment. This layout aligns with the Office of Management and Budget’s (OMB) Federal Register Notice of October 30, 1997 (62 FR 58782-58790).

(b) Mandatory reporters shall report primary language in accordance with ANSI/NISO guidance using the three-character string outlined in Codes for the Representation of Languages for Information Interchange.

(A) To the greatest extent practicable, race, ethnicity, and preferred language shall be self-reported.

(i) Collectors of race, ethnicity and primary language data may not assume or judge ethnic and racial identity or preferred signed, written and spoken language, without asking the individual.

(ii) If an individual is unable to self-report and a family member, advocate, or authorized representative is unable to report on his or her behalf, the information shall be recorded as unknown.

(B) When an individual declines to identify race, ethnicity or preferred language, the information shall be reported as refused.

(5) The membership total and claims control files shall be submitted by all mandatory reporters using the approved layout, format, and coding described in Appendix G, Membership Total and Claims Control.

(6) The subscriber-billed premium file shall be submitted by all mandatory reporters except CCOs using the approved layout, format, and coding described in Appendix F, Subscriber-Billed Premium.

(7) The provider file shall be submitted by all mandatory reporters except PBMs using the approved layout, format, and coding described in Appendix E, Provider.

(8) The medical claims file shall be submitted by all mandatory reporters except PBMs and dental carriers using the approved layout, format, and coding described in Appendix B, Medical Claims.

(9) The pharmacy claims file shall be submitted by PBMs, carriers and third party administratorsusing the approved layout, format, and coding described in Appendix C, Pharmacy Claims.

(10) The dental claims file shall be submitted by all mandatory reporters other than PBMs who provide dental coverage using the approved layout, format, and coding described in Appendix D, Dental Claims.

(11) All data elements are required unless specified as optional or situational within the file layout.

(12) All data files shall be submitted as tab-delimited files which have been encrypted and zipped prior to submission.

(13) Numeric data are positive integers unless otherwise specified.

(a) Negative values are allowed for quantities, charges, payment, co-payment, co-insurance, deductible, and prepaid amount.

(b) Negative values shall be preceded by a minus sign.

(14) All data files shall pass edit checks and validations implemented by the Authority or the Authority’s data vendor.

(a) Data vendors may perform quality and edit checks on data file submissions. If data files do not pass data vendor edit checks or validation, mandatory reporters must make corrections and resubmit data. Mandatory reporters must submit corrected data that passes all quality and edit checks or receive an approved exemption within 14 calendar days of notification by the Authority or the Authority’s data vendor of the error.

(b) Mandatory reporters must participate in efforts to validate and check the quality of current and historic APAC data, as prescribed and requested by the Authority.

(A) The Authority may request from mandatory reporter’s information from their internal records that is reasonably necessary to validate and check the quality of APAC data. This information may include, but is not limited to, aggregated number of enrolled members, number of claims and claim lines, charges, allowed amounts, paid amounts, co-insurance, co-payments, premiums, number of visits to primary care, emergency department, inpatient, and other health care treatment settings, and number of prescriptions.

(B) Mandatory reporters shall provide the aggregated information within 30 days of the Authority’s request.

(C) If the Authority finds errors through edit checks or validation, mandatory reporters must make corrections and resubmit data or receive an approved extension or exemption within 30 days or at the next regularly scheduled submission due date.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 442.373
Statutes/Other Implemented: ORS 442.373 & ORS 442.372
OHP 2-2025, amend filed 10/24/2025, effective 10/24/2025
OHP 4-2023, amend filed 12/01/2023, effective 12/01/2023
OHP 8-2022, amend filed 12/01/2022, effective 12/01/2022
OHP 3-2021, amend filed 09/02/2021, effective 09/02/2021
OHP 4-2020, amend filed 12/20/2020, effective 12/21/2020
OHP 3-2019, amend filed 05/30/2019, effective 01/01/2020
OHP 7-2018, amend filed 06/29/2018, effective 01/01/2019
OHP 2-2017, f. 6-23-17, cert. ef. 1-1-18
OHP 1-2017, f. & cert. ef. 5-3-17
OHP 13-2016, f. & cert. ef. 9-13-16
OHP 10-2016, f. 6-22-16, cert. ef. 1-1-17
OHP 1-2016, f. & cert. ef. 1-5-16
OHP 4-2012, f. 5-23-12, cert. ef. 6-1-12
OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10

Or. Admin. R. 409-025-0125 Payment Arrangement Reporting: File Layout, Format, and Coding Requirements

(1) All mandatory reporters other than PBMs shall report payment arrangements for all contracts sitused in Oregon. For contracts issued at the group level, the contract is considered sitused where the contract is sold. For contracts that are issued at the individual level, the contract is considered sitused where the individual resides.

(2) All data files shall include:

(a) Payment arrangement file described in Appendix 1; and

(b) Payment arrangement control file described in Appendix 2.

(3) The Payment arrangement file shall be submitted using the approved layout, format, and coding described in Appendix 1, Payment Arrangement File.

(4) The Payment arrangement control file shall be submitted using the approved layout, format, and coding described in Appendix 2, Payment Arrangement Control File.

(5) All data elements are required unless specified as optional or situational in the file layout.

(6) All required data files shall be submitted as delimited ASCII files or the template provided by the Authority. Both Appendix 1 and Appendix 2 are required regardless of method used.

(7) Numeric data are positive integers unless otherwise specified.

(a) Negative values are allowed for quantities, charges, payment, copayment, coinsurance, deductible, and prepaid amount.

(b) Negative values shall be preceded by a minus sign.

(8) All data values shall pass edit checks and validations implemented by the Authority or the Authority’s data vendor.

(a) Data vendor may perform quality and edit checks on data file submissions. If data files do not pass data vendor edit checks or validation, mandatory reporters must make corrections and resubmit data. Mandatory reporters must submit corrected data that passes all edit checks and validations or receive an approved exemption within 14 calendar days of notification by the Authority or the Authority’s data vendor of the error.

(b) Mandatory reporters must participate in efforts to validate and check the quality of current and historic APAC data, as prescribed and requested by the Authority.

(A) The Authority may request from any mandatory reporter information from their internal records that is reasonably necessary to validate and check the quality of APAC data. This information may include, but is not limited to, aggregated number of enrolled members, number of claims and claim lines, charges, allowed amounts, paid amounts, coinsurance, copayments, premiums, number of visits to primary care, emergency department, inpatient, and other health care treatment settings, and number of prescriptions.

(B) Mandatory reporters shall provide the aggregated information within 30 days of the Authority’s request or request an extension.

(9) These submissions shall meet the requirement that all Coordinated Care Organizations report primary care services to the Oregon Health Authority each year through 2027 for the prior calendar year’s data. The findings generated from these submissions will be presented to the legislature no later than February 1 of each year through 2028.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 442.373
Statutes/Other Implemented: ORS 442.373 & ORS 442.372
OHP 1-2023, amend filed 07/27/2023, effective 07/27/2023
OHP 5-2022, amend filed 08/23/2022, effective 08/23/2022
OHP 3-2021, amend filed 09/02/2021, effective 09/02/2021
OHP 1-2019, adopt filed 05/30/2019, effective 07/01/2019

Or. Admin. R. 409-025-0130 Data Submission Requirements

(1) Mandatory reporters shall submit data files as specified in the Data Submission Schedule. Voluntary reporters may consult with the Authority to submit healthcare claims data files on an alternative schedule.

(2) Mandatory and voluntary reporters shall submit data files directly to the data vendor unless otherwise specified by the Authority. Each mandatory reporter is required to maintain an active user in the data vendor’s reporting portal to receive communications on deadlines and submit files and resolve validation issues in a timely manner.

(3) Mandatory and voluntary reporters shall transmit data files using one of the following approved processes:

(a) Secure file transfer protocol (SFTP) including separate strong encryption of data files prior to SFTP transmission; or

(b) Any process incorporating strong encryption that is approved in writing by both the Authority and the data vendor.

History

Statutory/Other Authority: ORS 442.466
Statutes/Other Implemented: ORS 442.464 & 442.466
OHP 8-2022, amend filed 12/01/2022, effective 12/01/2022
OHP 2-2019, amend filed 05/30/2019, effective 01/01/2020
OHP 7-2018, amend filed 06/29/2018, effective 01/01/2019
OHP 2-2017, f. 6-23-17, cert. ef. 1-1-18
OHP 13-2016, f. & cert. ef. 9-13-16
OHP 10-2016, f. 6-22-16, cert. ef. 1-1-17
OHP 1-2016, f. & cert. ef. 1-5-16
OHP 4-2012, f. 5-23-12, cert. ef. 6-1-12
OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10

Or. Admin. R. 409-025-0140 Waivers, Exemptions and Extensions

(1) The Authority may grant a waiver, deadline extension, or exemption to the reporting and validation requirements.

(2) A mandatory reporter is required by law and rule to submit all required data files no later than the submission deadline and at sufficient quality to meet or exceed the published validation requirements. Mandatory reporters shall notify the Authority of their inability to meet any requirement within the timeline stated in rule or incorporated by reference.

(3) A mandatory reporter may request a waiver of reporting requirements. The request shall be submitted 60 calendar days prior to the applicable reporting deadline using the APAC-1a form.

(a) Mandatory reporters may request a waiver of reporting for the following reasons:

(A) A mandatory reporter who is a carrier, dental carrier or a third party administrator and, either due to decrease in covered lives or covered lives excluded as reporting to the federal Department of Labor under the Employment Retirement Income Security Act (ERISA), has fewer than 5,000 covered lives in Oregon to report;

(B) A mandatory reporter does not bill subscribers for premiums (Appendix F only);

(D) A mandatory reporter whose data is reported by another affiliated or contracted Oregon All Payer All Claims mandatory reporter if submitting files would create duplicate claims.

(b) A mandatory reporter who intends to withhold data under OAR 409-025-0110(8) must request a waiver and receive approval prior to withholding data.

(c) Mandatory reporters other than carriers, dental carriers and third party administrators may request a waiver of reporting based on the number of covered lives potentially reported. The Authority may approve a waiver if it determines the burden of reporting outweighs the value of the data in understanding services and costs in Oregon.

(d) Waivers are required only for the file types identified for the mandatory reporter type under OAR 409-025-0120 and OAR 409-025-0125.

(e) The Authority shall approve or deny the waiver request and provide written notification to the requestor within 14 calendar days of receipt of the request.

(f) Waivers of reporting are approved for one calendar year and may cover partial reporting years. Waivers must be requested each year that the reason for waiver continues to be in effect.

(4) A mandatory reporter may request a deadline extension for initial submission or correction of validation errors of required files. The request shall be submitted within the APAC vendor’s reporting portal at least 14 calendar days prior to the applicable reporting deadline.

(a) The mandatory reporter must explain why sufficient data or resources are not allocated to reporting to meet the published expectations for timing and data quality. The request must include the organization’s plan to mitigate future incidents and whether the plan has been approved and resources allocated to accomplish the activity within the stated timeline.

(b) The Authority shall approve or deny the extension request and provide notification to the requestor within seven (7) calendar days of receipt of the request.

(c) Extensions are approved for one reporting period. Failure to submit acceptable files at the end of the extension may result in a civil penalty under OAR 409-025-0150.

(5) A mandatory reporter may request an exemption for validation rules identified as ‘Exemption’ level. The request must be submitted through the APAC vendor’s reporting portal and cannot be submitted in advance of validation failure.

(a) Specific review of the failed validation results is required prior to requesting an exemption. Mandatory reporters must explain why the validation rule cannot be met and should not rely on receipt of poor-quality data as a reason for exemption. Requests that are not specific to the validation rule and data file submitted will be denied.

(b) The Authority shall approve or deny the exemption request and provide notification to the requestor through the APAC vendor’s reporting portal within seven (7) calendar days of receipt of the request.

(c) Exemptions are approved for a single submission or up to one calendar year. Failure to submit acceptable files based on approved exemptions may result in a civil penalty under OAR 409-025-0150.

(6) If the Authority denies the request, the requestor may appeal the denial by requesting a contested case hearing. The appeal must be filed within 30 business days of the denial. The appeal process is conducted pursuant to ORS Chapter 183 and the Attorney General’s Uniform and Model rules of Procedure for the Office of Administrative Hearings, OAR 137-003-0501 to 137-003-0700. The requestor shall have the burden to prove a compelling need for the waiver, exemption or extension.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 442.373
Statutes/Other Implemented: ORS 442.373 & ORS 442.372
OHP 2-2025, amend filed 10/24/2025, effective 10/24/2025
OHP 4-2023, amend filed 12/01/2023, effective 12/01/2023
OHP 8-2022, amend filed 12/01/2022, effective 12/01/2022
OHP 1-2016, f. & cert. ef. 1-5-16
OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10

Or. Admin. R. 409-025-0150 Compliance and Enforcement

(1) Unless approved by a waiver or extension, failure to comply with general reporting requirements includes but is not limited to:

(a) Failure to submit data files for a required line of business; or

(b) Submitting health information for an excluded line of business.

(2) Unless approved by a waiver or exemption, failure to comply with data file requirements includes but is not limited to:

(a) Submitting a data file in an unapproved layout;

(b) Submitting a data element in an unapproved format;

(d) Failure to submit a required data element; or

(e) Failure to comply with validation and quality control efforts, including resubmitting or correcting data as requested by the Authority.

(3) Unless approved by a waiver or extension, failure to comply with data submission requirements includes but is not limited to:

(a) Failure to maintain an active user in the data vendor reporting portal;

(b) Failure to submit test files as specified by the data vendor;

(d) Rejection of a data file by the data vendor that is not resubmitted or corrected by the submitter within 14 calendar days from notification of error; or

(e) Transmitting data files using an unapproved process.

(4) The Authority shall provide mandatory reporters written notification of each failure to comply prior to imposing a civil penalty under this rule. Mandatory reporters will have 30 calendar days to come into compliance.

(5) The Authority may impose civil penalties against mandatory reporters for each failure to comply that is not resolved within 30 calendar days of written notification. If a mandatory reporter does not come into compliance within 30 days of written notification, penalties will be assessed starting from the date the mandatory reporter was notified of non-compliance. Pursuant to ORS 442.993, the Authority adopts the following schedule of civil penalties:

(a) Up to $400.00 per day for violations of OAR 409-025-0150(1);

(b) Up to $300.00 per day for violations of OAR 409-025-0150(2) or OAR 409-025-0140(2)(a); and

(6) If a mandatory reporter was issued a final order imposing civil penalties within 24 months from the date the Authority issues a notice of intent to impose a civil penalty, the Authority may impose an additional $100.00 per day for each of the category of violations listed in section (5) of this rule.

(7) If a mandatory reporter has made documented efforts to comply with these rules, the Authority may consider this a mitigating factor before imposing civil penalties against the mandatory reporter.

History

Statutory/Other Authority: ORS 442.466 & 442.993
Statutes/Other Implemented: ORS 442.464, 442.993 & 442.466
OHP 8-2022, amend filed 12/01/2022, effective 12/01/2022
OHP 2-2019, amend filed 05/30/2019, effective 01/01/2020
OHP 7-2018, amend filed 06/29/2018, effective 01/01/2019
OHP 2-2017, f. 6-23-17, cert. ef. 1-1-18
OHP 13-2016, f. & cert. ef. 9-13-16
OHP 10-2016, f. 6-22-16, cert. ef. 1-1-17
OHP 1-2016, f. & cert. ef. 1-5-16
OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10

Or. Admin. R. 409-025-0160 Data Access and Release

(1) The Authority shall comply with all relevant state and federal data privacy, security, and antitrust regulations, including The Health Insurance Portability and Accountability Act (HIPAA), when sharing APAC data.

(2) The Authority may collect payment to recoup costs when APAC data requests are fulfilled.

(3) The Authority shall provide a public use data set, which shall include de-identified member health information, in compliance with applicable Authority policies and state and federal rules, regulations, and statutes.

(a) The Authority shall maintain a list of data elements included in APAC public use data sets.

(b) Requestors seeking access to an APAC public use data set shall complete a Public Use Data File Application (APAC-2). Payment is required as follows:

(A) Actual cost with a maximum cost of $500 per data year for Medical Claims;

(B) Actual cost with a maximum cost of $500 per data year for Pharmacy Claims;

(D) Enrollment file requested in conjunction with Medical, Pharmacy or Dental Claims will be provided without additional charge.

(c) The Authority may approve or deny the completed request and provide written notification to the requestor within 30 calendar days of receipt of the request.

(d) The Authority shall deny the completed request for reasons which include, but are not limited to:

(A) Requestor or any person who will have access to the data has previously violated a data use agreement with the Authority.

(B) The Authority finds that the specific details of the request do not sufficiently explain the proposed use.

(C) The Authority finds that the specific details of the request violate any state or federal rule, regulation, or statute.

(D) Full payment is not included with the application or received within thirty (30) days of invoicing.

(e) If the Authority denies the Public Use Application (APAC-2):

(A) The Authority shall provide written notification stating the reason for the denial and process return of payment; and

(B) The requestor may appeal the denial by requesting a contested case hearing. The appeal must be filed within 30 business days of the denial. The appeal process is conducted pursuant to ORS chapter 183 and the Attorney General’s Uniform and Model Rules of Procedure, OAR 137-003-0501 to 137-003-0700. The requestor shall have the burden to prove that the Authority unreasonably denied the application.

(f) The public use data sets may not be used to identify any individual, including members or subscribers. The requestor may not use outside information to attempt to ascertain the identity of individuals who are the subject of public use data sets.

(g) Provider information will be reviewed for information that may be considered personally identifiable information.

(A) If a taxpayer identification number is determined to be a social security number, such information shall not be released.

(B) Information already available to the public including published licensing data or public-facing data from the National Plan & Provider Enumeration System shall not be considered personally identifiable information.

(4) The Authority shall provide limited data sets, in compliance with applicable Authority policies and state and federal rules, regulations, and statutes. Limited data sets may include protected health information.

(a) The Authority shall maintain a list of data elements that may be included in APAC limited data sets if approved for a specific request.

(b) APAC limited data sets may be disclosed for purposes allowed by state and federal regulations, including research, public health, and health care operations.

(d) Requestors must identify each data element requested and explain the use of the data element within the description of activity in the application. The Authority will determine which data elements will be released after review under HIPAA and other applicable laws, regulations, and rules.

(e) The Authority shall determine the hours required to complete the data request and inform the requestor of the cost of the resulting data set.

(5) The Authority shall provide data, in compliance with applicable Authority policies and state and federal rules, regulations and statutes, to Oregon state agencies and local public health authorities. Use is limited to activities required to meet the agency’s duties as authorized by Oregon law.

(a) Agency-use data sets may include protected health information.

(b) Requestors seeking access to APAC agency data sets shall complete the Application for Agency Data Files and must explain use of each data element requested.

(c) Agency requests will be posted on the Data Review Committee for a minimum of two weeks to support transparency in data use.

(6) Requests for public use data set or limited data sets must be made using the form and manner prescribed by the Authority that is available on the agency’s website. The form shall collect sufficient information to evaluate any request for APAC data.

(7) Requestors who receive a limited data set must maintain Institutional Review Board (IRB) approval, if required for the data use agreement, throughout the span of authorized use of the data and until the data is destroyed. Requestors must submit updated documentation authorizing continued activity prior to the expiration of the previous authorization.

(8) Requesters who receive a limited data set must submit an amendment to the Authority when there is a change in the proposed use of the data within the scope of the original data request.

(a) Requestors shall file such an amendment when any of the following is anticipated:

(A) A change in persons accessing the data;

(B) Additional data elements are requested;

(D) Any change in the use of the data including linking or the addition of research questions; or

(E) Any change in research protocol, regardless of approval by an IRB.

(b) Changes or additions to use that are outside of the scope of the original data request will not be approved.

(c) Requestors may not implement any change related to access or use of data prior to receiving approval from the Authority.

(d) Changes in data elements, data use or research protocol must be reviewed by the Data Review Committee (DRC) described in OAR 409-025-0190. In addition, a recommendation by the DRC may be sought for additional years of data or new project staff for limited data sets the Authority determines to include vulnerable populations.

(e) The Authority shall review for completeness all applications and provide requestors written notification of completeness within 30 calendar days of receipt of the request. If the Authority determines that the application is incomplete, the requestor shall have 30 calendar days from notification of incompleteness to complete the application. Incomplete applications that are not completed shall be discarded without further notification to the requestor.

History

Statutory/Other Authority: ORS 442.373
Statutes/Other Implemented: ORS 442.373 & ORS 442.372
OHP 4-2023, amend filed 12/01/2023, effective 12/01/2023
OHP 5-2022, amend filed 08/23/2022, effective 08/23/2022
OHP 3-2021, amend filed 09/02/2021, effective 09/02/2021
OHP 1-2019, amend filed 05/30/2019, effective 07/01/2019
OHP 1-2016, f. & cert. ef. 1-5-16
OHP 2-2013, f. 1-24-13, cert. ef. 2-1-13
OHP 4-2012, f. 5-23-12, cert. ef. 6-1-12
OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10

Or. Admin. R. 409-025-0170 Public Disclosure

The Authority and applicable contractors, shall perform data analyses and publish data and reports that serve the public’s interest. This may include, but is not limited to:

(1) Comparing healthcare cost and quality;

(2) Assessing health care utilization;

(3) Assessing the capacity and distribution of healthcare resources;

(4) Assessing health care purchasing decisions;

(5) Assessing the effectiveness of public health programs; or

(6) Assessing disparities in health care delivery and outcomes.

History

Statutory/Other Authority: ORS 442.466
Statutes/Other Implemented: ORS 442.464 & 442.466
OHP 8-2022, amend filed 12/01/2022, effective 12/01/2022
OHP 1-2016, f. & cert. ef. 1-5-16
OHP 1-2010, f. 2-26-10, cert. ef. 3-1-10

Or. Admin. R. 409-025-0180 APAC Technical Advisory Group

The Oregon Health Authority shall convene a technical advisory group to advise the Authority on submission specifications including but not limited to file layouts, the Data Submission Schedule, and any additional data submission requirements. The advisory group shall include but is not limited to representatives from:

(1) Mandatory reporters;

(2) Providers;

(3) Researchers, and;

(4) Other stakeholders and interested parties.

History

Statutory/Other Authority: ORS 413.042 & 442.466
Statutes/Other Implemented: ORS 442.464 & 442.466
OHP 1-2019, adopt filed 05/30/2019, effective 07/01/2019

Or. Admin. R. 409-025-0190 Data Review Committee

(1) The Authority shall convene a Data Review Committee (DRC) to evaluate completed applications.

(2) The Authority may accept nominations for and make appointments to the DRC. The DRC shall include at least one mandatory reporter to serve in an advisory capacity.

(3) The DRC evaluation shall include, but is not limited to:

(a) Whether proposed purpose for accessing APAC data is allowable under Authority policies and state and federal rules, regulations, and statutes;

(b) Whether IRB documentation is required and, if submitted, is sufficient;

(d) Whether additional clarification is needed to complete the review.

(4) The Authority shall publish a DRC meeting schedule on its website and post applications scheduled to be reviewed, which detail the proposed use of the data and detail the data elements requested to be released at least two weeks prior to the next DRC meeting. The Authority shall receive public comment on applications scheduled for review. The DRC will review and consider all public comments as part of the data request review process.

(5) Consideration of applications for limited data sets:

(a) The Authority shall schedule completed applications for review by the DRC on a first-come-first-served basis.

(b) The DRC shall recommend that The Authority approve or deny the application or defer action pending clarification from the requestor.

(c) The Authority shall accept or reject the DRC’s recommendation and notify the requestor within 10 business days of the review.

(d) The Authority may deny a completed application for reasons which include, but are not limited to:

(A) Requestor or any person who will have access to the data has previously violated a data use agreement with the Authority;

(B) Full payment is not included with the application;

(D) Information provided is not sufficient to approve the request; and

(E) Proposed purpose for accessing APAC data is not allowable under authority policies or state or federal rules, regulations, or statutes.

(e) If the DRC requests clarification, the requestor shall have 30 calendar days to provide the requested information to the Authority. After 30 calendar days, applications with incomplete requests for clarification shall be discarded without further notification to the requestor.

(f) Upon receipt of the requested clarification the Authority shall schedule re-evaluation with the DRC on a first-come-first-served basis.

(g) If a request is denied, a person may submit a written request for reconsideration that includes the basis upon which the person believes the request should have been granted. If the Authority receives a request for reconsideration, it will determine whether to grant reconsideration and approve the request or whether the denial stands. The Authority shall provide its decision in writing to the person requesting reconsideration.

History

Statutory/Other Authority: ORS 413.042 & 442.466
Statutes/Other Implemented: ORS 442.464 & 442.466
OHP 1-2019, adopt filed 05/30/2019, effective 07/01/2019

Division 26 OREGON HEALTHCARE WORKFORCE DATABASE

Or. Admin. R. 409-026-0100 Definitions

The following definitions apply to OAR 409-026-0100 to 409-026-0140:

(1) “Authority” means the Oregon Health Authority.

(2) “Electronic media” means an electronic data storage medium.

(3) “Health care workforce information” means data collected using the license renewal process for selected Oregon health care professionals.

(4) “Health care workforce regulatory board” means the following:

(a) Board of Licensed Dietitians;

(b) Board of Medical Imaging;

(d) Oregon Board of Dentistry;

(e) Oregon Board of Examiners for Speech-Language Pathology and Audiology;

(f) Oregon Board of Licensed Professional Counselors and Therapists;

(g) Oregon Board of Naturopathic Medicine;

(h) Oregon Board of Optometry;

(i) Oregon Medical Board;

(j) Oregon State Board of Licensed Social Workers;

(k) Oregon State Board of Nursing;

(l) Physical Therapist Licensing Board;

(m) Respiratory Therapist and Polysomnographic Technologist Licensing Board;

(n) State Board of Chiropractic Examiners;

(o) State Board of Massage Therapists;

(p) State Board of Pharmacy; and

(q) State Board of Psychologist Examiners.

History

Statutory/Other Authority: ORS 676.410
Statutes/Other Implemented: ORS 676.410
OHP 3-2016, f. & cert. ef. 3-25-16
OHP 2-2016(Temp), f. & cert. ef. 2-8-16 thru 8-2-16
OHP 4-2009, f. 12-23-09, cert. ef. 1-1-10

Or. Admin. R. 409-026-0110 Data Elements

(1) Pursuant to ORS 676.410, a health care workforce regulatory board must collaborate with the Oregon Health Authority to collect health care workforce information. The information may include but is not limited to the following:

(a) Gender;

(b) Race;

(d) Languages spoken;

(e) Year of birth;

(f) Educational background;

(g) Specialty training or certification;

(h) Practice status and hours;

(i) Practice type and setting;

(j) Geographic location of practice; and

(k) Future practice plans.

(2) The Authority may not include any health care workforce information relating to licensees’ disciplinary actions or criminal background.

(3) The Authority shall collaborate with health care workforce regulatory boards to determine data elements and specifications and communicate the information to the health care workforce regulatory boards no later than six months prior to data collection.

(4) The Authority shall provide a data collection tool that health care workforce regulatory boards may use to collect required data elements.

(5) The healthcare workforce regulatory boards that utilize the Authority’s data collection tool shall provide verification information to the Authority, which may include:

(a) License number;

(b) Name;

(d) Original license date.

History

Statutory/Other Authority: ORS 676.410
Statutes/Other Implemented: ORS 676.410
OHP 3-2016, f. & cert. ef. 3-25-16
OHP 2-2016(Temp), f. & cert. ef. 2-8-16 thru 8-2-16
OHP 4-2009, f. 12-23-09, cert. ef. 1-1-10

Or. Admin. R. 409-026-0120 Reporting Schedule and Format

(1) Health care licensing boards shall include data collection set forth OAR 409-026-0110 in the license renewal process, using the Authority’s provided data collection tool or other tool agreed upon by the Authority.

(2) Collection of the health care workforce information required by this rule shall begin on the following dates:

(a) For health care professionals licensed by the Oregon State Board of Nursing; May 1, 2009;

(b) For health care professionals licensed by the Oregon Medical Board; October 1, 2009;

(c) For health care professionals licensed by the Oregon Occupational Therapy Licensing Board, the Oregon Board of Dentistry, the Oregon Physical Therapist Licensing Board, the State Board of Pharmacy, and the Board of Examiners of Licensed Dieticians; for license renewal periods on or after January 1, 2010.

(d) For health care professionals licensed by the Respiratory Therapist and Polysomnographic Technologist Licensing Board, and Oregon State Board of Social Workers; June 1, 2016.

(e) For chiropractic physicians licensed by the Oregon Board of Chiropractic Examiners; June 1, 2016. For chiropractic assistants licensed by the Oregon Board of Chiropractic Examiners; June 1, 2017.

(f) For health care professionals licensed by the Oregon Board of Massage Therapists, Oregon State Board of Licensed Professional Counselors and Therapists, and Oregon State Board of Psychologist Examiners; July 1, 2016.

(g) For the health care professionals licensed by the Oregon Board of Medical Imaging; September 1, 2016.

(h) For health care professionals licensed by the Oregon Board of Naturopathic Medicine; November 1, 2016.

(i) For the health care professionals licensed by the Oregon Board of Optometry; June 1, 2017.

(j) For the health care professionals licensed by the Oregon Board of Examiners for Speech-language Pathology and Audiology; November 1, 2017.

(3) Health care workforce regulatory boards shall submit required information to the Authority according to the following schedule:

(a) For health care workforce regulatory boards with a fixed licensing period or periods, the information shall be submitted within 90 days of the close of each period;

(b) For health care workforce regulatory boards with rolling licensing periods, the information shall be submitted annually, no later than July 1 of each year, or a date agreed upon by the Authority.

(4) The health care workforce information shall be submitted in one file that includes unique records for each individual license renewed during the reporting period.

(5) The records must be assembled in the format proscribed by the Authority and must be submitted electronically or on electronic media.

History

Statutory/Other Authority: ORS 676.410
Statutes/Other Implemented: ORS 676.410
OHP 3-2016, f. & cert. ef. 3-25-16
OHP 2-2016(Temp), f. & cert. ef. 2-8-16 thru 8-2-16
OHP 4-2009, f. 12-23-09, cert. ef. 1-1-10

Or. Admin. R. 409-026-0130 Fees

(1) The Authority shall establish a per-license fee to cover the cost of collecting and reporting health care workforce information. The fee shall be calculated by adding the costs necessary to compile, maintain, and analyze the health care workforce information and dividing that cost by the approximate number of individuals licensed in Oregon.

(2) Each health care licensing board shall submit, in a format agreed to by the Authority and each Board, the total number of individuals renewed in accordance with the schedule set forth in OAR 409-026-0120 for use in determination of fee calculation for the previous license period.

(3) The fee may not exceed $8.00 per individual licensed for two years and $4.00 per individual licensed for one year for individuals renewing on or after January 1, 2026. If the per-license fee calculation results in a figure above $8.00, the Authority shall review the process for calculating the fee with a stakeholder group with representation from each health care workforce regulatory board.

(4) The health care workforce information fees collected by health care workforce regulatory boards shall be paid to the Authority on a schedule agreed to by the Authority and each health care workforce regulatory board.

(5) Late payments are subject to recovery in accordance with the laws of the State of Oregon.

History

Statutory/Other Authority: ORS 676.410
Statutes/Other Implemented: ORS 676.410
OHP 5-2026, amend filed 07/07/2026, effective 07/07/2026
OHP 3-2016, f. & cert. ef. 3-25-16
OHP 2-2016(Temp), f. & cert. ef. 2-8-16 thru 8-2-16
OHP 4-2009, f. 12-23-09, cert. ef. 1-1-10

Or. Admin. R. 409-026-0140 Data Access

(1) For purposes of planning or analysis, the Authority may share de-identified, individual-level health care workforce data with other state agencies, including but not limited to:

(a) Agencies, offices, or contractors of the Authority.

(b) The Oregon Employment Department.

(2) The Authority may not provide individual-level public data sets to a non-governmental agency without written consent from the relevant health care workforce regulatory board.

History

Statutory/Other Authority: ORS 676.410
Statutes/Other Implemented: ORS 676.410
OHP 3-2016, f. & cert. ef. 3-25-16
OHP 2-2016(Temp), f. & cert. ef. 2-8-16 thru 8-2-16
OHP 4-2009, f. 12-23-09, cert. ef. 1-1-10

Division 30 HEALTH PROFESSION STUDENT CLINICAL TRAINING ADMINISTRATIVE REQUIREMENTS

Or. Admin. R. 409-030-0100 Purpose

These rules (OAR 409-030-0100 to 409-030-0250) establish standards for administrative requirements for health professional student placements in clinical training settings within the state of Oregon. The purpose of these rules is to mitigate inconsistencies that currently exist across clinical placements; to promote efficient solutions to reduce costs for students, health profession programs and clinical placement sites; and to ensure patient, clinical staff and student safety. These rules pertain to credentials that students must obtain and requirements that clinical placement sites may set.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0110 Definitions

The following definitions apply to OAR 409-030-0100 to 409-030-0250:

(1) “Administrative requirements” means those requirements that must be documented and verified before health professions program students may begin clinical placements, and includes criminal background checks, drug testing for substance abuse, health screenings, immunizations, and basic training standards.

(2) “Advanced practice nurse” means nursing practice areas inclusive of nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.

(3) “Authority” means the Oregon Health Authority.

(4) “CDC” means the federal Centers for Disease Control and Prevention.

(5) “Clinical placement” means any clinical rotations, internships, and any other clinical training experience that a student undergoes as part of their health professions or health-related professions program.

(6) “Clinical setting” or “clinical site” means the clinical facility at which a student undergoes training during a clinical placement.

(7) “Direct contact with patients” means in-person clinical, therapeutic, or administrative interaction with a patient that creates a potential risk for communicable disease exposure, occurring at a clinical placement site or associated location, including medical, dental, behavioral health, counseling, and social service settings.

(8) “Direct patient care” means all patient interactions, including in-person or virtual, performed as part of clinical responsibilities.

(9) “Educational institution” means the post-secondary college, university or other training program in which the student is matriculated for a health profession or health-related profession program.

(10) “Evidence of Immunization” means a statement by a licensed practitioner who has within the scope of the practitioner’s license the authority to administer immunizations; or a representative of the organization providing the immunization, or of the local health department certifying the immunizations the student has received.

(11) “For cause” means that the behavior of a student or instructor gives the health profession program or clinical site reason to believe that the individual is not complying with established standards set forth in these rules.

(12) “Health profession program” means a post-secondary course of study that concentrates on a health profession discipline as described in OAR 409-030-0130 and offers students instruction and training for becoming a health care professional.

(13) “Immunization” means receipt of any vaccine licensed by the United States Food and Drug Administration or the foreign equivalent for the prevention of a disease; proof of immunity to the disease via titer; or confirmed history of the disease.

(14) “Individually identifiable health information” has the meaning given that term in ORS 433.443.

(15) “Instructor” means a teacher, trainer, or advisor who is overseeing a student onsite during clinical training on behalf of the training program which the student attends. The degree of involvement of instructors in a student’s clinical training experience may vary between programs, and may include but is not limited to observation, demonstration of technique, modeling of behavior, and regular feedback.

(16) “Licensed independent practitioner” means an individual permitted by Oregon law to independently provide care and services, without direction or supervision, within the scope of the individual’s license.

(17) “Matriculated” means to be enrolled or registered for classes, as a student.

(18) “Patient” means an individual who is seeking care, guidance or treatment options at a clinical or other service location, or from a health professional or health-related professional as defined in these rules, via telehealth.

(19) “Student” means an individual enrolled or registered at a post-secondary college, university or other training program’s required minimum credit hours in an accredited health profession’s or health-related profession’s program of study.

(20) “Supervisor” means a staff member at a clinical facility who is delegated to provide preceptorship and/or supervision, to monitor student performance and to provide feedback to the student and the clinical educator and other educational training program faculty.

(21) “Telehealth” means the provision of patient care through electronic or digital communication when the patient and provider are not physically co-located.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0120 General applicability

(1) These rules apply to all students who:

(a) Plan to undergo clinical training at a setting listed in OAR 409-030-0140 within the state of Oregon; regardless of the location of the health profession or health-related profession program in which the student is matriculated;

(b) Concentrate on a health professional or health-related professional discipline listed in OAR 409-030-0130;

(d) Are matriculated into a health professional or health related professional training program as described in OAR 409-030-0130; and

(e) Engage in direct patient care activities.

(2) Clinical sites must require onsite instructors (unless prohibited by collective bargaining agreement) in the health profession program to satisfy the same requirements for immunizations, screenings, trainings, and other requirements set forth in these rules, if the instructor accompanies students onsite during clinical training and engages in direct contact with patients on behalf of or in support of the student.

(3) Except as provided in OAR 409-030-0150, covered clinical sites may not create additional or more stringent administrative requirements within the categories addressed by these rules for students and instructors covered by these rules.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0130 Health Professional Disciplines

(1) Except as provided in OAR 409-030-0150, these rules apply to students of the following health professions:

(a) Audiologists, as defined in ORS 681.205;

(b) Clinical laboratory science specialists, including medical technologists, medical laboratory scientists, medical laboratory technicians, and laboratory assistants, as defined in ORS 438.010;

(d) Dental hygienists, as defined in ORS 679.010;

(e) Dental therapists, as defined in ORS 679.603;

(f) Dentists, as defined in ORS 679.010;

(g) Dieticians, as defined in ORS 691.405;

(h) Emergency medical services providers, as defined in ORS 682.025;

(i) Hemodialysis technicians, as defined in ORS 688.635;

(j) Marriage and family therapists, as defined in ORS 675.705;

(k) Medical personnel (trained medical office and ancillary healthcare personnel who perform clinical tasks such as taking vital signs, preparing patients for examinations, or recording medical histories of patients, administrative duties, and other duties);

(L) Medical imaging practitioners and limited x-ray machine operators, as defined in ORS 688.405;

(m) Nurses, including registered nurses, practical nurses, advanced practice nurses, nurse practitioners, nursing assistants, medication aides and any other assistive nursing personnel licensed or certified under ORS 678.010 to 678.445;

(n) Occupational therapists and occupational therapy assistants, as defined in ORS 675.210;

(o) Optometrists, as described in ORS 683.010 to 683.310.

(p) Pharmacists and pharmacy technicians, as defined in ORS 689.005;

(q) Physical therapists, physical therapist aides, and physical therapist assistants, as defined in ORS 688.010;

(r) Physician assistants, as defined in ORS 677.495;

(s) Physicians (Medical/Osteopathic and Naturopathic), as defined in ORS 677.010 and 685.010;

(t) Podiatrists, as defined in ORS 677.805;

(u) Professional counselors, as defined in ORS 675.705;

(v) Psychologists, as defined in ORS 675.010;

(w) Regulated social workers, as defined in ORS 675.510;

(x) Speech-language pathologists and speech-language pathologist assistants, as defined in ORS 681.205; and

(y) Surgical technologists (allied health professionals under the supervision of a surgeon who are trained in advanced sterile techniques and theories and facilitate safety throughout the operative procedure);

(z) All other health-related disciplines not listed above that fall under the regulatory authority of the Oregon Health Licensing Office established in ORS 676.560-625 and ORS 676.990-992.

(2) These rules do not apply to students engaged in a field of study that is not explicitly listed in section (1). Academic institutions and clinical placement settings should individually negotiate the terms of placement for students not covered by these rules. Clinical facilities may choose to require that such students follow the standards set forth in these rules but are not required to do so.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0140 Clinical Settings

(1) Except as provided in OAR 409-030-0140(2) and 409-030-0150, these rules apply to the following clinical facilities hosting health professions students in the disciplines described in OAR 409-030-0130:

(a) Ambulatory care settings, including but not limited to clinics, private practices, Federally Qualified Health Centers, and primary care homes;

(b) Ambulatory surgical centers, as defined in ORS 442.015;

(d) Hospice, as defined in ORS 443.860;

(e) Hospitals and emergency departments, as defined in ORS 442.015;

(f) Long term care facilities, as defined in ORS 442.015;

(g) Residential care facilities, as defined in ORS 443.400;

(h) Skilled nursing facilities, as defined in ORS 442.015;

(i) Higher-education institutions, as defined in ORS 419B.005; and

(j) Other sites not listed above where health care is delivered or any health care facility licensed to render health care services by the Oregon Health Authority or the Oregon Department of Human Services.

(2) In addition to the exceptions provided in OAR 409-030-0150, these rules do not apply to the following clinical facilities hosting health professions students in the disciplines described in OAR 409-030-0130 for a clinical placement:

(a) Chiropractic, acupuncture, and massage therapy clinics that are independent and not associated with a clinical placement setting listed in OAR 409-030-0140(1).

(b) Federal facilities, including Department of Veterans’ Affairs facilities, Indian Health Service facilities, Tribal clinics, and federal prisons. Standards for clinical placement in federal facilities are set at the federal level.

(d) Public elementary and secondary schools (grades K-12).

(e) Radiosurgery clinical placements. The Nuclear Regulatory Commission sets requirements for students involved in radiosurgery.

(f) State prisons and correctional facilities.

(g) Oregon State Hospital.

(3) Completion of the administrative requirements in these rules only ensures administrative clearance for students. Clinical placement settings shall make all final clearance and placement decisions.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0150 Exceptions

(1) In addition to the exceptions listed in OAR 409-030-0130(2) and 409-030-0140(2), the standards in these rules:

(a) Only apply to students who engage in direct patient care as part of their clinical placement.

(b) Do not apply to students who are undergoing training overseen by their employer, academic institution, or training program at facilities that are located on the premises of or operated solely by the employer, academic institution or training program, or are otherwise considered “in-house” clinics.

(2) Clinical placement sites that have fewer or less stringent administrative requirements for newly hired non-student employees may request exemption from specific provisions of OAR 409-030-0170 through 409-030-0240 for students performing clinical placements at that site. For example, a clinical placement site that does not require regular employees to take a drug screen prior to being hired may request exemption from the section of these rules that require students to take a drug screen prior to being placed at that clinical site. However:

(a) All exemptions must be documented with the Authority prior to implementation of the exemption; and

(b) Clinical placement sites may only request exemptions from the specific category or section of these rules in which their requirements for newly hired non-student employees are less (such as immunizations, screenings, trainings or other listed in Table 1). Clinical placement sites with an exemption to a specific category of the administrative requirements must still comply with all other sections of these rules.

(3) Exemption requests may be submitted by:

(a) Clinical placement sites; or

(b) Educational institutions, on behalf of and in consultation with the clinical placement sites with which they contract and place students for clinical training.

(4) A request for exemption must include:

(a) The name and mailing address of the clinical placement setting.

(b) The supervisor or manager of student clinical placements on site, an email address and a phone number.

(c) The name and email address of the supervising instructor or department head at the affiliated educational institution if the request is made by a clinical placement site.

(d) A request for exemption from a specific section of the rules, that includes a description of the clinical placement setting’s requirements for newly hired non-student employees, and how they differ from the requirements set forth in these rules, using the form found online at https://www.oregon.gov/oha/HPA/HP/sctDocs/Health-Care-Facility-Exemption-Request-Form-fillable.docx .

(5) Clinical placement settings may temporarily institute a site-specific variation or change to a requirement listed in OAR 409-030-0170 through 409-030-0240 in extenuating circumstances including but not limited to a public health emergency, such as an outbreak that requires new or different vaccination or a safety breach that requires immediate action, provided that the clinical placement setting clearly notifies all affected parties and the Authority in advance of the changes.

(6) When instituted, a change or variation of these rule requirements may remain in place at the clinical training placement setting until the next annual review of the rules, at which point the Authority shall decide if:

(a) The change or variation is one mandated by a federal or state regulatory agency and will therefore be incorporated into these rules for all affected clinical placement settings and health profession students; or

(b) The change or variation would improve student and patient safety significantly and should be applied widely to clinical placement settings and health profession students in the state of Oregon, through an amendment to these rules; or

(c) The change or variation is not appropriate for widespread application to clinical placement settings and health professions students in the state of Oregon. In this case, the change or variation may not be re-instated by the clinical placement site after the annual review of the rules.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0160 Regular Review of Clinical Placement Standards

(1) The Authority shall convene an advisory group that may include representatives of affected students, health profession programs, clinical settings, and healthcare boards that regulate health profession programs. The Authority and the advisory group shall review the standards set forth in sections OAR 409-030-0170 through 409-030-0240 of these rules annually. Affected parties may bring proposed changes to the annual review process.

(2) Standards for immunizations are based on CDC guidance and other state and federal regulatory bodies overseeing immunization and vaccinations for health care workers. Rules shall be updated as needed to remain in compliance with suggested vaccination schedules and other recommendations from these regulatory bodies related to the applicable immunizations and screenings listed in Table 1 in OAR 409-030-0150.

(3) State and nationwide criminal background check standards are based on rules determined by authorized state and federal regulatory bodies, including but not limited to the Joint Commission.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0170 Administrative Requirements for Clinical Placement

(1) In order to be eligible for a clinical placement at a covered site within the state of Oregon, students subject to these rules must satisfy requirements for each of the following categories, as further described in Table 1, adopted by reference, prior to the start of the intended placement period:

(a) Immunizations;

(b) Screenings;

(d) Evidence of coverage for professional liability and general liability.

(2) Health profession programs and clinical placement settings are not required to pay for or otherwise administer any screenings or tests listed in these rules.

(3) Health profession programs must verify and retain evidence demonstrating that a student has completed all requirements listed in these rules prior to starting a placement for the student at a clinical setting, for a minimum of six months from the time the student leaves the educational program. The health profession program shall provide evidence of completed requirements to clinical sites, as requested.

(4) Students who engage in telehealth-only clinical placements are not subject to the following requirements:

(a) Immunizations;

(b) TB Screenings; and

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0180 Immunization Standards

(1) Evidence of immunizations required or recommended in OAR 409-030-0150, Table 1, may be demonstrated through the following:

(a) A document appropriately signed or officially stamped and dated by a qualified medical professional or an authorized representative of the local public health department, which must include one of the following:

(A) The day, month and year of each dose of each vaccine received; or

(B) Documentation of proof of immunity to the disease via titer; or

(C) In the case where a student has the disease, written documentation by a qualified medical professional indicating the day, month and year the diagnosis of the disease was confirmed.

(b) An official record from the Oregon ALERT Immunization Information System.

(2) Individual student medical exemptions from specific immunizations must be maintained by health profession programs as part of the overall record of the student. Documentation for exemption requires a written statement of exemption signed by a qualified medical professional. Non-medical exemptions from required immunizations are not allowed.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0190 Screening Standards

Table 1 in OAR 409-030-0150 provides detailed information related to required screenings for students’ clinical placements. Required screenings consist of:

(1) Tuberculosis (OAR 409-030-0200);

(2) Substance abuse or misuse (OAR 409-030-0210); and

(3) State and nationwide criminal background check (OAR 409-030-0220).

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0200 Tuberculosis Screening

(1) A student must obtain and provide documentation for TB screening consistent with the requirements for immunization in OAR 409-030-0180.

(2) TB screening must be conducted in a manner consistent with the CDC guidelines available at https://www.cdc.gov/tb-healthcare-settings/ or other Oregon or federal health authority guidelines prior to the start date of the initial clinical placement.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0210 Drug Testing for Substance Abuse and Misuse

(1) A student must undergo a drug test prior to the start date of initial placement at a covered clinical setting. Completion of a ten-panel drug test must take place prior to initial placement, but no more than 90 days before entry into the health profession training program requiring clinical training experience. A drug test is considered current while the student is enrolled and progressing in the health profession training program. Subsequent drug tests may not be required except for cause, or at re-entry into a program from which the student has taken more than three months of leave or has fallen out of progression. These rules do not aim to define an “acceptable” result to a drug screen. These rules ensure completion of the administrative requirements necessary for administrative clearance for students. Clinical placement settings shall make all final clearance and placement decisions.

(2) At a minimum, a student seeking a clinical placement at a covered clinical site must undergo a standard 10-panel drug test and must sign any necessary authorizations. Screens for the following eight substances must be included in the 10-panel drug screen:

(a) Amphetamines (including methamphetamines);

(b) Barbiturates;

(d) Cocaine;

(e) Marijuana;

(f) Methadone;

(g) Opioids; and

(h) Phencyclidine.

(3) All drug testing must be conducted by a laboratory licensed and operated in accordance with ORS 438.010 to ORS 438.450 and OAR 333-024-0305 through 333-024-0350. The health profession program must verify that screening is performed by a reputable vendor.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0220 State and Nationwide Criminal Background Checks

(1) Students must undergo a state and nationwide criminal background check in advance of the start of their initial clinical placements, but no more than 90 days before entry into the health profession training program requiring clinical training experience. A criminal background check is considered current while the student is enrolled and progressing in the health profession training program. Subsequent criminal background checks may not be required except for cause, or at re-entry into a program from which the student has taken leave or fallen out of progression.

(2) These rules do not aim to establish or define the composition of an “acceptable” result to a state and nationwide criminal background check. These rules ensure completion of the administrative requirements necessary for administrative clearance for students. Clinical placement settings shall make all final clearance and placement.

(3) Clinical placement settings may have the discretion to determine if state and national background checks are adequate or if more stringent requirements are required for students that resided in a foreign country for more than three months in the three years prior to their admission to the rotation program.

(4) State and nationwide criminal background checks must be:

(a) Performed by a vendor that is accredited by the National Association of Professional Background Screeners (NAPBS); or

(b) Performed by a vendor that meets the following criteria:

(A) Has been in the business of criminal background checks for at least two years;

(B) Has a current business license and private investigator license, if required in the company’s home state; and

(c) Conducted through an Oregon health professional licensing board, if required for students by such Board. (For example, students of pharmacy are required by the Oregon Board of Pharmacy to obtain an intern license prior to engaging in clinical training and must undergo a national fingerprint-based background check.)

(5) A criminal records check must include the following:

(a) Name and address history trace;

(b) Verification that the students’ records have been correctly identified, using date of birth and a Social Security number trace;

(c) A local criminal records check, including city and county records for the student’s places of residence for the last seven years;

(d) A nationwide multijurisdictional criminal database search, including state and federal records;

(e) A nationwide sex offender registry search;

(f) A query with the Office of the Inspector General’s List of Excluded Individuals/Entities (LEIE);

(g) The name and contact information of the vendor who completed the records check;

(h) Arrest, warrant and conviction data, including but not limited to:

(A) Charges;

(B) Jurisdictions; and

(i) Sources for data included in the report.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0230 Training Standards

(1) Students must complete all trainings listed in Table 1 of this rule, incorporated by reference, in advance of the start date of the students’ initial clinical placement.

(2) Students must complete the following steps for trainings that require certification:

(a) Complete an in-person training program in cardiopulmonary resuscitation (CPR), also known as Basic Life Support (BLS), at the healthcare provider level. On-line training will not meet this requirement. Training programs for CPR/BLS must include the following components:

(A) 1-Rescuer CPR and AED for adult, child and infant;

(B) 2-Rescuer CPR and AED for adult, child and infant;

(D) Bag-mask techniques for adult, child and infant;

(E) Rescue breathing for adult, child and infant;

(F) Relief of choking for adult, child and infant;

(G) CPR with an advanced airway; and

(H) Skills testing.

(b) Provide verified documentation as to the successful completion of CPR/BLS training, and

(3) Health profession programs must provide documentation or a signed statement that the student has received prior training, taken educational courses, or is otherwise familiar with the following:

(a) The Health Insurance Portability and Accountability Act (HIPAA);

(b) Bloodborne Pathogen training that is compliant with the federal Occupational Safety and Health Administration (OSHA) requirements;

(c) Infection prevention practices for all clinical care, including all the elements of the CDC’s Standard Precautions and Transmission-Based Precautions pertaining to hand hygiene, appropriate selection and use of personal protective equipment (PPE), respiratory hygiene/cough etiquette principles, appropriate patient placement, cleaning and disinfection of patient care equipment, devices, and environment, safe handling of textiles and laundry, safe injection practices (if relevant to scope of practice), and transmission-based precautions, including contact, droplet, and airborne restrictions; and

(d) Federal OSHA recommended safety guidelines, including:

(A) Fire and electrical safety; and

(B) Hazard communications.

(4) Health profession programs shall provide documentation of completed trainings, as requested by clinical sites.

(5) Clinical sites may require students to complete additional site-specific trainings or on-boarding procedures, including:

(a) Site-specific privacy and confidentiality trainings.

(b) Site-specific orientation trainings and on-boarding procedures, such as facility-specific protocols for safety, security, documentation systems, and standards of behavior or signing a non-disclosure statement.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 1-2025, amend filed 03/25/2025, effective 03/25/2025
OHP 5-2023, amend filed 12/28/2023, effective 12/28/2023
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 4-2015, f. & cert. ef. 7-1-15
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0240 Insurance and Liability Coverage

(1) Prior to clinical training, students or health profession programs must demonstrate that students have one of the following types of coverage and that the coverage will remain in place for the entire duration of each placement:

(a) Professional liability insurance coverage, and

(b) General liability insurance coverage; or

(2) Student coverage must have a minimum limit of $1 million per occurrence/ $3 million aggregate for professional liability and minimum limit of $1 million per occurrence/ $2 million aggregate for general liability.

(3) A health profession program may offer coverage for students through a self-insurance program or the student may obtain coverage individually.

(4) Health profession programs shall maintain records related to insurance and provide them to clinical sites, as requested.

(5) Prior to clinical placement, it is recommended but not required that students obtain some form of health insurance coverage, such as personal major medical insurance or Workers’ Compensation insurance provided by the health profession program, and that the coverage remain in place for the entire duration of each placement.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 1-2026, amend filed 05/13/2026, effective 06/01/2026
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Or. Admin. R. 409-030-0250 Information Sharing or Use of Data

(1) Only clinical sites that have a contractual agreement with a student’s training program may access the documentation and evidence related to completion of the administrative requirements.

(2) Students must provide written, signed permission that explicitly allows the sharing of required documents and necessary evidence with clinical sites, including but not limited to any release required under HIPAA or other applicable laws to disseminate the student’s personal health information under these rules.

(3) Dissemination of information received under these rules may only be made to individuals with a demonstrated and legitimate need to know the information.

History

Statutory/Other Authority: ORS 413.435
Statutes/Other Implemented: ORS 413.435
OHP 24-2019, amend filed 11/06/2019, effective 11/15/2019
OHP 8-2013, f. 9-30-13, cert. ef. 7-1-14

Division 35 PHYSICIAN VISA WAIVER PROGRAM

Or. Admin. R. 409-035-0000 Purpose of the Physician Visa Waiver Program

The purpose of the Physician Visa Waiver program is to make recommendations to the United States Department of State to waive the foreign country residency requirement of foreign medical graduates on behalf of physicians holding visas who seek employment in federally designated areas having a shortage of physicians. These rules set forth the requirements for Oregon to make requests to waive the foreign country residency requirement as authorized under 8 U.S.C. secs. 1182(e) and 1184(l).

History

Statutory/Other Authority: ORS 413.248
Statutes/Other Implemented: ORS 413.248
OHP 9-2022, amend filed 12/06/2022, effective 12/06/2022
Renumbered from 333-005-0000 by OHP 7-2010, f. 12-29-10, cert. ef. 1-1-11
PH 11-2004, f. 3-25-04, cert. ef. 3-29-04
PH 14-2003(Temp), f. 9-25-03 cert. ef. 10-1-03 thru 3-29-04

Or. Admin. R. 409-035-0010 Definitions

For the purposes of this Division, the following definitions apply:

(1) "Application" means the Physician Visa Waiver Program application form and supporting documentation.

(2) “Authority” means the Oregon Health Authority.

(3) "Department of State" means the federal agency that reviews J-1 waiver applications.

(4) “Flex Option” means the placement of a physician in an area that is not a federally

designated shortage area, who will serve patients living in designated shortage areas, as determined by the Health Resources and Services Administration.

(5) "Health Care Facility" means the clinic or hospital that employs the J-1 physician.

(6) "Health Services and Resources Administration" (HRSA) means the branch of the Department of Health and Human Services that designates federal shortage areas.

(7) "Health Care Shortage Area" means a geographic area or site approved by HRSA. Categories include Health Professional Shortage area (HPSA), Medically Underserved Area (MUA), and Medically Underserved Population (MUP).

(8) "J-1 Application" means the application form and supporting material submitted jointly by the health care facility and the J-1 physician to the Authority.

(9) "J-1 Physician" means allopathic or osteopathic physician who is requesting a waiver of the two-year foreign country residency requirement in order to practice in a facility in Oregon that is either located in a federally designated shortage area or serves patients living in designated shortage areas.

(10) "Low Income" means a patient whose income does not exceed 200% of the current Federal Poverty Guidelines (see: https://aspe.hhs.gov/poverty).

(11) "Mental Health Facility" means an agency that provides mental health services in an outpatient, residential, or hospital setting.

(12) “Oregon Health Plan” means the joint Federal/State entitlement program, enacted in 1965 as Title XIX of the Social Security Act, that pays for medical care on behalf of certain groups of low-income persons, as operated in Oregon.

(13) "Primary Care Physician" means a physician licensed in Oregon to practice family medicine, general internal medicine, obstetrics and gynecology, pediatrics, or general psychiatry.

(14) "United States Citizenship and Immigration Services” means the agency that replaced the

Immigration and Naturalization Service, effective March 1, 2003.

History

Statutory/Other Authority: ORS 413.248
Statutes/Other Implemented: ORS 413.248
OHP 9-2022, amend filed 12/06/2022, effective 12/06/2022
Renumbered from 333-005-0010 by OHP 7-2010, f. 12-29-10, cert. ef. 1-1-11
PH 11-2004, f. 3-25-04, cert. ef. 3-29-04
PH 14-2003(Temp), f. 9-25-03 cert. ef. 10-1-03 thru 3-29-04

Or. Admin. R. 409-035-0020 Health Care Facility Participation Requirements

(1) Federally Qualified Health Centers with a:

(a) HPSA score at or above the requirements of 22 CFR 41.63 shall apply for a J-1 Waiver either through the Authority or through the United States Department of Health and Human Services (see: http://www.globalhealth.gov/global-programs-and-initiatives/exchange-visitor-program);

(b) HPSA score below the requirements of 22 CFR 41.63 shall apply for a J-1 Waiver through the Authority.

(2) If a health care facility is located in a Medically Underserved Area (MUA) or Medically Underserved Population (MUP) that is not a Health Professional Shortage Area (HPSA) or if the request is for a flex option, the facility must obtain prior approval from the Authority upon providing documentation substantiating the area's need for a physician.

(3) To qualify for the Oregon Physician Visa Waiver Program, the health care facility must:

(a) Identify the nature of the business entity seeking to employ the physician, including but not limited to domestic or foreign professional corporation, LLC, or partnership and is registered to do business in Oregon;

(b) Have provided care for a minimum of six months in Oregon, or supply evidence of stability such as HRSA funding, prior to submitting an application;

(c) Currently serve Medicare and low-income uninsured patients, and Oregon Health Plan members that are members of the local community;

(d) Ensure that Oregon Health Plan member visits must represent a share of the overall facility’s patient visits that are equal to or greater than the statewide percentage of the population eligible for the Oregon Health Plan at the beginning of each program year as determined by the Authority (up to a maximum of 25%). If the facility does not meet this requirement, it must provide a plan to achieve that level of service for review and approval by the Authority. Plans that do not outline a strategy to achieve the required level of service within the physician’s first year will not typically be approved, but the Authority will consider additional information provided by the facility when making a final decision. If the total patient visits covered by the Oregon Health Plan or Medicare or from low-income, uninsured patients exceeds 50 percent of all patient visits, the Authority may waive the requirement for a plan;

(e) Post a sliding fee schedule in the primary languages of the population being served;

(f) Document attempts to actively recruit a United States citizen or permanent resident prior to submission of the application;

(g) Execute an employment contract with the physician that includes the following provisions:

(A) Duration of at least three years;

(B) Wages and working conditions comparable to those for a graduate from a United States medical school;

(C) Does not include a non-compete clause or restrictive covenant that prevents or discourages the physician from continuing to practice in any designated area after the term of the contract expires;

(D) Specifies the geographic shortage area within Oregon in which the physician will practice or, if requesting a flex option, the shortage area or areas where prospective patients live;

(E) Ensures the physician shall treat all patients regardless of their ability to pay; and

(F) Ensures the physician shall provide patient care on a full-time basis a minimum of 40 hours per week.

(h) Submit a letter outlining the need and intention to hire the physician, signed by the CEO or equivalent, or their designee.

(4) The health care facility shall submit to the Authority a fee of $2,000 and two sets of the application packet for each waiver requested.

History

Statutory/Other Authority: ORS 413.248
Statutes/Other Implemented: ORS 413.248
OHP 9-2022, amend filed 12/06/2022, effective 12/06/2022
OHP 21-2019, amend filed 09/27/2019, effective 10/21/2019
OHP 6-2016, f. & cert. ef. 4-22-16
OHP 9-2015, f. & cert. ef. 11-24-15
OHP 6-2015(Temp), f. & cert. ef. 9-22-15 thru 3-1-16
OHP 1-2015, f. 1-15-15, cert. ef. 2-1-15
OHP 3-2013, f. 1-24-13, cert. ef. 2-1-13
Renumbered from 333-005-0020 by OHP 7-2010, f. 12-29-10, cert. ef. 1-1-11
PH 11-2004, f. 3-25-04, cert. ef. 3-29-04
PH 14-2003(Temp), f. 9-25-03 cert. ef. 10-1-03 thru 3-29-04

Or. Admin. R. 409-035-0030 Physician Participation Requirements

To qualify for consideration by this program the physician must:

(1) Obtain a Department of State case number prior to submitting an application to the Authority;

(2) Submit a completed application that:

(a) Documents having, or having applied for, an active Oregon medical license. If the residency or fellowship is not completed, the license application may be listed as “pending”;

(b) Includes either a "No Objection" letter from the home country, or a statement that the physician is not contractually obligated to return to the home country;

(c) Includes a signed and dated statement certifying that the physician does not have any other pending J-1 waiver requests;

(d) Includes a copy of the medical degree or diploma;

(e) Includes legible copies of all DS 2019 Forms;

(f) Includes a curriculum vitae that documents the physician's date of birth, city and country of birth.

History

Statutory/Other Authority: ORS 413.248
Statutes/Other Implemented: ORS 413.248
OHP 9-2022, amend filed 12/06/2022, effective 12/06/2022
Renumbered from 333-005-0030 by OHP 7-2010, f. 12-29-10, cert. ef. 1-1-11
PH 11-2004, f. 3-25-04, cert. ef. 3-29-04
PH 14-2003(Temp), f. 9-25-03 cert. ef. 10-1-03 thru 3-29-04

Or. Admin. R. 409-035-0040 Application Review Process

(1) The Authority shall review completed health care facility applications that meet all requirements of 409-035-0020. Potential physician participants must meet all requirements set forth in 409-035-0030.

(2) The following factors shall be considered in determining whether to recommend a request for waiver of the foreign country residency requirement:

(a) The type of medicine to be practiced.

(b) Applications from community health centers with HPSA scores below 7 and from mental health facilities shall receive priority.

(c) Geographic distribution of physicians. To the extent possible, the Authority shall attempt equitable distribution of waiver requests for eligible areas of the state. The number of physicians already working under waivers or recommended for waivers in a particular geographic area shall be taken into consideration.

(d) Distribution of physicians among employers. The Authority may limit the number of slots to six per employer (as defined by EIN) in a program year.

(e) Facility patient profile. The health care facility's percentage of patient visits which are covered by the Oregon Health Plan, Medicare, or are low income, uninsured.

(3) The Authority shall return incomplete applications, including application fees to the health care facility applying for the waiver. The Authority shall process completed resubmitted applications, including fees, as of the new date of receipt.

(4) The Authority shall review each completed application and notify the health care facility of the results within 15 business days of receiving the application.

(5) The Authority shall forward the recommended waiver requests to the United States Department of State. The United States Department of State shall forward waiver requests recommended for approval to the United States Citizenship and Immigration Services, which shall determine whether to grant or deny the waiver.

(6) The Authority may reallocate positions based on a review of current access needs in the state. The Authority may also recommend or decline to recommend a waiver request.

History

Statutory/Other Authority: ORS 413.248
Statutes/Other Implemented: ORS 413.248
OHP 9-2022, amend filed 12/06/2022, effective 12/06/2022
OHP 13-2018, amend filed 09/30/2018, effective 10/01/2018
OHP 1-2015, f. 1-15-15, cert. ef. 2-1-15
Renumbered from 333-005-0040 by OHP 7-2010, f. 12-29-10, cert. ef. 1-1-11
PH 11-2004, f. 3-25-04, cert. ef. 3-29-04
PH 14-2003(Temp), f. 9-25-03 cert. ef. 10-1-03 thru 3-29-04

Or. Admin. R. 409-035-0050 Monitoring and Follow-up Requirements

To maintain participation in the Physician Visa Waiver Program the health care facility must:

(1) Notify the Authority in writing as soon as the physician starts work.

(2) Promptly submit annual reports signed by the physician and the Chief Executive Officer of the health care facility or their designee. These reports shall include:

(a) Verification that the physician is employed full-time;

(b) A current breakdown of patient visits from Oregon Health Plan members, Medicare, and low-income uninsured patients served by the physician; and

(3) The first report is due one year after employment begins, and annually thereafter, until the term of the contract is complete. Failure to submit timely, accurate reports may result in a report of non-compliance to the United States Citizenship and Immigration Services; and may adversely affect the facility’s eligibility for future participation in the program.

(4) Notify the Authority immediately of any change or prospective change in the physician’s employment status.

(5) Allow Authority auditors access to health care facility and physician records.

History

Statutory/Other Authority: ORS 413.248
Statutes/Other Implemented: ORS 413.248
OHP 9-2022, amend filed 12/06/2022, effective 12/06/2022
OHP 21-2019, amend filed 09/27/2019, effective 10/21/2019
OHP 13-2018, amend filed 09/30/2018, effective 10/01/2018
Renumbered from 333-005-0050 by OHP 7-2010, f. 12-29-10, cert. ef. 1-1-11
PH 11-2004, f. 3-25-04, cert. ef. 3-29-04
PH 14-2003(Temp), f. 9-25-03 cert. ef. 10-1-03 thru 3-29-04

Or. Admin. R. 409-035-0060 Transfer of J-1 Waiver Physician Obligation

(1) A physician who is granted a visa waiver and who encounters a practice failure due to extenuating circumstances may, with Authority approval, finish the three-year service obligation at another approved health care facility. A written notification of the intended transfer must be submitted to the Authority documenting the need for the transfer before the transfer takes place. Failure to submit written notification prior to a transfer may adversely affect the facility’s eligibility for future participation in the program.

(2) The notification must include the reason for transfer, proposed new employer, the health care facility director's name, practice name, address, telephone number, and proposed date of transfer.

(3) The original employer must provide a letter releasing the physician from the employment contract and providing an explanation for the termination. The Authority may waive this requirement if the original employer is in non-compliance with federal requirements, federal or state law, or with these rules.

(4) The new employer must:

(a) Provide a letter of intent to employ the physician;

(b) Provide a copy of the new employment contract;

(d) Work with the physician to jointly submit annual Verification of Employment forms as required by the Authority.

History

Statutory/Other Authority: ORS 413.248
Statutes/Other Implemented: ORS 413.248
OHP 9-2022, amend filed 12/06/2022, effective 12/06/2022
Renumbered from 333-005-0060 by OHP 7-2010, f. 12-29-10, cert. ef. 1-1-11
PH 11-2004, f. 3-25-04, cert. ef. 3-29-04
PH 14-2003(Temp), f. 9-25-03 cert. ef. 10-1-03 thru 3-29-04

Division 36 HEALTH CARE PROVIDER INCENTIVE PROGRAM

Or. Admin. R. 409-036-0000 Purpose and Scope

These rules (OAR 409-036-0000 to 409-036-0150) establish the Health Care Provider Incentive Program within the Oregon Health Authority. The program promotes culturally responsive care by ensuring equitable incentives for qualified health providers who commit to serving patients in both rural and non-rural underserved areas across Oregon, thereby improving access to care for all residents.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 4-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0010 Definitions

The following definitions apply to OAR 409-036-0000 to OAR 409-036-0150:

(1) “Authority” means the Oregon Health Authority.

(2) “Board” means the Oregon Health Policy Board.

(3) “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 and 731.072 and does not include DCBS-listed insurers pursuant to ORS 735.300 to 735.365 and 735.400 to 735.495.

(4) “Certified Alcohol and Drug Counselor” means a behavioral health professional that practices substance use disorder counseling pursuant to OAR 309-019-0125.

(5) “Certified registered nurse anesthetist” means an individual licensed by the Oregon State Board of Nursing as a certified registered nurse anesthetist under ORS Chapter 678.

(6) “Clinical Psychologist” means an individual licensed to practice psychology pursuant to ORS 675.010 to 675.090.

(7) “Clinical Social Worker” means an individual licensed to practice clinical social work pursuant to ORS 675.510 to 675.600.

(8) “Contract” means an eligible provider’s agreement with the Authority governing the distribution of incentives under these rules.

(9) "DCBS” means the Department of Consumer and Business Services.

(10) “Dentist” means any individual licensed to practice dentistry under ORS Chapter 679.

(11) “Dental Assistant” means a person who, under the supervision of a dentist, renders assistance to a dentist, dental hygienist, dental therapist or another dental assistant or renders assistance under the supervision of a dental hygienist providing dental hygiene services under OAR Chapter 818 Division 42.

(12) “Dental Therapist” means a person licensed to practice dental therapy under ORS 679.603.

(13) “Dental Therapy” means the provision of preventive dental care, restorative dental treatment and other educational, clinical and therapeutic patient services as part of a dental care team, including the services described under ORS 679.621.

(14) “Eligible provider” means a practitioner licensed, certified, or credentialed to deliver health care services to patients in Oregon that meets the eligibility requirements for incentives listed under these rules.

(15) “Eligible student” means a student currently participating in an approved health care professional Training Program.

(16) “Essential health care services” means medical, dental or behavioral health services that have been determined to be necessary to support the health of the population of the community.

(17) “Expanded Practice Dental Hygienist” means an individual licensed to practice dental hygiene with an expanded practice dental hygienist permit issued under ORS 680.200.

(18) “Licensed Professional Counselor” means an individual licensed under ORS 675.715.

(19) “Long Term Care” means:

(a) A licensed skilled nursing facility as defined under ORS 442.015;

(b) An intermediate care facility as defined under ORS 442.015;

(d) A residential care facility as defined in ORS 443.400.

(20) “Marriage and Family Therapist” means an individual licensed under ORS 675.715.

(21) “Medical assistance” has the meaning given that term in ORS 414.025.

(22) “Medicare” means medical coverage provided under Title XVIII of the Social Security Act.

(23) “National Health Services Corps” or “NHSC” means that program pursuant under 42 CFR Part 23.

(24) “Naturopathic Physician” means an individual licensed pursuant to ORS Chapter 685.

(25) "Nurse Practitioner" means any individual licensed by the Oregon State Board of nursing pursuant to ORS 678.375 to 678.390.

(26) “Office” means the Office of Rural Health.

(27) “Office Website” means https://www.ohsu.edu/oregon-office-of-rural-health.

(28) “Oregon Area Health Education Centers (AHEC) Scholars Program” means the program developed to recruit, train and retain health care professionals committed to underserved populations, supported by the Health Resource and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under U77HP03052 Model State Area Health Education Centers.

(29) “Overpayment” means a payment made by the Authority to an eligible provider participating in the Program in excess of the correct payment amount specified under the terms of the contract.

(30) “Patient-Centered Primary Care Home Program” or “PCPCH” means the program described ORS 413.259.

(31) “Pharmacist” means an individual licensed under ORS Chapter 689.

(32) "Physician" means an individual licensed under ORS Chapter 677.

(33) "Physician Associate" means any individual licensed under ORS 677.495 to 677.535.

(34) "Practice full-time" means working at a minimum of 32 hours per week spent providing direct patient care, averaged over the month for a minimum of 45 weeks per service year.

(35) “Practice part-time” means working a minimum of 16 hours per week spent providing direct patient care, averaged over the month for a minimum of 45 weeks per service year.

(36) “Priority Populations” has the meaning given that term in ORS 413.256.

(37) “Program” means the Health Care Provider Incentive Program.

(38) “Program Website” means https://www.oregon.gov/oha/hpa/hp-pco/pages/hc-provider-incentive.aspx.

(39) “Psychiatric Mental Health Nurse Practitioner” means any individual licensed under ORS Chapter 678.

(40) “Psychiatrist” means a physician licensed by the Oregon Medical Board pursuant to ORS 677.010 through 677.450.

(41) "Qualified Mental Health Associate" means a mental health professional delivering services under the direct supervision of a QMHP that meets the minimum qualifications of OAR 309-019-0125.

(42) "Qualified Mental Health Professional" or “QMHP” means a licensed medical practitioner or any other person who meets the minimum qualifications of OAR 309-036-0105.

(43) “Qualifying loan” means one or more government, or commercial loans received solely to cover the cost of health professional training, or undergraduate or other educational training. This does not include credit card loans, lines of credit, and personal loans.

(44) “Qualified Practice Site” has the meaning given that term in OAR 409-036-0015.

(45) “Rural” has the meaning given that term in ORS 431.122.

(46) “Site Application” means the Site Eligibility Application for All State Incentive Programs issued by the Office to determine whether a site is a Qualified Practice Site.

(47) “Telehealth” means the provision of health services as defined by OAR 410-141-3566.

(48) “These rules” means the rules set forth in OAR 409-036-0000 through OAR 409-036-0150.

(49) “Training Program” means a course of study that results in certification, licensure or other credential related to the health care workforce; or other programs as determined by the Authority.

(50) "Trauma informed approach” has the meaning given that term in OAR 410-141-3500.

(51) “Trauma informed services” has the meaning given that term in OAR 410-141-3500.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 2-2024, minor correction filed 06/06/2024, effective 06/06/2024
OHP 7-2022, amend filed 08/31/2022, effective 08/31/2022
OHP 4-2022, temporary amend filed 06/16/2022, effective 06/16/2022 through 09/01/2022
OHP 2-2022, temporary amend filed 03/04/2022, effective 03/06/2022 through 09/01/2022
OHP 1-2021, amend filed 03/29/2021, effective 03/29/2021
OHP 5-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0015 Qualified Practice Site

In order to qualify as a Qualified Practice Site under these rules, a site must meet the following requirements under this rule.

(1) For Loan Repayment Subsidies under OAR 409-036-0030, a Qualified Practice Site must meet (a) below and also must meet either (b), (c), or (d) below:

(a) Have a valid Site Application on file with the Oregon Office of Rural Health, dated within the past 12 months and have received confirmation of site qualification; and

(b) Be located in a Health Professional Shortage Area (HPSA), have a Facility HPSA designation, serve in an underserved area or area of unmet need; or

(d) Provide essential health care services to an underserved population, as determined by the Authority.

(2) For Loan Forgiveness Payments under OAR 409-036-0035, a Qualified Practice Site must meet (a) and (b) below and also must meet either (c), (d), or (e) below:

(a) Have a valid Site Application on file with the Oregon Office of Rural Health, dated within the past 12 months and have received confirmation of site qualification; and

(b) Be located in a rural community; and

(c) Be located in a Health Professional Shortage Area (HPSA), have a Facility HPSA designation, serve in an underserved area or area of unmet need; or

(d) Serve Medicaid and/or Medicare patients in a proportion equal to or greater than the county average; or

(e) Provide essential health care services to an underserved population, as determined by the Authority.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, adopt filed 05/28/2026, effective 07/01/2026

Or. Admin. R. 409-036-0020 Types of Incentives Offered Under the Program

The types of incentives that may be provided under the Program include:

(1) Loan Repayment subsidies that meet the requirements of OAR 409-036-0030 to support the retention of health care providers in Oregon;

(2) Primary Care Loan Forgiveness Payments that meet the requirements of OAR 409-036-0035; to support the expansion of health care workforce capacity in rural areas of Oregon;

(3) Incentive opportunity for scholarships for eligible students in health professional Training Programs at the Oregon Health and Science University. Scholarships must be consistent with the requirements of the Scholars for a Healthy Oregon Initiative created by ORS 348.303;

(4) Incentive opportunities specific to Health Care Workforce Scholarships. Public and private institutions or organizations that train students and offer scholarships for eligible students enrolled in health professional Training Programs are eligible to receive Health Care Workforce Scholarship funding. Scholarships must meet the requirements in OAR 409-036-0040 to help eligible students located in rural and non-rural underserved areas of Oregon;

(5) Rural medical practitioner insurance subsidies that meet the requirements in OAR 409-036-0050 and enable providers to remain practicing in rural areas of the state;

(6) Community Workforce Assistance Grants that meet the requirements of OAR 409-036-0060 to support community-based training initiatives, and recruitment and retention of providers who will deliver care to address workforce shortages and expand diversity;

(7) Other Incentives Opportunities as determined and allocated by the Authority and based on the most recent Health Care Workforce Needs Assessment conducted by the Board, as required under ORS 676.459.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 7-2022, amend filed 08/31/2022, effective 08/31/2022
OHP 2-2022, temporary amend filed 03/04/2022, effective 03/06/2022 through 09/01/2022
OHP 6-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0030 Eligibility Criteria and Application Requirements specific to Loan Repayment Subsidies

(1) Eligibility Criteria.

(a) Eligible provider types include:

(A) Dentists in general or pediatric practice;

(B) Expanded Practice Dental Hygienists;

(D) Dental Therapists;

(E) Pharmacists who practice in general or psychiatric pharmacy;

(F) Physicians (MD, DO or ND) who practice in the specialties of family medicine or general practice, general internal medicine, geriatrics, pediatrics, or obstetrics and gynecology;

(G) Nurse Practitioners who practice in the specialties of adult primary care, women's health care, geriatrics, pediatrics, family practice, psychiatry or nurse midwifery;

(H) Physician Associates who practice in the specialties of family medicine or general practice, general internal medicine, geriatrics, pediatrics or obstetrics and gynecology;

(I) Pre-licensed/Licensed Clinical Social Workers;

(J) Pre-licensed/Licensed Marriage and Family Therapists;

(K) Pre-licensed/Licensed Professional Counselors;

(L) Psychiatrists who practice in the specialties of general psychiatry, child and adolescent psychiatry, and geriatrics;

(M) Counseling/Clinical Psychologists;

(N) Psychiatric Mental Health Nurse Practitioners;

(O) Certified Alcohol and Drug Counselor I, II and III;

(P) Qualified Mental Health Associate (QMHA); and

(Q) Qualified Mental Health Professional (QMHP).

(b) Eligible providers must:

(A) Have, or have applied for, an unrestricted license or certification (if required) to practice in Oregon within their discipline.

(B) Depending on the type of loan repayment incentive as outlined on the Office Website, provide health care services at a Qualified Practice Site.

(C) Commit to practice either full-time or part-time for a three-year minimum service obligation at a Qualified Practice Site.

(D) Not participate in the National Health Services Corps (NHSC), NurseCorps, Oregon Partnership State Loan Repayment Program or the NHSC Scholarship Program, or any other state or federal program(s) offering funds in exchange for a service obligation, unless expressly permitted under state or federal law.

(2) Application Requirements. Applications for Loan Repayment Subsidies must be completed and submitted pursuant to the instructions posted on the Office Website.

(a) The Office will notify eligible providers if submissions are incomplete. Complete applications must be submitted before the application deadline posted on the Office Website to be considered.

(b) The Office will notify applicants of the status of their completed applications within 90 calendar days of a complete application submission.

(3) An eligible provider that is currently employed at a Qualified Practice Site or has an employment contract with a Qualified Practice Site must submit a letter to the Office, with a copy submitted to the Authority, attesting that the site meets the requirements of OAR 409-036-0015.

(4) The Authority may consider the factors outlined in OAR 409-036-0070 in determining whether to accept an eligible provider for participation.

(5) Maximum award amounts for loan repayment subsidies under this rule must be awarded in the manner provided in OAR 409-036-0080.

(6) Non-Compliance. A loan repayment subsidies recipient may be considered in non-compliance with these rules when the eligible provider fails to meet certain requirements as outlined in OAR 409-036-0120.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 7-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0035 Eligibility Criteria and Application Requirements specific to Primary Care Loan Forgiveness Payments

(1) Eligibility Criteria.

(a) Eligible provider types include:

(A) Physicians (MD, DO or ND) who practice in the specialties of family medicine or general practice, general internal medicine, geriatrics, community psychiatry, pediatrics, or obstetrics and gynecology;

(B) Physician Associates who practice in the specialties of family medicine or general practice, general internal medicine, geriatrics, pediatrics or obstetrics and gynecology;

(C) Nurse Practitioners who practice in the specialties of adult primary care, women's health care, geriatrics, pediatrics, family practice, psychiatry or nurse midwifery;

(D) Dentists in general or pediatric practice; and

(E) Pharmacists who practice in general or psychiatric pharmacy.

(b) An eligible provider must:

(d) Participate in either the Oregon Area Health Education Centers (AHEC) Scholars Program or be accepted to an Authority-approved Oregon rural training track;

(e) Be prepared to begin practice at a Qualified Practice Site within 90 calendar days of graduation or completion of residency, as applicable;

(f) Commit to practice full-time at a Qualified Practice Site for the duration of their obligation to the Authority or one obligation year for every year of funding; and

(g) Not participate in the National Health Services Corps (NHSC), NurseCorps, Oregon Partnership State Loan Repayment Program or the NHSC Scholarship Program, or any other state or federal program(s) offering funds in exchange for a service obligation, unless expressly permitted under state or federal law.

(2) Application Requirements. Applications for Primary Care Loan Forgiveness Payments must be completed and submitted pursuant to the instructions posted on the Office Website.

(a) The Office will notify eligible providers if submissions are incomplete. Complete applications must be submitted before the application deadline posted on the Office Website to be considered.

(b) The Office will notify applicants of the status of their completed applications within 90 calendar days of a complete application submission.

(4) The Authority may consider the factors outlined in OAR 409-036-0070 in determining whether to accept an eligible provider for participation.

(5) Maximum award amounts for Primary Care Loan Forgiveness payments under this rule must be awarded in the manner provided in OAR 409-036-0080.

(6) Non-compliance. A loan forgiveness recipient may be considered in non-compliance with these rules when the eligible provider fails to meet certain requirements as outlined in OAR 409-036-0120.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, adopt filed 05/28/2026, effective 07/01/2026

Or. Admin. R. 409-036-0040 Incentive Opportunities specific to Health Care Workforce (HCWF) Scholarships

(1) The application cycle is determined by the Authority.

(2) Public and private institutions in Oregon or organizations training students in Oregon (for purposes of this rule, “Applicant”), not otherwise governed by the Scholars for a Healthy Oregon Initiative (SHOI) created by ORS 348.303, may submit applications in response to an incentive opportunity from the Authority for scholarships to eligible students in health care professional Training Programs.

(3) The purpose of the program under this rule is to provide an opportunity for education, Training Programs, and other health-related workforce programs in Oregon to apply for funds to administer a scholarship program for eligible students that will meet the health care workforce objectives set by the Oregon Health Policy Board, the Health Care Workforce Committee, and the Oregon Legislature.

(4) Applicant must meet the following minimum qualifications prior to submitting a response to the incentive opportunity from the Authority. Applicants must:

(a) Be an institution that provides health care related training serving students located in Oregon;

(b) Have the ability to collect and supply the Authority with a list of eligible student scholarship awardees no more than 30 calendar days prior to the end of the school term;

(d) Meet any other minimum qualification specified by the Authority in the incentive opportunity.

(5) Applications must be submitted to the Authority in the form and manner identified by the Authority in the incentive opportunity.

(6) The Authority must only consider timely and complete applications or proposals for possible approval and offering of a contract.

(7) It is within the Authority’s sole discretion to issue an incentive opportunity, review and consider applications submitted, set the time for submission of applications or proposals or extend the time for applications or proposals, and to make awards that, in its best judgment, achieve the purposes of the incentive opportunity, ORS 676.454, these rules, and other applicable law.

(8) Non-compliance. A scholarship recipient may be considered in non-compliance with these rules when the eligible provider participating in the Program fails to meet certain requirements as outlined in OAR 409-036-0120.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 7-2022, amend filed 08/31/2022, effective 08/31/2022
OHP 2-2022, temporary amend filed 03/04/2022, effective 03/06/2022 through 09/01/2022
OHP 8-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0050 Rural Medical Practitioners Insurance Subsidy Program-Health Care Provider Eligibility Criteria

(1) The Health Care Provider Incentive Fund may subsidize eligible practitioners for the cost of medical professional liability insurance coverage in force or renewed on or after July 1, 2026.

(2) Eligibility Criteria. An eligible practitioner must:

(a) Provide health services in rural Oregon;

(b) Hold an active, unrestricted license or certification, issued by either the Oregon Medical Board or the Oregon State Board of Nursing;

(c) Pay for and be covered by an in-force medical professional liability insurance policy issued by a participating Carrier with minimum coverage limits of $1 million per occurrence and $1 million annual aggregate, maximum coverage limits of $1 million per occurrence and $3 million annual aggregate, and which specifically names the individual health care provider and calculates the provider’s premium; and

(d) Practice at least 60 percent of the time in a Qualified Practice Site that meets the requirements of OAR 409-036-0015.

(3) An eligible practitioner whose medical professional liability insurance coverage is provided through a health care facility, as defined in ORS 442.400, is eligible for a premium subsidy if that practitioner:

(a) Is covered by a medical professional liability insurance policy that names the practitioner and separately calculates the premium for the practitioner; and

(b) Fully reimburses the health care facility for the premium calculated for the practitioner.

(4) Application Requirements. Applications for Rural Medical Providers Insurance Subsidy must be completed and submitted pursuant to the instructions posted on Office Website.

(a) The Office will notify eligible providers if submissions are incomplete. Complete applications must be submitted before the application deadline posted on the Office Website to be considered; and

(b) The Office will notify applicants of the status of their completed applications within 90 calendar days of a complete application submission.

(5) An eligible provider must submit a letter to the Office, with a copy submitted to the Authority, attesting that the place of employment meets the requirements of a Qualified Practice Site under OAR 409-036-0015.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 7-2022, amend filed 08/31/2022, effective 08/31/2022
OHP 1-2021, amend filed 03/29/2021, effective 03/29/2021
OHP 9-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0055 Rural Medical Practitioners Insurance Subsidy Program-Medical Professional Liability Carrier Participation

(1) Carrier Participation. To participate in the medical professional liability insurance premium subsidy program outlined in OAR 409-036-0050, a Carrier must certify that it is authorized to issue professional liability insurance policies or certificates in Oregon. The Carrier must provide written certification to the Authority no more than 30 days prior to the beginning date of a calendar quarter in which the Carrier will participate in the subsidy program.

(a) The certification must be delivered to the Authority:

(A) By mail, to the following address: Oregon Health Authority, 500 Summer St NE, Salem, OR 97301, Attention: Health Care Provider Incentive Program–Medical Malpractice Insurance Subsidy; or

(B) By email, to providerincentives@odhsoha.oregon.gov.

(b) The certification must be signed by an individual authorized to represent the Carrier.

(A) Is an insurance company 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 ORS 735.300 to 735.365 and ORS 735.400 to 735.495;

(B) Understands the Authority may confirm the representations in paragraph OAR 409-036-0055(1)(c)(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) must be relied upon by the Authority in determining whether an insurer may participate in the subsidy program; and

(C) Agrees to comply with the terms and conditions of the rules applicable to the subsidy 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) If a Carrier does not provide the certification to the Authority within the time established in subsection (1), the Carrier may not submit a request for premium subsidy payment for the applicable calendar quarter and eligible practitioners insured by the Carrier may not receive a premium subsidy for that quarter.

(e) 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 subsidy program.

(2) Carrier Discontinuation. A Carrier must notify the Authority at least 90 days prior to the beginning date of the next calendar quarter if the Carrier wants to discontinue participation in the program. The Carrier must notify its insured eligible practitioners of its intent to discontinue to participate at least 60 days prior to the date of the next calendar quarter.

(3) Each Carrier participating in the program must electronically (using Microsoft Excel or similar spreadsheet application) submit:

(a) A report to the Authority within 30 days after the end of each billing period (monthly or quarterly), showing the following information for each insured eligible practitioner who has been determined eligible for a premium subsidy as of the end of the billing quarter. This report must be delivered to the Authority by email to providerincentives@odhsoha.oregon.gov. The report must include the following:

(A) Carrier’s name;

(B) Practitioner’s name; and

(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 OAR 409-036-0080 (3);

(ix) Dollar amount of premium subsidy, calculated in accordance with OAR 409-036-0080 (3);

(x) Explanation of any adjustments under this program from previous reports;

(xi) Policy coverage limits;

(xii) Claims-made step of practitioner, if applicable; and

(xiii) Identify practitioners who were not on the eligible list at the beginning of the quarter.

(b) Annually a copy of their base rates and increased limits factors table. Carrier must also notify the Authority if there is any change to the current base rates and increased limits factors table within 30 days of the change.

(4) Failure to make timely submissions under subsection (3) may result in delay in processing or declining a payment request.

(5) The Authority must calculate the payment of premium subsidies from the Rural Medical Liability Subsidy Fund based on the funds available for the applicable billing period. A Carrier must reduce the premium charged to an eligible practitioner by the amount of any premium subsidy paid or to be paid under the program.

(6) If there are insufficient funds to provide the maximum premium subsidy to all eligible practitioners, the Authority may reduce or eliminate subsidies for eligible practitioners in an equitable manner and will notify affected Carriers and eligible practitioners. 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 will be based on the subsidy requests received timely for each applicable billing period.

(7) Each Carrier participating in the program must provide its insured eligible practitioners with the following information quarterly with each eligible practitioner’s billing statement:

(a) The quarterly premium due before the premium subsidy is applied;

(b) The amount of the premium subsidy; and

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, adopt filed 05/28/2026, effective 07/01/2026

Or. Admin. R. 409-036-0060 Eligibility Criteria for Community Workforce Assistance Grants

(1) The application cycle is determined by the Authority.

(2) Applicants may submit proposals in response to a request for grant proposals (RFGP) or request for grant application (RFGA), as applicable, from the Authority to expand health professional training within Oregon to address current and future shortages in the health care workforce.

(3) The purpose of the Community Workforce Assistance Grants is to support community-based training initiatives and expand health professional training within Oregon to address health care workforce shortages and expand diversity for people in:

(a) Culturally and linguistically diverse groups;

(b) Groups that have been economically and socially marginalized;

(d) Rural communities;

(e) Communities experiencing inequities throughout Oregon.

(4) In order to be eligible for a Community Workforce Assistance Grant applicants must be launching training initiatives that address documented shortages in the areas outlined in Section (3). The Authority will accept proposals from projects in all or specified disciplines of the health care system, as specified in the RFGP or RFGA.

(5) Proposals must be submitted to the Authority in the form and manner identified by the Authority in the RFGP or RFGA.

(6) The Authority will only consider timely and complete proposals for possible approval and offering a contract.

(7) It is within the Authority’s sole discretion to issue a RFGP or RFGA, review and consider proposals submitted, set the time or extend the time for submission of proposals, and to award grants that, in its best judgment, achieve the purposes of the RFGP or RFGA, ORS 676.454, these rules, and other applicable law.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 7-2022, amend filed 08/31/2022, effective 08/31/2022
OHP 1-2021, amend filed 03/29/2021, effective 03/29/2021
OHP 10-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0070 Review Process for Loan Repayment Subsidies and Primary Care Loan Forgiveness Payments

(1) This rule relates solely to Loan Repayment Subsidies under OAR 409-036-0030 and Primary Care Loan Forgiveness Payments under OAR 409-036-0035.

(2) Review Criteria. The Authority may consider the following factors in determining whether to accept an eligible provider for participation in the Program:

(a) Eligible providers who apply to practice at a Qualified Practice Site, under OAR 409-036-0015, located in a Health Professional Shortage Area (HPSA), as defined by the federal Health Resources and Services Administration, that has been determined to not reach the threshold for federal National Health Service Corps (NHSC) or NurseCorps awards in a given year.

(b) Eligible providers who apply to practice at a Qualified Practice Site located in a service area ranking below the median in the most recent Areas of Unmet Health Care Need report published by the Office and posted to the Office Website.

(c) Eligible providers who will provide services in, or in affiliation with, a Patient-Centered Primary Care Home Program (PCPCH) recognized by the State of Oregon.

(d) Physical location of eligible providers delivering telehealth services.

(e) Eligible provider types, disciplines, or ethnic or linguistic diversity particularly needed in a community, including ethnicity, language spoken, specialty, or provider type.

(f) Qualified Practice Site client demographic represents a priority population.

(3) Upon approval of an application, the Authority will enter into a contract with the eligible provider. The Authority will disburse funds in accordance with the terms of this contract.

(4) Funds are not considered obligated and must not be transferred until all required contractual documents have been executed by the applicant and the Authority designee.

(5) An eligible provider participating in the Program may request to change their Program award status from practice full-time to practice part-time a maximum of one (1) time per term of the contractual agreement.

(a) To request such change, an eligible provider must submit a completed Request for Program Award Status Change, available on the Office Website, and submit to the Office of Rural Health 30 days prior to the change occurring and then must meet approval by the Authority.

(b) If approved by the Authority:

(A) The eligible provider’s remaining disbursements under the contractual agreement will be reduced by half; and

(B) The eligible provider will be required to enter into an amendment of the contract to reflect this change in status and updated disbursement terms.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 7-2022, amend filed 08/31/2022, effective 08/31/2022
OHP 1-2021, amend filed 03/29/2021, effective 03/29/2021
OHP 11-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0080 Maximum Award Amounts

(1) Loan Repayment subsidy recipients under OAR 409-036-0030 are eligible for a maximum loan repayment award in the following manner:

(a) Eligible providers who practice full-time:

(A) Those with less than $29,000 in qualifying loan debt are eligible to receive up to 100% of qualifying loan debt for initial 3-year service obligation;

(B) Those with $29,000 or more in qualifying loan debt are eligible to receive:

(i) Seventy percent of the balance owed on qualifying loans upon program entry for an initial three years of service;

(ii) Eighty percent of the balance owed on remaining qualifying loans for an additional three years of service; or

(iii) One hundred percent of the balance owed on remaining qualifying loans for a final three years of service;

(b) Eligible providers who practice part-time:

(A) Those with less than $15,000 in qualifying loan debt are eligible to receive up to 100% of qualifying loan debt for initial, or subsequent service obligations;

(B) Those with $15,000 or more in qualifying loan debt are eligible to receive:

(i) Thirty-five percent of the balance owed on qualifying loans upon program entry for an initial three years of service;

(ii) Forty percent of the balance owed on remaining qualifying loans for an additional three years of service; or

(iii) Fifty percent of the balance owed on remaining qualifying loans for a final three years of service;

(2) Scholarship Recipients governed by the Scholars for a Health Oregon Initiative under ORS 348.303 and Primary Care Loan Forgiveness recipients under OAR 409-036-0035 are eligible for incentives as follows:

(a) Scholarship recipients under the Scholars for a Healthy Oregon Initiative at Oregon Health and Science University shall receive a scholarship covering the entire cost of tuition and fees for the participant’s health care education at the university.

(b) Eligible students participating in educational or Training Programs other than those identified in Section (3) below shall receive a scholarship or loan forgiveness covering an amount equal to at least half of and up to the entire cost of tuition and fees for the participant’s training in the program in which they are participating, at the discretion of the sponsoring organization, so long as the maximum scholarship for each eligible student does not exceed the highest resident tuition rate at the publicly-funded health professional Training Programs in this state.

(3) Rural Medical Practitioners Insurance Subsidy Recipients under OAR 409-036-0050 shall receive a maximum subsidy of:

(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;

(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 subsection (a) through (c) above.

(4) Other subsidies. The Authority may provide Health Care Workforce Scholarships under OAR 409-036-0040 and Community Workforce Assistance Grants under OAR 409-036-0060 to an organization to support evidence-based practices for recruitment and retention of health care providers at its own discretion.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 7-2022, amend filed 08/31/2022, effective 08/31/2022
OHP 4-2022, temporary amend filed 06/16/2022, effective 06/16/2022 through 09/01/2022
OHP 2-2022, temporary amend filed 03/04/2022, effective 03/06/2022 through 09/01/2022
OHP 1-2021, amend filed 03/29/2021, effective 03/29/2021
OHP 12-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0090 Transfer of Provider Service Obligation to Another Site

(1) This rule applies to eligible providers under contract with the Authority for incentives under these rules.

(2) In the event of a practice site closure, consolidation of practice sites or entities (merger or acquisition), or other extenuating circumstance, an eligible provider may transfer the service obligation to another Qualified Practice Site that meets the requirements of OAR 409-036-0015 upon prior approval from the Authority. A transfer without prior approval is considered a violation of the contract. An eligible provider requesting transfer to another Qualified Practice Site must submit a written transfer request to the Office 30 days prior to the change occurring, for submission and approval by the Authority, documenting the:

(a) Circumstances surrounding the need to transfer;

(b) Proposed new Qualified Practice Site; and

(3) The eligible provider must also submit all of the following:

(a) A letter from the original Qualified Practice Site releasing the eligible provider from any employment contract (if applicable) and providing an explanation for the termination of employment. The Authority may waive this requirement if the original Qualified Practice Site is not in compliance with federal or state law or these rules;

(b) An employment contract with the new Qualified Practice Site, a letter of intent from the new Qualified Practice Site to employ the provider, or documentation of the provider having established a sole proprietorship, Limited Liability Corporation, Limited Liability Partnership, or Professional Corporation;

(c) A letter of support attesting that the place of employment meets the requirements for a Qualified Practice Site as described in OAR 409-036-0015;

(d) Confirmation that the site will cooperate with the eligible provider to comply with the monitoring and follow-up requirements set forth in these rules; and

(e) Any other information as requested by the Authority.

(4) An eligible provider’s failure to obtain prior approval from the Authority prior to transferring their service obligation to another site, or failure to notify the authority upon termination of employment at practice site within 30 days of the occurrence, may be deemed in breach of their contract with the Authority.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 1-2021, amend filed 03/29/2021, effective 03/29/2021
OHP 13-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0100 Suspension or Waiver of Minimum Service Obligation

(1) The Authority may agree to suspend a participating provider’s service obligation for a specified time under circumstances it deems appropriate, including, but not limited to parental leave, medical leave, military service leave, or other factors beyond a provider’s control.

(2) A participant requesting a temporary suspension of minimum service obligation must complete a Request for Temporary Suspension form, located on the Office Website, citing the reasons for such request and providing supporting documentation of the circumstances. The eligible provider must submit the written request to the Office 30 days prior to the change occurring, for submission and approval by the Authority.

(3) The Authority may temporarily suspend all or part of the provider’s minimum service obligation, as outlined in these rules and the provider’s contract with the Authority, under the following circumstances:

(a) Removal from the employment site due to unforeseen circumstances beyond the provider’s control; parental leave; closure of Qualified Practice Site; unforeseen life event beyond the provider’s control; or

(b) Provider agrees to execute a contract amendment reflecting the terms of suspension and updated incentives disbursement.

(4) The Authority may waive all or part of the minimum service obligation under the following circumstances:

(a) Death of the participant, upon receipt of copy of a valid death certificate or other written documentation acceptable to the Authority;

(b) Medically verified, total and permanent disability of the participant; or

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 14-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0110 Monitoring and Follow-up Requirements

(1) To maintain participation in the Program, an eligible provider must:

(a) Notify the Authority immediately upon beginning work at a Qualified Practice Site.

(b) Submit semi-annual reports signed by the eligible provider and the administrator of the Qualified Practice Site verifying the eligible provider’s employment, or licensed business (in the case of a sole eligible provider). This semi-annual report must include all of the following:

(A) Qualified Practice Site’s and eligible provider’s caseload (panel size or equivalent);

(B) Qualified Practice Site’s and eligible provider’s Medicaid caseload and Medicare caseload;

(D) Any additional information requested by the Authority.

(c) An eligible provider must submit the first semi-annual report six months after employment begins, and every six months thereafter, until the term of the contract is complete.

(2) An eligible provider participating in the Program that wishes to transfer the service obligation to another Qualified Practice Site that meets the requirements of OAR 409-036-0015 must follow the requirements of OAR 409-036-0090 and the terms of the contract with the Authority.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 15-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0120 Failure to Comply; Penalties & Appeals

(1) A loan repayment recipient, under OAR 409-036-0030 shall be considered in non-compliance with OARs 409-036-0000 to 409-036-0150 when the eligible provider participating in the program:

(a) Fails to comply with the terms of the contract;

(b) Fails to maintain employment at a Qualified Practice Site for the duration of the contract term;

(c) Fails to complete the minimum service obligation and does not apply for, or receive, a suspension or waiver of minimum service obligations under OAR 409-036-0100;

(d) Participates in the National Health Services Corps (NHSC), NurseCorps, Oregon Partnership State Loan Repayment Program or the NHSC Scholarship Program, or any other state or federal program(s) offering funds in exchange for a service obligation, unless expressly permitted under state or federal law.

(2) The Authority may impose a penalty on an eligible provider receiving loan repayment subsidies in an amount up to the sum of:

(a) The total paid from the Health Care Provider Incentive Fund to the participant or on behalf of the participant for any periods of obligated service not served;

(b) $500 for each month of the minimum service period not completed according to the terms of the contract, up to 10% of total award amount; and

(c) Interest on the above amounts at the maximum prevailing rate, as determined by the Oregon Department of Revenue, calculated from the date of breach until full repayment has been made.

(3) A loan forgiveness or scholarship recipient under OAR 409-036-0035 and 409-036-0040, respectively must be considered in non-compliance with OARs 409-036-0000 to 409-036-0150 when the eligible provider participating in the Program:

(a) Fails to complete their residency or training;

(b) Fails to comply with the terms of the contract;

(d) Fails to complete the minimum service obligation and does not apply for or receive a waiver under OAR 409-036-0100;

(e) Participates in the National Health Services Corps (NHSC), NurseCorps, Oregon Partnership State Loan Repayment Program or the NHSC Scholarship Program, or any other State or Federal program(s) offering funds in exchange for a service obligation, unless expressly permitted under state or federal law.

(4) The Authority may impose a penalty on any eligible provider participating in the Program and receiving a loan forgiveness or scholarship incentive as follows:

(a) If the eligible provider fails to complete their residency or training: payment to the Authority may be collected in an amount equal to 100% of the funds received from the Authority plus interest on the unpaid balance as accrued from the disbursement date of the funds according to the terms of the contract.

(b) If the eligible provider completes their residency or training but fails to comply with the Sections (3)(b) to (e) of this rule: payment to the Authority may be collected in an amount equal to 100% of the funds received from the Authority plus interest at the maximum prevailing rate, as determined by the Oregon Department of Revenue, plus a 25 percent penalty on the total award paid to date on the unpaid balance as accrued from the disbursement date of the funds according to the terms of the contract.

(5) The Authority must collect any penalties imposed under this section and deposit the funds in the Authority’s account established under ORS 676.450.

(6) If the Authority determines that an eligible provider participating in the Program is subject to a penalty under this section, the Authority must issue a notice of proposed action as pursuant to ORS Chapter 183.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 2-2022, temporary amend filed 03/04/2022, effective 03/06/2022 through 09/01/2022
OHP 16-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0130 Contributions to the Health Care Provider Incentive Fund

(1) The Authority shall publish on its Office Website terms and conditions for receipt of funds from Qualified Practice Sites or other sources to contribute toward the cost of the subsidies for participants.

(2) The Authority shall deposit all contributions to the Health Care Provider Incentive Fund established in ORS 676.450.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 17-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0140 Program Integrity

(1) The Authority shall analyze and monitor the operation of the Program and audit and verify the accuracy and appropriateness of all payments made under the terms of this Program.

(2) Eligible providers participating in the Program, under contract with the Authority and receiving payments from the Authority are subject to audit or other post-payment review procedures for all applicable payments.

(3) Eligible providers participating in the Program must develop and maintain adequate financial and other documentation as determined by the Authority and in compliance with the eligible provider’s contract with the Authority. This includes records:

(a) Of all activities associated with the funds received under the contract;

(b) Of all prerequisites to disbursement of funds under the contract;

(c) Reflecting that the eligible provider participating in the Program maintains employment at a Qualified Practice Site;

(4) The Authority may communicate with and coordinate any program integrity actions with the federal and state oversight authorities.

(5) Any overpayment made to an individual or Carrier is subject to recovery. The Authority must take appropriate action and may redress payment errors or false claims for payment under the Program.

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 18-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Or. Admin. R. 409-036-0150 Data Sharing

(1) The Authority may not share data about eligible providers or students participating in the Program, other than for purposes of planning, program evaluation or analysis.

(2) Data may only be shared with:

(a) Agencies, offices, or contractors of the Authority;

(b) The Oregon Employment Department; and

History

Statutory/Other Authority: ORS 676.454
Statutes/Other Implemented: ORS 676.454
OHP 2-2026, amend filed 05/28/2026, effective 07/01/2026
OHP 19-2019, minor correction filed 07/25/2019, effective 07/25/2019
OHP 4-2017, adopt filed 12/23/2017, effective 01/02/2018

Division 39 TEMPORARY HEALTH CARE STAFF RATE SETTING PROGRAM

Or. Admin. R. 409-039-0000 Purpose

These rules (OAR 409-039-0000 to 409-039-0120) establish requirements related to the maximum rates that a temporary staffing agency may charge to or receive from a hospital or facility that engages the temporary staffing agency.

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.716
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0010 Definitions

The following definitions apply to OAR 409-039-0000 through 409-039-0120:

(1) “Activities of daily living” means self-care activities that must be accomplished by an individual to meet his or her daily needs, but do not necessarily occur on a daily basis.

(2) “Agency Margin” means the amount represented as a percentage of the bill rate, including any costs not paid directly to the Personnel. This includes, but is not limited to, administrative costs, contracting fees, employee costs, margin, profit.

(3) “Authority” means Oregon Health Authority.

(4) “Bill rate” means the hourly wage rate plus fees, taxes, other supplemental pay and Agency Margin charged to the client, exclusive of per diem stipends.

(5) “Certified medical assistant” means an individual who is certified through the American Association of Medical Assistants as a certified medical assistant and performs administrative and clinical tasks including taking and recording vital signs, preparing patients for examinations, drawing blood, giving vaccines, recording medical histories of patients, updating and filing patient medical records, and other administrative and clinical tasks.

(6) “Certified nursing assistant” means an individual who is certified as a certified nursing assistant by the Oregon State Board of Nursing as provided in ORS 678.440 to ORS 678.448.

(7) “Direct caregiver” means a person who provides assistance with activities of daily living or assistance with personal care tasks, household and supportive services, or medication services.

(8) “Emergency” has the meaning given the term in ORS 401.025.

(9) “Emergency Waiver” refers to the process outlined in OAR 409-039-0050(1).

(10) “Employment agency” has the meaning given that term in ORS 658.005.

(11) “Facility” means an in-home care agency as defined in 443.305; facility with a memory care endorsement facility as described in ORS 443.886; residential care facility as defined in ORS 443.400; or a skilled nursing facility as defined in ORS 442.015 that engages a temporary staffing agency to provide personnel to deliver health care services or assistance with activities of daily living to clients, patients, or residents of the facility.

(12) “Home care worker” has the meaning given that term in ORS 410.600.

(13) “Home health agency” has the meaning given for that term in ORS 443.014.

(14) “Hospital” has the meaning given for that term in ORS 442.015.

(15) “In-home care agency” has the meaning given for that term in ORS 443.305.

(16) “Indian Health Care Provider (IHCP)” means an Indian health program operated by the Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or an Urban Indian Organization (otherwise known as an I/T/U) as those terms are defined in the Indian Health Care Improvement Act (25 U.S.C. § 1603).

(17) “Indian Health Program” means any IHS facility, any federally recognized tribe or tribal organization, or any Federally Qualified Health Center (FQHC) with a 638 designation.

(18) “In good standing” means the status of a holder of a license, certification or registration that is not suspended, revoked, expired, resigned or lapsed.

(19) “Licensed practical nurse” means:

(a) An individual who is licensed as a licensed practical nurse by the Oregon State Board of Nursing as provided in ORS 678.040 and ORS 678.050; or

(b) A non-Oregon individual who is licensed and in good standing as a licensed practical nurse in another state if approved by the Oregon State Board of Nursing, as provided by ORS 678.031, to practice as a licensed practical nurse in this state on a single, temporary assignment of not to exceed 90 days and renewable for not to exceed 90 days (the "90-Day Nurse Licensure Exception").

(20) “Non-Emergency Waiver” refers to the process outlined in OAR 409-039-0050(2).

(21) “Per Diem Stipend” refers to a daily payment intended to cover the costs of lodging, meals and incidental expenses incurred by Personnel while on assignment.

(22) “Personal support worker” has the meaning given that term in ORS 410.600.

(23) “Personnel” means:

(a) A registered nurse, licensed practical nurse, certified medical assistant, certified nursing assistant or direct caregiver who provides health care services or assistance with activities of daily living to clients, patients or residents of a facility; or

(b) A registered nurse or certified nursing assistant who provides health care services to patients for or on behalf of a hospital that engages the temporary staffing agency with which the registered nurse or certified nursing assistant is associated.

(24) “Program” means the Temporary Health Care Staff Rate Setting Program in the Health Policy and Analytics Division of the Oregon Health Authority.

(25) “Program website” means the Authority’s website for the Temporary Health Care Staff Rate Setting Program, currently located at https://www.oregon.gov/oha/hpa/hp-pco/pages/rate-setting.aspx.

(26) “Registered nurse” means:

(a) An individual who is licensed as a registered nurse by the Oregon State Board of Nursing as provided in ORS 678.040 and ORS 678.050; or

(b) A non-Oregon individual who is licensed and in good standing as a registered nurse in another state if approved by the Oregon State Board of Nursing, as provided by ORS 678.031, to practice as a registered nurse in this state on a single, temporary assignment of not to exceed 90 days and renewable for not to exceed 90 days (the "90-Day Nurse Licensure Exception").

(27) “Service date” means the calendar day on which temporary personnel provide health care services at a hospital or facility.

(28) “Temporary staffing agency” means:

(a) An entity that operates in this state for the purpose of providing temporary work to personnel providing health care services or assistance with activities of daily living for or on behalf of hospitals or facilities that engage the temporary staffing agency.

(b) “Temporary staffing agency” does not include:

(A) A staff arrangement established by an entity solely for use by the entity, or by any entity associated with the entity, and in which the only costs are salaries paid to individuals who perform work;

(B) An individual who provides the individual’s services on a temporary basis;

(D) Home health agencies licensed under ORS 443.015;

(E) In-home care agencies licensed under ORS 443.315; or

(F) Home care workers and personal support workers listed on the home care registry.

(29) “Wage Rate” means the hourly pay rate received by the Personnel, exclusive of Agency Margin, Per Diem Stipend and other supplemental pay.

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0020 Scope and Applicability; Exceptions

These rules apply to temporary staffing agencies, facilities, and hospitals, except as provided below:

(1) These rules do not apply to Indian Health Care Providers or Indian Health Programs.

(2) A temporary staffing agency engaged by a hospital to provide 25 or fewer personnel in a single licensed care setting may charge to and receive from a hospital, rates that exceed the maximum bill rates set under OAR 409-039-0040. This 25 or fewer exception applies collectively to all personnel provided by a temporary staffing agency for each single licensed care setting. This applies:

(a) Per licensed facility, and

(b) Per work order or contract.

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0030 Health Professions (Personnel) Covered

(1) Facilities: For facilities, the maximum bill rates established in OAR 409-039-0040 apply to the following categories of personnel:

(a) Registered nurse,

(b) Licensed practical nurse,

(d) Certified nursing assistant, and

(e) Direct caregiver who provides health care services or assistance with activities of daily living to clients, residents, or patients.

(2) Hospitals: Maximum bill rates apply to a registered nurse or certified nursing assistant providing health care services to patients.

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0040 Maximum Rates for a Hospital or Facility

(1) The maximum bill rates a Temporary Staffing Agency may charge to or receive from hospitals and facilities, as described in Section 3 of this rule:

(a) Are based on the most recently available wage data from the Oregon Employment Department and include any applicable fringe benefits, charges for administrative and contract fees and other special charges; and

(b) Bear a reasonable relationship to this wage data from the Oregon Employment Department.

(2) The differences in the maximum bill rates established in this rule are based on the following factors:

(a) The minimum wages in geographic regions of this state;

(b) Shift differentials;

(d) Type of licensed care setting;

(e) Relevant state and federal regulatory requirements;

(f) Personnel with specialty training; and

(g) Information obtained through consultation with temporary staffing agencies and their representatives and providers of long-term care services, acute care services, and primary care services, or representatives of the providers described in this paragraph.

(3) The maximum bill rates established under this Section include the maximum Agency Margin rate a temporary staffing agency can charge for each respective position. The maximum Agency Margin is 34.2%.

(4) Maximum Bill Rates for a Hospital or Facility are effective as follows:

(a) For calendar year 2025, maximum bill rates are effective starting January 1, 2025, and apply to rates negotiated on or after January 1, 2025.

(b) For calendar year 2026, maximum bill rates are effective starting January 1, 2026, and apply to rates negotiated on or after January 1, 2026.

(c) For calendar year 2027 and later, maximum bill rates will be published in the fourth quarter of the prior year and are effective January 1st of each year for service dates on or after January 1st.

(5) Calendar year 2026 maximum bill rates are listed in 409-039-0040 Table 1.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0050 Waivers to Charge More than the Maximum Bill Rates

A temporary staffing agency, hospital, or facility may apply for a waiver of the maximum bill rates described in ORS 676.716 in either of the following two circumstances.

(1) Emergency Waiver. A hospital, facility or temporary staffing agency that intends to engage at a rate higher than a maximum rate established under ORS 676.716, in order to respond to an Emergency or state of emergency, may request an Emergency Waiver of the maximum bill rates pursuant to the process outlined in OAR 409-039-0060 in the following circumstances:

(a) There is an Emergency;

(b) A state of emergency is declared pursuant to ORS 401.165; or

(2) Non-Emergency Waiver: A temporary staffing agency, hospital, or facility may apply to the Authority for a Non-Emergency Waiver of the maximum bill rates pursuant to the process outlined in OAR 409-039-0070 if the applicant clearly demonstrates to the Authority that:

(a) It has made reasonable, good faith efforts to stay within the maximum bill rates;

(b) It has exhausted all other possibilities to stay within the maximum bill rates; and

(c) An acute incident has occurred, or an imminent event is anticipated, that the applicant expects will substantially and negatively impact access to care.

(3) Waivers approved by the authority permit a Temporary Staffing Agency to exceed the maximum bill rate for a certain period of time. Maximum Agency Margin must not exceed the percentage specified in OAR 409-039-0040(3).

History

Statutory/Other Authority: ORS 676.722
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0060 Application Process and Review of Emergency Waiver Requests

(1) A hospital, facility, or temporary staffing agency requesting to waive the maximum bill rate established in OAR 409-039-0040 for circumstances outlined in OAR 409-039-0050(1) must submit a request for an Emergency Waiver to the Authority.

(2) An Emergency Waiver request required to be filed under Section (1) of this rule will be submitted using the form available at the Program Website.

(3) An initial request submitted to the Authority requesting an Emergency Waiver will be automatically approved and issued by the Authority upon submission.

(4) An Emergency Waiver automatically approved and issued under Section (3) of this rule is valid for 90 calendar days and may be renewed. Upon expiration of the Emergency Waiver, the temporary staffing agency, hospital, or facility must comply with the maximum bill rates established in OAR 409-039-0040 unless a renewal is timely requested and approved by the Authority pursuant to Section (5) of this rule.

(5) An Emergency Waiver waiving the maximum bill rates established in OAR 409-039-0040 for circumstances outlined in OAR 409-039-0050(1) may be renewed and issued to a hospital, facility, or temporary staffing agency that possesses a license, certification or registration in good standing to operate in Oregon. A temporary staffing agency, hospital, or facility may submit a request to renew an Emergency Waiver under this Section for an additional 90 calendar day period.

(a) The Authority will approve or deny a request to renew an Emergency Waiver within three (3) business days after such request is received by the Authority.

(b) Such request must be made no sooner than 10 business days before, or no later than four (4) business days prior to, the expiration date of the Emergency Waiver.

(c) For the purposes of this rule, a request to renew an Emergency Waiver that is filed with the Authority on or after 4:00 p.m. on a weekday, or on a Saturday, Sunday, or legal holiday, will be considered received on the next following business day.

(6) Upon approval of an Emergency Waiver under this rule, a temporary staffing agency engaged by a hospital or facility for which an emergency waiver is issued under this rule may charge to or receive from the hospital or facility rates consistent with the Emergency Waiver.

History

Statutory/Other Authority: ORS 676.722
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0070 Application Process and Review of Non-Emergency Waiver Requests

(1) A Non-Emergency Waiver waiving the maximum bill rates established in OAR 409-039-0040 for circumstances outlined in OAR 409-039-0050(2) may be issued to a hospital, facility, or temporary staffing agency that possesses a license, certification or registration in good standing to operate in Oregon. A hospital, facility, or temporary staffing agency requesting such waiver must submit a request for a Non-Emergency Waiver to the Authority.

(2) A Non-Emergency Waiver request required to be filed under Section (1) of this rule will be submitted using the form available at the Program Website.

(3) A Non-Emergency Waiver requested may be for a period of 30, 60 or 90 calendar days. A temporary staffing agency, facility, or hospital may request to renew an approved Non-Emergency Waiver.

(a) A request to renew a Non-Emergency Waiver must be filed with the Authority no sooner than 25 business days before, and no later than twelve (12) business days before, the approved Non-Emergency Waiver is set to expire.

(b) Upon expiration of the Non-Emergency Waiver, the temporary staffing agency, hospital, or facility must comply with the maximum bill rates established in OAR 409-039-0040 unless a renewal is timely requested and approved by the Authority.

(4) The Authority will approve or deny a request for a Non-Emergency Waiver made pursuant to Section (1) of this rule or a request to renew an approved Non-Emergency Waiver pursuant to Section (3) of this rule within ten (10) business days after request is received by the Authority.

(5) For the purposes of this rule, a request to renew an Emergency Waiver that is filed with the Authority on or after 4:00 p.m. on a weekday, or on a Saturday, Sunday, or legal holiday, will be considered received on the next following business day.

(6) A temporary staffing agency, hospital, or facility for which a Non-Emergency Waiver is approved under this rule may charge and/or pay rates consistent with the terms of the Non-Emergency Waiver.

(7) Upon expiration of the Non-Emergency Waiver, or renewed Non-Emergency Waiver, the temporary staffing agency, hospital, or facility must comply with the maximum bill rates established in OAR 409-039-0040.

History

Statutory/Other Authority: ORS 676.722
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0080 Reconsideration Process for Denied Waivers

(1) A temporary staffing agency, facility, or hospital may submit a request for the Authority to reconsider a decision to deny a request to renew an Emergency Waiver under OAR 409-039-0060, or a Non-Emergency Waiver, including a renewal, under OAR 409-039-0070.

(2) A request for reconsideration under Section (1) of this rule will be submitted using the form available at the Program Website.

(3) A request for reconsideration must be submitted within ten (10) business days of a denial.

(4) The Authority will render a determination on a request for reconsideration filed pursuant to Section (1) of this rule within ten (10) business days after the date such request is received by the Authority.

(6) If the Authority denies the request for reconsideration, the requestor may appeal the denial by requesting a contested case hearing. The appeal must be filed with the Authority within 15 calendar days from the date of service of the denial.

(a) Contested case hearings will be conducted pursuant to ORS Chapter 183 and the Attorney General's Uniform and Model Rules of Procedure for the Office of Administrative Hearings.

(b) The requestor will have the burden to prove a compelling need for the Emergency Waiver or Non-Emergency Waiver.

(c) The issues to be considered in a contested case hearing conducted pursuant to this rule will be limited in scope to the facts and conclusions contained in the Authority’s denial.

History

Statutory/Other Authority: ORS 676.722
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0090 Annual Evaluation of Maximum Rates

(1) The Authority will annually evaluate the maximum rates established under OAR 409-039-0040 and may adjust these maximum rates based on changes in the labor market, the wage data described in ORS 676.716, and other factors the authority considers relevant, including temporary staff wages, bill rates, and agency margin.

(2) In evaluating and adjusting the maximum rates established under OAR 409-039-0040, the Authority will solicit feedback from the same entities consulted in the creation of the initial rates, as outlined in OAR 409-039-0040.

(3) The Authority will refer violations of ORS 676.695 to 676.725 and these rules, including the maximum bill rates, maximum agency margin and/or waivers to the Authority’s Health Licensing Office for investigation and disciplinary action in accordance with ORS 676.710, 676.713, and 676.725.

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0100 Data Requests

(1) In furtherance of the Authority’s annual evaluation of the maximum bill rates pursuant to OAR 409-039-0090, the Authority may request information from temporary staffing agencies to assess and evaluate the maximum bill rates established under OAR 409-039-0040.

(2) A temporary staffing agency must respond to all requests from the Authority under this rule within 45 calendar days from the date such request is issued.

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0110 Regular Review of Waiver Conditions and Processes

The authority will conduct periodic, annual review of conditions for requesting waivers and the effectiveness of the administration of the program.

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Or. Admin. R. 409-039-0120 Information Sharing and Use of Data

(1) If a temporary staffing agency, facility, or hospital that files documents, materials, information, or data with the Authority believes such information may be considered confidential and exempt from public disclosure under the Oregon Public Records Law, ORS 192.311 to 192.478, such entity filing the confidential information must provide a redaction log that provides a reasonably detailed statement of the grounds on which confidentiality is claimed, citing the applicable statutory basis for confidentiality of each portion.

(2) The Authority may use a confidential document, material, information, or data in administering these rules. In order to assist in the performance of the Authority’s duties, the Authority may authorize sharing a confidential document, material, information, or data or other information, as appropriate, among the administrative divisions and staff offices of the Authority and the Authority’s Health Licensing Office.

History

Statutory/Other Authority: ORS 676.716
Statutes/Other Implemented: ORS 676.695 - 676.725
OHP 5-2025, temporary amend filed 11/26/2025, effective 11/26/2025 through 12/31/2025
OHP 4-2025, amend filed 11/26/2025, effective 11/26/2025
OHP 5-2024, adopt filed 11/22/2024, effective 11/25/2024

Division 45 HEALTH CARE PRACTITIONER CREDENTIALING

Or. Admin. R. 409-045-0025 Definitions

The following definitions apply to OAR 409-045-0025 to 409-045-0135:

(1) “Authority” means the Oregon Health Authority.

(2) “Credentialing” means a standardized process of inquiry undertaken by credentialing organizations to validate specific information that confirms a health care practitioner’s identity, background, education, competency, and qualifications related to a specific set of established standards or criteria.

(3) “Credentialing information” means information necessary to credential or recredential a health care practitioner.

(4) “Credentialing organization” means a health care organization that credentials health care practitioners. This includes, but is not limited to the following:

(a) Ambulatory surgical centers;

(b) Coordinated care organizations;

(d) Third-party administrators;

(e) Worker’s compensation health plans;

(f) Dental plan issuers;

(g) Health plan issuers;

(h) Hospitals;

(i) Independent practice associations as defined in ORS 743B.001;

(j) Health care practitioner organizations; and

(k) Other health care facilities or organizations that are required to credential health care practitioners.

(5) “Delegated credentialing agreement” means a written agreement between credentialing organizations that delegates the responsibility to perform specific activities related to the credentialing and recredentialing of health care practitioners. For telemedicine credentialing, delegated credentialing agreement has the meaning given that term in ORS 442.015.

(6) “Distant-site” means the hospital or health care facility where a telemedicine provider, at the time the telemedicine provider is providing telemedicine services, is practicing as an employee or under contract.

(7) “Health care facility” has the meaning given that term in ORS 442.015.

(8) “Health care practitioner” means an individual authorized to practice a profession related to the provision of health care services in this state for which the individual must be credentialed. This may include, but is not limited to individuals licensed as:

(a) Acupuncturists;

(b) Audiologists;

(d) Chiropractic Physicians;

(e) Clinical Nurse Specialists;

(f) Doctors of Dental Medicine;

(g) Doctors of Dental Surgery;

(h) Doctors of Medicine;

(i) Doctors of Osteopathic Medicine;

(j) Doctors of Podiatric Medicine;

(k) Licensed Clinical Social Workers;

(L) Licensed Dietitians;

(m) Licensed Marriage and Family Therapists;

(n) Licensed Massage Therapists;

(o) Licensed Professional Counselors;

(p) Naturopathic Physicians;

(q) Nurse Practitioners;

(r) Occupational Therapists;

(s) Optometrists;

(t) Oral and Maxillofacial Surgeons;

(u) Pharmacists;

(v) Physical Therapists;

(w) Physician Assistants;

(x) Psychologist Associates;

(y) Psychologists;

(z) Registered Nurse First Assistants; and

(aa) Speech-Language Pathologists.

(9) “Hospital” has the meaning given that term in ORS 442.015.

(10) “Originating-site” means a hospital or health care facility in which a patient is located while receiving telemedicine services.

(11) “Primary source verification” means the verification of a health care practitioner’s reported qualifications from the original source.

(12) “Telemedicine” has the meaning given that term in ORS 442.015.

History

Statutory/Other Authority: ORS 413.042, 441.056 & 441.223
Statutes/Other Implemented: ORS 441.056, 441.223 & 442.015
OHP 3-2022, amend filed 03/15/2022, effective 03/15/2022
OHP 6-2018, amend filed 06/27/2018, effective 07/01/2018
OHP 1-2018, temporary amend filed 01/18/2018, effective 01/18/2018 through 07/16/2018
OHP 3-2014, f. 6-30-14, cert. ef. 7-1-14

Or. Admin. R. 409-045-0035 Oregon Practitioner Credentialing Application

(1) Credentialing organizations shall use the latest versions of the Oregon Practitioner Credentialing Application and the Oregon Practitioner Recredentialing Application approved and published by the Authority based on recommendations from the Advisory Committee on Physician Credentialing Information.

(2) The Authority approved applications are available on the Committee’s website at https://www.oregon.gov/oha/HPA/OHIT-ACPCI/Pages/index.aspx.

(3) Each credentialing organization shall use the application forms listed in section (1) of this rule for the purpose of credentialing and recredentialing health care practitioners.

(4) Credentialing organizations shall have ten months to comply with sections (1) and (3) of this rule after new version(s) of the application forms are approved and published by the Authority.

History

Statutory/Other Authority: ORS 413.042, 441.056 & 441.223
Statutes/Other Implemented: ORS 441.056 & 441.221
OHP 3-2022, amend filed 03/15/2022, effective 03/15/2022
OHP 6-2018, amend filed 06/27/2018, effective 07/01/2018
OHP 1-2018, temporary amend filed 01/18/2018, effective 01/18/2018 through 07/16/2018
OHP 3-2014, f. 6-30-14, cert. ef. 7-1-14

Or. Admin. R. 409-045-0115 Telemedicine Providers General Applicability Credentialing Requirements

(1) These rules apply to all:

(a) Telemedicine health care practitioners who provide telemedicine services from any distant-site hospital or health care facility in Oregon to patients in originating-site hospitals or health care facilities in Oregon.

(b) Originating-site hospitals or health care facilities located in Oregon that credential telemedicine health care practitioners located at distant-site hospitals or health care facilities in Oregon.

(2) Completion of credentialing requirements does not require a governing body of a hospital to grant privileges to a telemedicine health care practitioner and does not affect the responsibilities of a governing body under ORS 441.055.

History

Statutory/Other Authority: ORS 413.042, 441.056 & 441.223
Statutes/Other Implemented: ORS 441.056 & 442.015
OHP 3-2022, amend filed 03/15/2022, effective 03/15/2022
OHP 6-2018, amend filed 06/27/2018, effective 07/01/2018
OHP 1-2018, temporary amend filed 01/18/2018, effective 01/18/2018 through 07/16/2018
OHP 3-2014, f. 6-30-14, cert. ef. 7-1-14
OHP 10-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14

Or. Admin. R. 409-045-0120 Telemedicine Providers Standard List of Credentialing Documents

(1) To become credentialed by an originating-site hospital or health care facility a telemedicine health care practitioner or the distant-site hospital or health care facility must provide the following information and documentation to the originating-site hospital or health care facility:

(a) A completed current (within the past 6 months) Oregon Practitioner Credentialing Application (OPCA) and the following documents:

(A) A copy of the state license authorizing practice;

(B) Drug Enforcement Agency certificate;

(D) Certification of professional liability insurance.

(b) Attestation by medical staff at the distant-site hospital or health care facility that they have conducted primary source verification of all materials of the OPCA except for:

(A) Hospital affiliations other than to the distant-site hospital or health care facility; and

(B) Work history beyond the previous five years.

(2) Originating-site hospitals or health care facilities may request documentation of all the verifications above from the distant-site hospital or health care facility or the telemedicine health care practitioner. Verifications that are not provided may be obtained separately by the originating-site hospital or health care facility.

(3) Originating-site hospitals or health care facilities may not require either the telemedicine health care practitioner or the distant-site hospital to provide the following documentation for the purposes of credentialing or privileging a telemedicine provider:

(a) Proof of Tuberculosis screening;

(b) Proof of vaccination or immunity to communicable diseases; and

(4) Originating-site hospitals or health care facilities may not require a telemedicine provider to attend physician and staff meetings at the originating-site hospital or health care facility.

(5) Originating-site hospitals or health care facilities may not request credentialing information if the credentialing information was made available under OAR 409-045-0120 and is not subject to change.

(6) To become recredentialed by an originating-site hospital or health care facility, every two years a telemedicine health care practitioner or the distant-site hospital or health care facility must provide a completed current Oregon Practitioner Recredentialing Application and all other information required in OAR 409-045-0120.

History

Statutory/Other Authority: ORS 413.042, 441.056 & 441.223
Statutes/Other Implemented: ORS 441.056, 441.223 & 442.015
OHP 3-2022, amend filed 03/15/2022, effective 03/15/2022
OHP 6-2018, amend filed 06/27/2018, effective 07/01/2018
OHP 1-2018, temporary amend filed 01/18/2018, effective 01/18/2018 through 07/16/2018
OHP 3-2014, f. 6-30-14, cert. ef. 7-1-14
OHP 10-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14

Or. Admin. R. 409-045-0125 Telemedicine Providers Distant-Site Hospital Agreements

Health care facilities or hospitals may use delegated credentialing agreements instead of the requirements in OAR-409-045-0120 to stipulate that the medical staff of the originating-site hospital or health care facility shall rely upon the credentialing and privileging decisions of the distant-site hospital or health care facility in making recommendations to the governing body of the originating-site hospital or health care facility as to whether to credential a telemedicine provider, practicing at the distant-site hospital or health care facility either as an employee or under contract, to provide telemedicine services to patients in the originating-site hospital or health care facility. If a delegated credentialing agreement is in place, the originating-site hospital or health care facility is not limited to the information and documents set forth in OAR 409-045-0120.

History

Statutory/Other Authority: ORS 413.042, 441.056 & 441.223
Statutes/Other Implemented: ORS 441.056, 441.223 & 442.015
OHP 3-2022, amend filed 03/15/2022, effective 03/15/2022
OHP 6-2018, amend filed 06/27/2018, effective 07/01/2018
OHP 1-2018, temporary amend filed 01/18/2018, effective 01/18/2018 through 07/16/2018
OHP 3-2014, f. 6-30-14, cert. ef. 7-1-14
OHP 10-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14

Or. Admin. R. 409-045-0135 Telemedicine Providers Information Sharing or Use of Data

(1) Telemedicine health care practitioners must provide written, signed permission that explicitly allows the sharing of required documents and necessary evidence by a distant-site hospital with originating-site hospitals, including but not limited to any release required under HIPAA or other applicable laws.

(2) Dissemination of information received under these rules shall only be made to individuals with a demonstrated and legitimate need to know the information.

History

Statutory/Other Authority: ORS 413.042, 441.056, 441.223 & 441.226
Statutes/Other Implemented: ORS 441.056, 441.223 & 442.015
OHP 6-2018, amend filed 06/27/2018, effective 07/01/2018
OHP 1-2018, temporary amend filed 01/18/2018, effective 01/18/2018 through 07/16/2018
OHP 3-2014, f. 6-30-14, cert. ef. 7-1-14
OHP 10-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14

Division 50 PAIN MANAGEMENT

Or. Admin. R. 409-050-0100 Purpose

The Pain Management Commission is established within the Oregon Health Authority for the purpose of developing pain management educational programs, recommendations and curriculum; representing patient concerns to the Governor and Legislative Assembly; and creating ways to improve pain management in Oregon through research, policy analysis, and model projects. In addition, the Pain Management Commission is charged with developing a specific pain management educational program for required completion by health care professionals under specified Licensing Boards.

History

Statutory/Other Authority: ORS 413.570
Statutes/Other Implemented: ORS 413.570 - 413.599
Renumbered from 407-020-0000, OHP 1-2011, f. 1-26-11, cert. ef. 2-1-11
DHSD 1-2007, f. & cert. ef. 2-1-07

Or. Admin. R. 409-050-0110 Definitions

The following definitions apply to OAR 409-050-0100 to 409-050-0130:

(1) "Commission" means the Oregon Pain Management Commission.

(2) "Licensed health care professionals" means those specifically identified licensees that report to the following Licensing Boards:

(a) Oregon Board of Medical Examiners, which includes physicians, physician assistants and acupuncturists (except for those listed under OAR 847-008-0075, identified as waived);

(b) Oregon State Board of Nursing, which includes all registered nurses, licensed practical nurses and nurse practitioners;

(d) Oregon Board of Chiropractic Examiners, which includes all licensed chiropractors;

(e) Oregon Board of Naturopathic Examiners, which includes all licensed naturopathic physicians;

(f) Oregon Board of Pharmacy, which includes all licensed pharmacists;

(g) Oregon Board of Dentistry, which includes all licensed dentists;

(h) Oregon Board of Occupational Therapy, which includes all licensed occupational therapists;

(i) Oregon Board of Physical Therapy, which includes all licensed physical therapists; and

(j) Oregon Board of Optometry, which includes all licensed optometrists.

(3) "Curriculum" means a recommended list of educational topics, compiled by the Commission, for medical professionals treating pain.

(4) "Pain management education program" means a specific one-hour web-based program developed by the Commission, in addition to six accredited hours of continuing education in pain management, end of life care or a combination of both.

History

Statutory/Other Authority: ORS 413.570; Ch. 3, Sec. 2 (OL 2019)
Statutes/Other Implemented: ORS 413.570-413.599; Ch. 3, Sec. 2 (OL 2019)
OHP 22-2019, amend filed 09/27/2019, effective 01/01/2020
OHP 3-2018, minor correction filed 05/17/2018, effective 05/17/2018
OHP 9-2011, f. 11-28-11, cert. ef. 12-1-11
OHP 5-2011(Temp), f. 8-30-11, cert. ef. 9-1-11 thru 2-27-12
Renumbered from 407-020-0005, OHP 1-2011, f. 1-26-11, cert. ef. 2-1-11
DHSD 1-2007, f. & cert. ef. 2-1-07

Or. Admin. R. 409-050-0120 Commission Positions

(1) The Commission consists of:

(a) Nineteen members – seventeen voting members and two non-voting ex-officio members from the Oregon legislature; and

(b) Members that have experience or a demonstrated interest in pain management issues.

(2) In order to apply for a position on the Commission, an individual must:

(a) Complete a Commission interest form; and

(b) Submit the interest form to the Pain Management Program.

(3) Voting member appointments to the Commission are:

(a) Made by the Director of the Oregon Health Authority; and

(b) Must comply with the approved Commission bylaws.

(4) Prior to making appointments, the Director of the Oregon Health Authority shall request and consider recommendations from individuals, public and private agencies and organizations, but not limited to individuals with a healthcare background or individuals representing the healthcare industry or members of the public.

(5) Oregon Health Authority staff shall include a Pain Management Coordinator, who shall staff and facilitate Commission meetings, provide daily organization of Commission business and perform other duties as directed by the Commission.

History

Statutory/Other Authority: ORS 413.570
Statutes/Other Implemented: ORS 413.570 - 413.599
OHP 9-2011, f. 11-28-11, cert. ef. 12-1-11
OHP 5-2011(Temp), f. 8-30-11, cert. ef. 9-1-11 thru 2-27-12
Renumbered from 407-020-0010, OHP 1-2011, f. 1-26-11, cert. ef. 2-1-11
DHSD 1-2007, f. & cert. ef. 2-1-07

Or. Admin. R. 409-050-0130 Pain Management Education Program Requirements

(1) Licensed health care professionals must complete a pain management education program in order to improve the care and treatment of individuals with painful conditions. The program includes:

(a) Six accredited hours of continuing education in pain management, end of life care or a combination of both; and

(b) The web-based training offered by the Commission.

(c) Dentists licensed under Oregon Board of Dentistry are only required to complete the web-based training offered by the Commission.

(2) For out of state health care professionals obtaining Oregon licensure or newly licensed health care professionals within Oregon, the pain management education program must be completed within 24 months of their first license renewal.

Example: If an individual becomes newly licensed in Oregon on June 15, 2009, their first renewal will be June 15, 2011. The individual may obtain their training from June 15, 2009 through June 15, 2013 under section (2) to comply with this requirement.

(3) If the licensing board for a licensed health care professional adopts, by rule, a pain management education program with topics substantially similar to the topics in the Commission's curriculum, that program satisfies this rule for the continuing education portion of the requirement, as long as the total number of hours is the same.

(4) The Commission shall review its curriculum every two years and update as needed.

History

Statutory/Other Authority: ORS 413.570
Statutes/Other Implemented: ORS 413.570 - 413.599
OHP 10-2011, f. & cert. ef. 12-22-11
OHP 8-2011(Temp), f. & cert. ef. 10-19-11 thru 2-27-12
Renumbered from 407-020-0015, OHP 1-2011, f. 1-26-11, cert. ef. 2-1-11
DHSD 1-2007, f. & cert. ef. 2-1-07

Division 55 PATIENT-CENTERED PRIMARY CARE HOME PROGRAM

Or. Admin. R. 409-055-0000 Purpose and Scope

These rules (OAR 409-055-0000 to 409-055-0090) establish the Patient-Centered Primary Care Home (PCPCH) Program and define criteria and process that the Authority shall use to recognize and verify status as PCPCHs. The PCPCH is a model of primary care that has received attention in Oregon and across the country for its potential to advance the “triple aim” goals of health reform: a healthy population, extraordinary patient care for everyone, and reasonable costs, shared by all. PCPCHs achieve these goals through a focus on wellness and prevention, coordination of care, active management and support of individuals with special health care needs, and a patient and family-centered approach to all aspects of care. PCPCHs emphasize whole-person care to address a patient and family’s physical and behavioral health care needs.

History

Statutory/Other Authority: ORS 413.042, 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 16-2018, minor correction filed 12/03/2018, effective 12/03/2018
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0010 Definitions

The following definitions apply to OAR 409-055-0000 to 409-055-0090:

(1) “Authority” means the Oregon Health Authority.

(2) “NCQA” means National Committee for Quality Assurance.

(3) “Patient Centered Medical Home (PCMH)” means a practice or provider who has been recognized as such by the National Committee for Quality Assurance.

(4) “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.

(5) “Personal Health Information” means demographic information, medical history, test and laboratory results, insurance information and other data that is collected by a health care professional to identify an individual and determine appropriate care.

(6) “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 BP(s) unless otherwise specified.

(7) “Program” means Patient-Centered Primary Care Home Program.

(8) “Program website” means www.primarycarehome.oregon.gov.

(9) “Provider” 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 BP(s) unless otherwise specified.

(10) “Recognition” means the process through which the Authority determines if a practice has met the Oregon Patient-Centered Primary Care Home Standards.

(11) “Recognized” means that the Authority has affirmed that a practice meets the Oregon Patient-Centered Primary Care Home Standards.

(12) “Tier” means the level of Patient-Centered Primary Care Home at which the Authority has scored a practice.

(13) “Verification” means the process that the Authority shall conduct to ensure that a practice has submitted accurate information to the Authority for purposes of Patient-Centered Primary Care Home recognition.

(14) “Health Equity Designation” means a designation assigned to Patient-Centered Primary Care Homes meeting specific PCPCH measures.

History

Statutory/Other Authority: ORS 413.042, 413.259, 414.655
Statutes/Other Implemented: ORS 413.259, 413.260, 414.655
OHP 3-2023, amend filed 11/30/2023, effective 11/30/2023
OHP 15-2018, amend filed 11/29/2018, effective 12/01/2018
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 10-2015(Temp), f. 12-29-15, cert. ef. 1-1-16 thru 6-24-16
OHP 2-2015, f. 1-16-15, cert. ef. 2-1-15
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0020 Program Administration

(1) The Program is intended to ensure that there is a uniform process for recognizing PCPCHs throughout the State of Oregon in order to support primary care transformation.

(2) The Authority shall recognize practices as PCPCHs upon meeting defined criteria through the Program.

(3) The Authority shall administer the Program, including data collection and analysis, recognition, and verification that a practice meets the defined PCPCH criteria. The Authority may also provide technical assistance as is feasible.

(4) The Authority may contract for any of the work it deems necessary for efficient and effective administration of the Program.

History

Statutory/Other Authority: ORS 413.042, 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0030 Practice Application and Recognition Process

(1) Practices, or other entities on behalf of the practice, that wish to be recognized as a PCPCH shall submit a PCPCH Recognition Application electronically to the Authority via the Program’s online application system found on the Program website or by mail to the address posted on the Program website. The application shall include the quantitative data described in OAR 409-055-0040.

(2) The Authority shall review the application within 60 days of its submission to determine whether it is accurate, complete, and meets the recognition requirements. If the application is incomplete the Authority shall notify the applicant in writing of the information that is missing and when it must be submitted.

(3) The Authority shall review a complete application within 60 days of submission. If the Authority determines that the applicant has met the requirements of these rules the Authority shall:

(a) Inform the applicant in writing that the application has been approved as a recognized PCPCH;

(b) Assign a Tier level; and

(4) The Authority shall maintain instructions and criteria for submitting a PCPCH Recognition Application posted on the Program website.

(5) The Authority may deny PCPCH recognition if an applicant does not meet the requirements of these rules.

(6) A practice may request that the Authority reconsider the denial of PCPCH recognition or reconsider the assigned tier level. A request for reconsideration must be submitted in writing to the Authority within 90 days of the date of the denial or approval letter and must include a detailed explanation of why the practice believes the Authority’s decision is in error along with any supporting documentation. The Authority shall inform the practice in writing whether it has reconsidered its decision.

(7) Recognition shall expire two years from the recognition effective date issued by the Authority.

(a) At the Authority’s discretion a 30-day grace period may be allowed for PCPCHs to submit a renewal application without having a lapse in recognition status.

(b) If a PCPCH believes that it meets the criteria to be recognized at a higher tier or increase its point threshold by at least 15 points, it may request to have its tier status reassessed by re-submitting an application not more than once every six months. The Authority may grant exceptions to the six-month time period for good cause shown.

(c) Practices that apply or re-apply for PCPCH recognition between January 2024 and December 2024 will be recognized for one year.

History

Statutory/Other Authority: ORS 413.042, 413.259, 414.655
Statutes/Other Implemented: ORS 413.259, 413.260, 414.655
OHP 3-2023, amend filed 11/30/2023, effective 11/30/2023
OHP 2-2020, temporary amend filed 05/04/2020, effective 05/04/2020 through 10/30/2020
OHP 17-2018, minor correction filed 12/03/2018, effective 12/03/2018
OHP 15-2018, amend filed 11/29/2018, effective 12/01/2018
OHP 16-2016, f. & cert. ef. 12-22-16
OHP 12-2016(Temp), f. & cert. ef. 8-29-16 thru 2-21-17
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 10-2015(Temp), f. 12-29-15, cert. ef. 1-1-16 thru 6-24-16
OHP 2-2015, f. 1-16-15, cert. ef. 2-1-15
OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14
OHP 6-2013, f. 8-23-13, cert. ef. 9-3-13
OHP 5-2013, f. 3-22-13, cert. ef. 4-1-13
OHP 7-2012(Temp), f. & cert. ef. 10-4-12 thru 4-1-13
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0040 Recognition Criteria

(1) The PCPCH recognition criteria are divided into “Must-Pass” measures and other measures that place the practice on a scale of maturity or ‘tier’ that reflect basic to more advanced PCPCH functions.

(2) Must-Pass and 5-point measures focus on foundational PCPCH elements.

(3) 10- and 15-point measures reflect intermediate and advanced functions.

(4) Except for the 13 Must-Pass measures, each measure is assigned a point value. A practice must meet the following point allocation criteria to be recognized as a PCPCH:

(a) Tier 3: 100-245 points and all 13 Must-Pass Measures;

(b) Tier 4: 250-390 points and all 13 Must-Pass Measures;

(5) The Authority may award a Patient-Centered Primary Care Home the Health Equity Designation for implementing health equity measures as described OAR 409-055-0045.

(6) The Authority shall calculate a practice’s point score through the recognition process described in OAR 409-055-0030.

(7) Table 1, incorporated by reference, contains the detailed list of Measures and corresponding point assignments.

(8) National Committee for Quality Assurance (NCQA) recognition shall be acknowledged in the Authority’s PCPCH recognition process; however, a practice is not required to use its NCQA recognition to meet the Oregon PCPCH standards. A practice that does not wish to use its NCQA recognition to meet the Oregon PCPCH standards must indicate so during the PCPCH application process and submit a complete PCPCH application.

(9) A practice seeking Oregon PCPCH Tier 5 recognition based on its NCQA recognition must submit an abbreviated PCPCH application attesting to selected Oregon PCPCH standards and evidence of its NCQA recognition along with its application.

(10) A practice seeking Oregon PCPCH Health Equity Designation based on its NCQA recognition must submit a complete PCPCH application and comply with OAR 409-055-0045.

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042, ORS 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 3-2023, amend filed 11/30/2023, effective 11/30/2023
OHP 3-2020, amend filed 08/10/2020, effective 08/10/2020
OHP 16-2016, f. & cert. ef. 12-22-16
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 10-2015(Temp), f. 12-29-15, cert. ef. 1-1-16 thru 6-24-16
OHP 2-2015, f. 1-16-15, cert. ef. 2-1-15
OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0045 Health Equity Designation

(1) The Authority shall award Health Equity designations to practices implementing multiple PCPCH Health Equity measures.

(2) A practice seeking the Health Equity Designation, must meet the following criteria:

(a) Be recognized as a PCPCH under the Measures in 409-055-0040 Table 1, adopted and incorporated by reference;

(b) Attest to 15 or more of the 20 PCPCH Health Equity Measures in Table 2 adopted and incorporated by reference;

(3) The Authority shall review PCPCH applications of practices attesting to the Measures in Table 2 and the documentation submitted to determine which practices meet the criteria in section (2) of this rule.

(4) The Authority shall notify a practice meeting Health Equity designation criteria in writing of their eligibility.

(5) The Authority shall award Health Equity designation to a practice after verifying the practice meets all Health Equity designation criteria.

(6) Health Equity designation is valid for the duration of the practice’s current PCPCH recognition as described in OAR 409-055-0030(7).

[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

History

Statutory/Other Authority: ORS 413.042, ORS 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 3-2023, amend filed 11/30/2023, effective 11/30/2023
OHP 3-2020, amend filed 08/10/2020, effective 08/10/2020
OHP 15-2018, amend filed 11/29/2018, effective 12/01/2018
OHP 12-2018, minor correction filed 09/25/2018, effective 09/25/2018
OHP 11-2018, minor correction filed 09/25/2018, effective 09/25/2018
OHP 16-2016, f. & cert. ef. 12-22-16
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 2-2015, f. 1-16-15, cert. ef. 2-1-15

Or. Admin. R. 409-055-0050 Data Reporting Requirements for Recognized PCPCHs

(1) To be recognized as a PCPCH, a practice must attest to meeting the criteria and submit quantitative data elements to support its attestation in accordance with 409-055-0040 Table 1 incorporated by reference.

(2) Quantitative data shall be aggregated at the practice level, not the individual patient level, and a practice may not transfer any personal health information to the Authority during the PCPCH application process.

(3) PCPCHs must submit new quantitative and attestation data as a part of the recognition renewal process and must use the specifications found on the Program website for calculating application data.

(4) If approved by the practice, other entities may submit information on behalf of a practice, as long as appropriate practice staff has reviewed all application information and data prior to submission.

(5) Practices are required to submit 12 months of quantitative data to meet PCPCH standards. A practice may request an exception to the 12-month data reporting period by submitting a form prescribed by the program. The Authority may grant exceptions for good cause shown.

(6) The Authority shall notify the practice within 60 days of complete application and exception submission whether the requested exception has been granted.

History

Statutory/Other Authority: ORS 413.042, 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 3-2023, amend filed 11/30/2023, effective 11/30/2023
OHP 16-2016, f. & cert. ef. 12-22-16
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0060 Verification

(1) The Authority shall conduct at least one on-site verification review of each recognized PCPCH to determine compliance with PCPCH criteria every five years and at such other times as the Authority deems necessary or at the request of the Health Systems Division (Division), or any other applicable program within the Authority. The purpose of the review is to verify reported attestation and quantitative data elements for the purposes of confirming recognition and Tier level.

(2) PCPCHs selected for a verification review shall be notified no less than 30 days prior to the scheduled review.

(3) PCPCHs shall permit Authority staff access to the practice’s place of business during the review.

(4) A verification review may include but is not limited to:

(a) Review of documents and records.

(b) Review of patient medical records.

(d) Review of data reports from electronic systems or other patient registry and tracking systems.

(e) Interviews with practice management, clinical and administrative staff.

(f) On-site observation of practice staff.

(g) On-site observation of patient environment and physical environment.

(5) Following a verification review, Authority staff may conduct an exit conference with the PCPCH representatives. During the exit conference Authority staff shall:

(a) Inform the PCPCH representative of the preliminary findings of the review; and

(b) Give the PCPCH a reasonable opportunity to submit additional facts or other information to the Authority staff in response to those findings.

(6) Following the review, Authority staff shall prepare and provide the PCPCH specific and timely written notice of the findings.

(7) If the findings result in a referral to the Division pursuant to OAR 409-055-0070, Authority staff shall submit the applicable information to the Division for its review and determination of appropriate action.

(8) If no deficiencies are found during a review, the Authority shall issue written findings to the PCPCH indicating that fact.

(9) If deficiencies are found, the Authority shall take informal or formal enforcement action pursuant to OAR 409-055-0070.

(10) The Authority may share application information and content submitted by practices and verification findings with managed or coordinated care plans, and insurance carriers.

History

Statutory/Other Authority: ORS 413.042, 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 3-2023, amend filed 11/30/2023, effective 11/30/2023
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 10-2015(Temp), f. 12-29-15, cert. ef. 1-1-16 thru 6-24-16
OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0070 Compliance

(1) If the Authority finds that the practice is not in compliance with processes as attested to, the Authority shall issue a written warning requiring the practice to submit an improvement plan within 90 days of the date of the written warning. The improvement plan must include a description of the practice’s plan and timeline to correct the deficiency and proposed documentation or other demonstration that would verify the practice is in compliance.

(2) The Authority shall review the improvement plan and any documentation the practice submits in accordance with the deficiency, and if remedied, no further action shall be taken.

(3) If a practice fails to submit the improvement plan or move into compliance within 90 days of the date of the written warning, the Authority may issue a letter of non-compliance and amend the practice’s PCPCH recognition to reflect the appropriate Tier level or revoke its PCPCH status.

(4) If the Authority amends a practice’s tier level or revokes PCPCH status this information shall be made available to the Health Systems Division (Division), the coordinated care or managed care plans, and insurance carriers.

(5) A practice that has had its PCPCH status revoked may have it reissued after reapplying for recognition and when the Authority determines that compliance with PCPCH Standards has been achieved satisfactorily.

(6) The Authority may revoke a practice’s PCPCH recognition in the following circumstances:

(a) The practice submits false quantitative data elements or falsely attests to meeting PCPCH recognition criteria;

(b) The practice misrepresents its PCPCH status or tier level;

History

Statutory/Other Authority: ORS 413.042, ORS 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 3-2020, amend filed 08/10/2020, effective 08/10/2020
OHP 18-2018, minor correction filed 12/03/2018, effective 12/03/2018
OHP 15-2018, amend filed 11/29/2018, effective 12/01/2018
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 10-2015(Temp), f. 12-29-15, cert. ef. 1-1-16 thru 6-24-16
OHP 9-2013, f. 10-1-13, cert. ef. 1-1-14
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0080 Insurance Carrier, Managed Care Plan, and Public Stakeholder Communication

(1) The Authority shall develop a system for making recognized PCPCH Tier status recognition information available to insurance carriers and managed care organizations.

(2) The Authority shall maintain and update monthly the recognized PCPCH Tier status lists.

(3) The Authority shall develop a system for making recognized PCPCH practice names available to the general public through the Program website.

(4) Practices that do not wish to have their name listed on the publicly available list must send an e-mail to PCPCH@state.or.us with the title “opt-out” in the subject line within 10 business days of receiving confirmation of Tier status pursuant to OAR 409-055-0040.

History

Statutory/Other Authority: ORS 413.042, 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12
OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

Or. Admin. R. 409-055-0090 Reimbursement Objectives

(1) One objective of these standards is to facilitate appropriate reimbursement for PCPCHs consistent with their recognized Tier levels. The standards and Tier recognition process established in this rule are consistent with statutory objectives to align financial incentives to support utilization of PCPCHs, in recognition of the standards that are required to be met at different Tiers.

(2) Managed care plans and insurance carriers may obtain from the Authority the Tier level recognition of any practice.

(3) Within applicable programs, the Authority shall develop and implement reimbursement methodologies that reimburse practices based on recognition of Tier level, taking into consideration incurred practice costs for meeting the Tier criteria.

History

Statutory/Other Authority: ORS 413.042, 413.259 & 414.655
Statutes/Other Implemented: ORS 413.259, 413.260 & 414.655
OHP 9-2016, f. & cert. ef. 5-13-16
OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12

Division 58 HEALTH EVIDENCE REVIEW COMMISSION

Or. Admin. R. 409-058-0100 Scope

These rules (OAR 409-058-0100 to 409-058-0110) require the Health Evidence Review Commission to adopt bylaws to govern, among other things, the management of potential conflicts of interest, actual conflicts of interest, and significant personal interests among Commissioners, subcommittee members, and appointed ad hoc experts. These rules apply to the Health Evidence Review Commission and its subcommittees as of October 16, 2021.

History

Statutory/Other Authority: ORS 413.042 & 414.689
Statutes/Other Implemented: ORS 414.688 & 414.689
OHP 4-2021, adopt filed 11/03/2021, effective 11/03/2021

Or. Admin. R. 409-058-0110 Health Evidence Review Commission Bylaws

The Health Evidence Review Commission shall adopt bylaws to govern its operations. The bylaws shall, among other things:

(1) Require Commission, subcommittee members, and appointed ad hoc experts to disclose potential or actual conflicts of interest as well as other significant personal interests.

(2) Specify how potential and actual conflicts of interest will be disclosed and managed.

(3) Describe the qualifications for subcommittee membership.

History

Statutory/Other Authority: ORS 413.042 & 414.689
Statutes/Other Implemented: ORS 414.688 & 414.689
OHP 4-2021, adopt filed 11/03/2021, effective 11/03/2021

Division 60 HEALTH EVIDENCE REVIEW COMMISSION MEDICAL TECHNOLOGY ASSESSMENTS

Or. Admin. R. 409-060-0100 Scope

(1) These rules (OAR 409-060-0100 to 409-060-0150) define criteria and processes that the Health Evidence Review Commission shall use to develop evidence-based reports, including medical technology assessments, evidence-based guidelines and coverage guidances. These rules apply to evidence-based reports and revisions to approved evidence-based reports whose development commences on or after February 1, 2013.

(2) The Commission may consider evidence relating to prescription drugs that is relevant to an evidence-based report but may not conduct a drug class evidence review or evidence-based report solely of a prescription drug.

History

Statutory/Other Authority: ORS 414.695 & 413.042
Statutes/Other Implemented: 414.695 & 414.698
OHP 4-2013, f. & cert. ef. 2-1-13

Or. Admin. R. 409-060-0110 Definitions

The following definitions apply to OAR 409-060-0100 to 409-060-0150:

(1) “Ad hoc expert” means an individual identified by the Commission as having particular expertise in a technology or its application.

(2) “Authority” means the Oregon Health Authority.

(3) “Commission” means the Health Evidence Review Commission.

(4) “Coverage guidance” means a report approved by the Commission on a health service or technology which makes coverage recommendations for insurers and health care purchasers in furthering the use of evidence-based healthcare.

(5) “Evidence-based guideline” means an evidence-based report on a health service or technology, for use by health care providers in encouraging the use of the safest and most effective care possible.

(6) “Evidence-based report” means a medical technology assessment, evidence-based guideline or coverage guidance which includes conclusions and recommendations based on the information in the source documents, and which incorporates the clinical context necessary for the information to be properly interpreted by policymakers.

(7) “EbGS” means the Evidence-based Guidelines Subcommittee.

(8) “HTAS” means the Health Technology Assessment Subcommittee

(9) “Medical technology” or “technology” means medical equipment and devices, medical or surgical procedures and other techniques used or prescribed by health care providers in delivering health care to individuals, and the organizational or supportive systems within which health care is delivered.

(10) “Medical technology assessment” means an evidence-based report on the use, clinical effectiveness and risks, and cost of a technology in comparison with its alternatives.

(11) “Subcommittee” means a subcommittee established by the Commission.

(12) “Scientific evidence” means scientific studies found in peer-reviewed medical literature, printed in journals or other publications that publish original manuscripts only after the manuscripts have been critically reviewed by unbiased independent experts for scientific accuracy, validity and reliability. Such evidence will be evaluated by the Commission for evidence of bias based on the current principles of evidence-based medicine.

History

Statutory/Other Authority: ORS 414.695 & 413.042
Statutes/Other Implemented: 414.695 & 414.698
OHP 17-2016, f. & cert. ef. 12-22-16
OHP 5-2016, f. & cert. ef. 4-19-16
OHP 4-2013, f. & cert. ef. 2-1-13

Or. Admin. R. 409-060-0120 Health Evidence Review Commission Process for Evidence-based Reports

(1) The Commission shall base its reports on scientific evidence, taking into account the strength of the evidence, including an assessment of any biases present. Meetings shall be public and conducted in a manner consistent with the Commission’s policies and procedures.

(2) Topics for review shall be publicly identified at least 28 days prior to the initial Subcommittee meeting at which a draft evidence-based report is reviewed. In this notice, the Subcommittee shall make publicly available the primary evidence source documents to be used in creating the initial draft report, except when source documents are proprietary. If additional sources are added to the initial draft report after this notice, the Subcommittee shall publicly identify them no later than 14 days prior to the Subcommittee meeting where they will be discussed. In lieu of proprietary source documents, the Subcommittee shall make publicly available a citation of the evidence source. In the case of a proprietary evidence source, a full listing of citations from the proprietary source shall be made available when allowed by the source. If providing the citations is not allowed or not otherwise feasible, a summary of the evidence findings will be provided at least 14 days in advance of the meeting at which the initial draft report will be discussed.

(3) When developing an evidence-based report other than a coverage guidance, the Commission or its designated Subcommittee shall consult with two or more ad hoc experts on the subject matter of the evidence-based report. Subcommittee shall publicly solicit ad hoc experts at least 28 days prior to the meeting at which it reviews the initial draft evidence-based report. One of the ad hoc experts must be a provider who manages patients who would potentially receive the treatment, service or device in question. Candidates wishing to serve as ad hoc experts shall disclose conflicts of interest according to HERC bylaws. The Authority shall appoint ad hoc experts that best meet the needs of the state, considering any conflicts of interest, and shall not be limited to those who have volunteered to serve.

(4) After the Subcommittee reviews the initial draft report, the subcommittee may revise the initial draft report. The Subcommittee shall then solicit public comment on this version of the draft report over a 30-day period. Draft reports posted for comment shall include citations for all sources used in developing the report and a summary of evidence findings. The Subcommittee shall publicly disclose written comments received during the 30-day period, draft responses and additional revisions (if any) to the draft report at least seven days before the Subcommittee meeting at which the Subcommittee reviews public comments. After discussing the available evidence and considering public comment, including additional verbal testimony, the Subcommittee shall make conclusions as to the overall importance of beneficial effects versus potential harms and approve its final draft evidence-based report reflecting these conclusions.

(5) Before an evidence-based report is reviewed at a Commission meeting, a final draft report approved by the Subcommittee, along with all written public comments received during the public comment period and the Subcommittee’s responses to these public comments shall be made publicly available 14 days prior to the meeting. At the meeting, the Commission shall consider the Subcommittee’s approved draft report and accept further public comment.

(6) After evaluating the report and public comments the Commission may take one of three actions:

(a) Accept the report as written.

(b) Make edits to the report and accept as modified.

(7) The Commission or its Subcommittees may revise evidence-based reports when additional information relevant to the report is presented to the Commission or its Subcommittees. The Commission or its Subcommittees may initiate a review of evidence-based reports at the request of interested parties who provide information or interpretations not considered in developing an existing evidence-based report. The Commission may also elect to retire a coverage guidance based on an assessment of the importance of the coverage guidance and the resources that would be required to update it. HERC shall annually solicit requests to revise its coverage guidances and any requests shall be presented to HERC at a regular meeting along with the results of staff research on the topic and any recommendations related to the request.

History

Statutory/Other Authority: ORS 414.695 & 413.042
Statutes/Other Implemented: 414.695 & 414.698
OHP 17-2016, f. & cert. ef. 12-22-16
OHP 5-2016, f. & cert. ef. 4-19-16
OHP 4-2013, f. & cert. ef. 2-1-13

Or. Admin. R. 409-060-0130 Medical Technology Assessments

Medical technology assessments undertaken by the Commission shall be developed by HTAS and may include any technologies listed in the definition in ORS 414.695 and 414.698(1). Medical technology assessments shall be performed in cases where technology assessments from trusted sources do not exist or require the consideration of additional evidence. Medical Technology Assessments shall include a new search of the current peer-reviewed research on the topic. Assessments shall be developed according to the process described in OAR 409-060-0120 except as described in this section.

History

Statutory/Other Authority: ORS 414.695 & 413.042
Statutes/Other Implemented: 414.695 & 414.698
OHP 4-2013, f. & cert. ef. 2-1-13

Or. Admin. R. 409-060-0140 Evidence-based Guidelines

The EbGS shall develop evidence-based guidelines based on one or more existing guidelines which may involve the consideration of additional research. Evidence-based guidelines shall be developed according to the process described in OAR 409-060-0120 except as described in this section.

History

Statutory/Other Authority: ORS 414.695 & 413.042
Statutes/Other Implemented: 414.695 & 414.698
OHP 17-2016, f. & cert. ef. 12-22-16
OHP 4-2013, f. & cert. ef. 2-1-13

Or. Admin. R. 409-060-0150 Coverage Guidances

(1) A Subcommittee shall develop coverage guidances based on evidence searches using scope statements approved by the EbGS or HTAS after a seven-day public comment period. These evidence searches may be supplemented as necessary to provide additional contextual, economic, clinical or policy information based on questions which arise during the development of the coverage guidance. Coverage guidances shall be developed according to the process described in OAR 409-060-0120 except as described in this section.

(2) OAR 409-060-0120(3) does not apply to this section. Instead, if the Subcommittee responsible for development of the report determines that it lacks sufficient expertise in the relevant field, or a request is received from an interested outside party, the Subcommittee shall solicit one or more ad hoc experts to provide additional information. Requests from interested parties to appoint ad hoc experts must be submitted within fourteen days after the public notice announcing the subcommittee’s first review of the initial draft coverage guidance. The subcommittee may solicit ad hoc experts at any time thereafter if the committee determines such expertise is necessary. Candidates wishing to serve as ad hoc experts shall disclose conflicts of interest according to HERC bylaws. Ad hoc experts, if needed, shall be appointed by the Authority. The Authority shall select experts that best meet the needs of the state, considering any conflicts of interest, and shall not be limited to those who have volunteered to serve. Ad hoc experts shall answer technical questions and provide clinical context during the review of the evidence.

History

Statutory/Other Authority: ORS 414.695 & 413.042
Statutes/Other Implemented: 414.695 & 414.698
OHP 17-2016, f. & cert. ef. 12-22-16
OHP 5-2016, f. & cert. ef. 4-19-16
OHP 4-2013, f. & cert. ef. 2-1-13

Division 62 VALUE-BASED BENEFITS SUBCOMMITTEE

Or. Admin. R. 409-062-0100 Purpose

These rules establish a public notice for advance meeting materials, which must be posted for an advance comment period, before being considered by the Value-based Benefits Subcommittee (VbBS) of the Health Evidence Review Commission (HERC). Public comments help HERC learn about community needs and perspectives to inform its deliberations about coverage recommendations and prioritization of health services. An accessible public comment policy supports HERC’s goals to eliminate health inequities and ensure that covered services are appropriate for the populations affected by its decisions.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.688
OHP 2-2023, adopt filed 11/09/2023, effective 11/09/2023

Or. Admin. R. 409-062-0110 VbBS Meeting Material Requirements

(1) Advance meeting materials include draft materials developed by Health Evidence Review Commission (HERC) staff in preparation for a scheduled Value-based Benefits Subcommittee (VbBS) meeting. Each item includes, but is not limited to, an issue summary document which may include staff description of the issue, staff analysis, research, draft recommendations, and/or supporting literature.

(2) Advance comment period means a 14-calendar-day period of time for members of the public to review advance meeting materials and to allow time to provide written feedback.

(3) Final meeting materials include materials that will be presented to the VbBS subcommittee members at the public meeting.

(4) Exempt topics. The following topics are exempt from this advance meeting material notice and comment process:

(a) Topics for which there is no recommendation to change the Prioritized List or bylaws.

(b) Recommendations related to:

(A) Topics placed on a consent agenda related to topics that do not require discussion.

(B) Placement or disposition of new medical codes issued by federal authorities fewer than 60 days prior to the meeting.

(D) An emergency use authorization by the United States Food and Drug Administration.

(E) Coverage changes that require immediate attention as determined by the HERC Director in order to ensure timely access to health care services.

(c) Topics for which advance meeting materials were previously posted but for which related recommendations were considered but not approved by VbBS, either as recommended by staff or in revised form.

(d) Topics for which advance meeting materials were previously posted and approved by VbBS and which HERC discussed but did not approve either as recommended by VbBS or in revised form.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.688
OHP 2-2023, adopt filed 11/09/2023, effective 11/09/2023

Or. Admin. R. 409-062-0120 Notice and Comment Process

(1) Prior to each Value-based Benefits Subcommittee (VbBS) meeting, Health Evidence Review Commission (HERC) staff must develop advance meeting materials, comprised of materials and draft recommendations related to all topics planned for discussion, excluding exempt topics.

(2) HERC staff must post a list of topics planned for VbBS discussion as well as advance meeting materials for a comment period on the HERC website and provide notice by electronic means (including but not limited to HERC’s listserv).

(a) The list of topics planned for VbBS discussion may include exempt topics for which meeting materials are prepared.

(b) HERC staff must post advance meeting materials by close of business 42 days in advance of a public meeting of the VbBS, unless there is an unexpected state office closure due to weather, infrastructure technology, or other emergency situation, in which case materials must be posted no later than 38 days in advance of a public VbBS meeting.

(c) The advance comment period for each publication of advance meeting materials must be specified on the first page and must end no sooner than 8 a.m., Pacific time, 15 calendar days after the posting of advance meeting materials.

(3) After publication of advance meeting materials, the HERC staff may revise these draft materials based on comments received and other new information they encounter. Staff may also include additional information, research or supporting information.

(4) HERC staff must create a public comment table for each topic that received written comment.

(a) The public comment table may include but is not limited to:

(A) The name of the commenter and any professional credentials provided.

(B) The date the comment was received.

(D) The written comment verbatim, up to the first 1,000 words. Comments may be redacted if they include personal health information of another person or excluded if they include hostile, obscene, or other inappropriate content as determined by the HERC Director.

(E) Any citations included with the public comment.

(F) For each comment, HERC staff may provide any additional context that may be pertinent for VbBS decision-making, including responding to any substantive or technical information provided in the comment.

(b) If more than 10 comments are received for any given topic, HERC staff may summarize major themes derived from the comments and include additional evidence, policy context, rationale for its recommendation or other information as necessary to support the Commission in informed decision-making. This summary table is included in addition to the public comment table that contains written comments verbatim.

(c) For each comment received, HERC staff must acknowledge receipt of the written comment to each individual submitting written comment.

(5) HERC staff must post the final meeting materials on the HERC website and provide notice by electronic means (including but not limited to HERC’s listserv).

(a) Final meeting materials must include any meeting materials related to exempt topics planned for discussion.

(b) Final meeting materials must be published by close of business seven days in advance of a VbBS meeting unless there is an unexpected state office closure due to weather, infrastructure technology, or other emergency situation, in which case materials must be posted no later than 4 days in advance of a public VbBS meeting.

History

Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.688
OHP 2-2023, adopt filed 11/09/2023, effective 11/09/2023

Division 65 SUSTAINABLE HEALTH CARE COST GROWTH TARGET PROGRAM

Or. Admin. R. 409-065-0000 Purpose

Senate Bill 889 (2019 Legislature) established the Sustainable Health Care Cost Growth Target Program within the Oregon Health Authority and House Bill 2081 (2021 Legislature) authorized accountability mechanisms to achieve a sustainable rate of health care cost growth. These rules (OAR 409-065-0000 to 409-065-0055) define reporting and accountability requirements to the Oregon Health Authority. Submitted data will inform the work of the Sustainable Health Care Cost Growth Target Program as it reports on health care cost drivers and trends.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.385 & 442.386
OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024
OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021
OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021

Or. Admin. R. 409-065-0005 Definitions

The following definitions apply to OAR 409-065-0000 to 409-065-0055:

(1) “Accident policy” means an insurance policy that provides benefits only for a loss due to accidental bodily injury.

(2) “Authority” means the Oregon Health Authority.

(3) “Calendar year” means a twelve-month year beginning on January 1 and ending on December 31.

(4) “Cost Growth Target-1” or “CGT-1” means the Data Submission Template as set forth on the website of the Authority.

(5) "Cost Growth Target-2” or “CGT-2” means the Cost Growth Target Data Specification Manual as set forth on the website of the Authority.

(6) "Cost Growth Target-3” or “CGT-3” means the Cost Growth Target Waiver/Extension Request as set forth on the website of the Authority.

(7) "Cost Growth Target-4” or “CGT-4” means the Cost Growth Target Frontline Worker Data Submission Template as set forth on the website of the Authority.

(8) "Cost Growth Target-5” or “CGT-5” means the Cost Growth Target Performance Improvement Plan Template as set forth on the website of the Authority.

(9) "Cost Growth Target-6” or “CGT-6” means the Cost Growth Target Performance Improvement Plan Guidance as set forth on the website of the Authority.

(10) "Cost Growth Target-7” or “CGT-7” means the Cost Growth Target Sub-Regulatory Guidance on Accountability document as set forth on the website of the Authority.

(11) “DCBS” means the Oregon Department of Consumer and Business Services.

(12) “Dental-only insurance” means an insurance policy that provides benefits only for dental services.

(13) “Disability policy” means an insurance policy that provides benefits for losses due to a covered illness or disability.

(14) “Frontline worker” means any worker whose total annual compensation is less than $200,000, adjusted by the annual percentage increase (if any) in the Consumer Price Index for All Urban Consumers, West Region (All Items), as published by the Bureau of Labor Statistics of the United States Department of Labor, excluding executive managers and salaried managers.

(15) “Health benefit plan” has the meaning provided in ORS 743B.005.

(16) “Health care” has the meaning provided in ORS 442.385.

(17) “Health insurance” has the meaning provided in ORS 731.162.

(18) “Hospital indemnity policy” means an insurance policy that provides benefits only for covered hospital stays.

(19) “Long-term care insurance” has the meaning provided in ORS 743.652.

(20) “Mandatory reporter” means any reporting entity determined to be a mandatory reporter in OAR 409-065-0010.

(21) “Medicare supplemental insurance” or “Medicare supplemental policy” has the meaning provided in OAR 836-052-0119.

(22) “Payer” has the meaning provided in ORS 442.385.

(23) “Performance improvement plan” (PIP) has the meaning provided in OAR 409-065-0040.

(24) “Program website” means the Authority’s website for the Sustainable Health Care Cost Growth Target Program, currently at https://www.oregon.gov/oha/hpa/hp/pages/sustainable-health-care-cost-growth-target.aspx.

(25) “Provider organization” means an entity including but not limited to a clinic, health system, hospitals with primary care, medical group, accountable care organization, or independent practice association.

(26) “Specific disease policy” means an insurance policy that provides benefits only for a loss due to a covered disease.

(27) “Stand-alone prescription drug plan” means an insurance policy that provides benefits only for prescription drugs.

(28) “Stop-loss plan” means insurance against the risk of economic loss assumed under a less than fully-insured employee health benefit plan as provided in ORS 742.065.

(29) “Third-party administrator (TPA)” means any person who directly or indirectly solicits or effects coverage of, underwrites, collects charges or premiums from, or adjusts or settles claims on, residents of Oregon or residents of another state from offices in Oregon, in connection with life insurance or health insurance coverage; or any person or entity who must otherwise be licensed under ORS 744.702.

(30) “Vision policy” means a health benefits plan covering only vision health care.

(31) “Voluntary reporter” means a payer or third-party administrator that does not meet the requirements to be considered a Mandatory reporter and elects to submit cost growth target data on a voluntary basis.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.385 & 442.386
OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024
OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021
OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021

Or. Admin. R. 409-065-0010 General Reporting Requirements for Mandatory Reporters

(1) Determination of a mandatory reporter.

(a) For payers or licensed third-party administrators, the Authority must identify mandatory reporters using health insurance enrollment data from DCBS and Medicaid enrollment reports from the Authority.

(A) The Authority must aggregate the most recent four (4) quarters of data.

(B) The Authority must calculate the mean total lives for each payer and licensed third-party administrator for each reporting year.

(b) All payers or licensed third-party administrators with calculated mean total lives of 1,000 or more across all lines of business must be mandatory reporters.

(c) The Authority must make annual mandatory reporter determinations and provide written notification no later than April 30 of each year to all mandatory reporters subject to the reporting requirements of OAR 409-065-0010 to 409-065-0030 for the current year.

(2) All Mandatory reporters must submit data files in a manner and form as prescribed by 409-065-0015.

(3) The Authority must identify voluntary reporters that have calculated mean total lives of 1,000 or higher across all lines of business and invite them to participate in the annual data submission.

(4) New mandatory reporters submitting for the first time, or mandatory reporters that did not submit data in the previous year, must attend a data submission training session prior to their first submission of data, as provided by the Authority.

(5) A mandatory reporter may submit a waiver of reporting in compliance with OAR 409-065-0020.

(6) An entity may appeal the Authority’s determination of mandatory reporter status pursuant to the procedure outlined in OAR 409-065-0050.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.385 & 442.386
OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024
OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021
OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021

Or. Admin. R. 409-065-0015 Data Submission Requirements

(1) Annual data submission dates are provided in the CGT-2; the data submission dates must not be before September 1st of each year.

(2) Annual data submissions must be submitted on the CGT-1 in accordance with instructions published by the Authority in the CGT-2.

(3) Mandatory reporters, and voluntary reporters who agree to participate, must submit data files for all required lines of business as defined in the CGT-2 and OAR 409-065-0015 (3)(a). Mandatory and voluntary reporters may submit data files for the voluntary lines of business and may not submit data files for any excluded lines of business as defined in the CGT-2 and OAR 409-065-0015 (3)(b). Mandatory and voluntary reporters must submit data files without subtracting or adjusting any costs including those listed as reasonable causes of cost growth in OAR 409-065-0035.

(a) Required lines of business include:

(A) Commercial;

(B) Medicare; and

(b) Excluded lines of business include:

(A) Accident policy;

(B) Disability policy;

(D) Long-term care insurance;

(E) Medicare supplemental insurance;

(F) Stand-alone prescription drug plans;

(G) Specific disease policy;

(H) Stop-loss plans;

(I) Supplemental insurance that pays deductibles, copays or coinsurance;

(J) Vision-only insurance;

(K) Workers compensation; and

(L) Dental-only insurance.

(c) A mandatory reporter that contracts with another entity remains responsible for reporting all required lines of business. If the mandatory reporter elects to have the data reported by a contracted entity, the mandatory reporter must notify the Authority and provide contact information for the contracted entity.

(4) The Authority must validate the submitted data on the CGT-1 in accordance with CGT-2.

(5) The Authority must review a submitted CGT-1 within 90 calendar days after confirming receipt. If the Authority finds errors during its review through edit checks or validation, the Authority must issue a notice of the error(s) to the mandatory or voluntary reporter, as applicable.

(a) Mandatory reporters must correct and resubmit data to the Authority within 30 calendar days after the date the Authority issues notice of the error(s). The Authority will consider the annual data submission complete after the mandatory reporter submits all necessary corrections and resubmissions, as determined by the Authority.

(b) Voluntary reporters may correct and resubmit data to the Authority, as applicable.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.385 & 442.386
OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024
OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021
OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021

Or. Admin. R. 409-065-0020 Data Submission Waivers

(1) The Authority may grant a waiver or deadline extension to the data submission requirements in OAR 409-065-0015.

(2) If a mandatory reporter believes they are eligible for a waiver of all or part of the data submission requirements they may request a waiver of reporting requirements by submitting a CGT-3 to the Authority.

(a) Mandatory reporters must submit a CGT-3 form to request a waiver as follows:

(A) To request a partial waiver to the data submission requirements, mandatory reporters must submit a completed CGT-3 form to the Authority no later than 14 calendar days before the annual reporting deadline.

(B) To request a waiver of all data submission or validation requirements, mandatory reporters must submit a completed CGT-3 form to the Authority no later than 60 calendar days before the annual reporting deadline.

(b) The Authority must approve or deny the waiver request and provide written notification to the requestor within 14 calendar days following receipt of the request.

(3) If a mandatory reporter believes they need a deadline extension for the data submission requirements, they may request a deadline extension by submitting CGT-3 form to the Authority.

(a) Mandatory reporters may submit a CGT-3 form to request a deadline extension as follows:

(A) To request a deadline extension for data submission, mandatory reporters must submit a completed CGT-3 form to the Authority no later than 14 calendar days before the annual reporting deadline.

(B) To request a deadline extension for data correction, resubmission, or validation requirements, mandatory reporters must submit a completed CGT-3 form to the Authority no later than seven calendar days after the date of the notice issued by the Authority requesting data correction, resubmission, or validation.

(b) The Authority must issue its determination on a mandatory reporter’s CGT-3 deadline extension request within 14 calendar days after the date of the request.

(4) If the Authority denies a CGT-3 request, the mandatory reporter may request a contested case hearing following the procedure outlined in OAR 409-065-0050.

(5) The Authority will only grant CGT-3 requests for one data submission cycle at a time.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.385 & 442.386
OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024
OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021
OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021

Or. Admin. R. 409-065-0025 Data Submission Compliance and Enforcement

(1) Unless the Authority approves a waiver submitted pursuant to OAR 409-065-0020, a mandatory reporter fails to comply with general data submission requirements under OAR 409-065-0015 when a mandatory reporter:

(a) Fails to submit data files by the specified submission date, or

(b) Fails to submit data files for a required line of business.

(2) Unless the Authority approves a waiver submitted pursuant to OAR 409-065-0020, a mandatory reporter fails to comply with data file requirements when a mandatory reporter:

(a) Submits a data file in an unapproved layout;

(b) Submits a data element in an unapproved format;

(d) Fails to submit a required data element; or

(e) Fails to comply with validation and quality control efforts, including resubmitting or correcting data in a timely fashion as requested by the Authority.

(3) The Authority must issue a notice of noncompliance to mandatory reporters before imposing a civil penalty in accordance with section (4) of this rule. Mandatory reporters must come into compliance within 30 calendar days from the date the Authority issues its notice of noncompliance.

(4) The Authority may impose a civil penalty on a mandatory provider for a violation of this rule if the mandatory reporter does not come into compliance as required under section (3) of this rule. Pursuant to ORS 442.993, the Authority adopts the following schedule of civil penalties:

(a) Up to $500 per day starting from the data of the notice in section (3) of this rule for each violation of OAR 409-065-0025(1)(a) through (b);

(b) Up to $400 per day starting from the data of the notice in section (3) of this rule for each violation of OAR 409-065-0025(2)(a) through (e).

(5) Civil penalties must be imposed in the manner provided in ORS 183.745.

History

Statutory/Other Authority: ORS 442.386 & 442.993
Statutes/Other Implemented: ORS 442.385, 442.386 & 442.993
OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024
OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021
OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021

Or. Admin. R. 409-065-0028 General Reporting Requirements for Provider Organizations

(1) Determination of a provider organization that is required to report data.

(a) The Authority must identify provider organizations with 10,000 or more attributed patients in at least one market using the annual report titled Health Care Cost Trends, which is set forth on the Program website.

(b) The Authority must make annual determinations regarding which provider organizations are required to report data. The Authority must provide written notification no later than April 30 of each year to all provider organizations required to report data for the current year.

(c) A provider organization may appeal the Authority’s determination of the status as a provider organization required to report data pursuant to the procedure outlined in OAR 409-065-0050.

(2) Provider organizations with less than 10,000 attributed patients in a given market, pediatric provider organizations, or federally qualified health centers, as identified by the Authority in the annual report titled Health Care Cost Trends and set forth on the Program website, may voluntarily submit a complete CGT-4 to the Authority.

(3) Data submission requirements.

(a) Annual data submission dates are provided in the CGT-4; the data must not be submitted before September 1st of each year, subject to section (7) of this rule.

(b) The Authority must review a submitted CGT-4 within 90 calendar days after confirming receipt. If the Authority finds errors during its review through edit checks or validation, the Authority must issue a notice of the error(s) to the provider organization. Provider organizations must correct and resubmit data within 30 calendar days after the date the Authority issues notice of the error(s). The Authority will consider the annual data submission complete after the provider organization submits all necessary corrections and resubmissions, as determined by the Authority. Voluntary reporters may correct and resubmit data, as applicable.

(4) Data submission waivers

(a) The Authority may grant a waiver or deadline extension to the data submission requirements.

(b) If a provider organization believes they are eligible for a waiver of all or part of the data submission requirements they may request a waiver of reporting requirements by submitting a CGT-3 to the Authority.

(A) A provider organization must submit a CGT-3 form to request a waiver as follows:

(i) To request a partial waiver to the data submission requirements, provider organizations must submit a completed CGT-3 form to the Authority no later than 14 calendar days before the annual reporting deadline.

(ii) To request a waiver of all data submission or validation requirements, a provider organization must submit a completed CGT-3 form to the Authority no later than 60 calendar days before the annual reporting deadline.

(B) The Authority must approve or deny the waiver request and provide written notification to the requestor within 14 calendar days following receipt of the request.

(c) If a provider organization believes they need a deadline extension for the data submission requirements, they may request a deadline extension by submitting a CGT-3 form to the Authority.

(A) Provider organizations may submit a CGT-3 form to request a deadline extension as follows:

(i) To request a deadline extension for data submission, provider organizations must submit a completed CGT-3 form to the Authority no later than 14 calendar days before the annual reporting deadline.

(ii) To request a deadline extension for data correction, resubmission, or validation requirements, mandatory reporters must submit a completed CGT-3 form to the Authority no later than seven calendar days after the date of the notice issued by the Authority requesting data correction, resubmission, or validation.

(B) The Authority must issue its determination on a provider organization’s CGT-3 deadline extension request within 14 calendar days after the date of the request.

(d) If the Authority denies a CGT-3 request, the mandatory reporter may request a contested case hearing following the procedure outlined in OAR 409-065-0050.

(e) The Authority will only grant CGT-3 requests for one data submission cycle at a time.

(5) Data submission Compliance and Enforcement

(a) Unless the Authority approves a waiver submitted pursuant to section (4) of this rule, a provider organization fails to comply with data submission requirements under section (3) of this rule when a provider organization fails to submit data files by the specified submission date.

(b) Unless the Authority approves a waiver submitted pursuant to section (4) of this rule, a provider organization fails to comply with data file requirements when a provider organization:

(A) Submits a data file in an unapproved layout;

(B) Submits a data element in an unapproved format;

(D) Fails to submit a required data element; or

(E) Fails to comply with validation and quality control efforts, including resubmitting or correcting data in a timely fashion as requested by the Authority.

(c) The Authority must issue a notice of noncompliance to provider organizations before imposing a civil penalty under section (6) of this rule. Provider organizations must come into compliance within 30 calendar days from the date the Authority issues its notice of noncompliance.

(6) The Authority may impose a civil penalty on a provider organization for a violation of this rule if the provider organization does not come into compliance as required under section (5) of this rule. Civil penalties must be imposed in the manner provided in ORS 183.745. Pursuant to ORS 442.993, the Authority adopts the following schedule of civil penalties:

(a) Up to $500 per day starting from the date of the notice in (5)(c) of this rule for each violation of (5)(a) of this rule;

(b) Up to $400 per day starting from the date of the notice in (5)(c) of this rule for each violation of (5)(b) of this rule.

(7) For calendar year 2024, the Authority will notify provider organizations that are required to submit a CGT-4 file under section (1) of this rule no later than July 31, 2024, with submissions due to the Authority no later than December 6, 2024. Annual data submissions for subsequent years must comply with the requirements of section (3) of this rule.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.385 & 442.386
OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024

Or. Admin. R. 409-065-0029 Automatic Change in Monetary Limits for Frontline Workers

Monetary limits for frontline workers will automatically change, without the necessity for amending such rules, by annual percentage increase (if any) in the Consumer Price Index for All Urban Consumers, West Region (All Items), as published by the Bureau of Labor Statistics of the United States Department of Labor, as determined by the Authority. The Authority must calculate the changes and post changes by June 1 of each year.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.386
OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024

Or. Admin. R. 409-065-0030 Data Access and Disclosure

(1) The Authority may use and disclose data submitted to it under these rules in accordance with ORS 442.386 and any applicable Authority policies and state and federal rules, regulations, and statutes.

(2) The Authority may disclose data to payers or provider organizations in the administration of the program, excluding any information determined to be confidential pursuant to OAR 409-065-0042, regarding the determination of a reasonable cause of cost growth.

(3) The Authority may provide a public use data set in compliance with applicable Authority policies and state and federal rules and regulations.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.385 & 442.386
OHP 4-2024, amend filed 07/22/2024, effective 07/22/2024
OHP 5-2021, adopt filed 11/19/2021, effective 11/19/2021
OHP 2-2021, temporary adopt filed 06/02/2021, effective 06/02/2021 through 11/27/2021

Or. Admin. R. 409-065-0035 Reasonable Causes of Cost Growth

(1) The Authority must not impose a performance improvement plan outlined in OAR 409-065-0040 or financial penalty outlined in OAR 409-065-0045 on an entity that exceeded the cost growth target due to unforeseen market conditions or other equitable factors, as enumerated in section (2) of this rule. The Authority must conduct analyses to understand potential systematic causes, market conditions, or other factors that might result in entities exceeding the cost growth target. The Authority must determine, on a case-by-case basis, when such a condition or factor or a combination of such conditions or factors suffices as a reasonable cause for an entity to exceed the cost growth target (“determination of reasonableness”).

(2) Reasonable cause for exceeding the cost growth target includes but is not limited to:

(a) Changes in mandated benefits codified in Oregon Revised Statute, Oregon Administrative Rule, Federal law, or Federal Regulations, to the extent that the mandated benefits are not defrayed under applicable law;

(b) Changes in federal, state, or local law that increases costs, including, but not limited to workforce and labor requirements and compliance requirements;;

(c) New pharmaceuticals, and new uses of existing pharmaceuticals, or new medical treatments entering the market, including new medical procedures and devices;

(d) Changes in taxes related to health care or other administrative requirements including but not limited to changes in medical loss ratio rebate requirements pursuant to state or federal regulation;

(e) Acts of God such as natural disasters or pandemics;

(f) Entity investments to improve population health or address health equity including but not limited to investments in primary care or behavioral health;

(g) Macro-economic factors wholly outside of the ability of the entity to influence or mitigate, such as periods of significant inflation, supply chain shortages, or labor shortages;

(h) A provider organization’s total compensation, defined as wages, benefits, salaries, bonuses, and incentive payments, paid to frontline workers;

(i) High-cost patient or member outliers defined as per member per year costs totaling $1 million or more; and

(j) Any other reasonable cause specified in writing by the Authority and published as guidance on the Program website.

(3) The Authority must notify an entity in writing if the entity’s cost growth for that measurement period exceeded the cost growth target with statistical confidence and if the entity must participate in the Authority’s determination of reasonableness process, as specified in writing by the Authority and published on the Program website.

(4) Entities must participate in conversations regarding the determination of reasonableness process with the Authority. Participation may include, but is not limited to, the entity or its delegate or authorized representative:

(a) attending meetings with the Authority,

(b) responding to Authority questions, or

(5) Failure of an entity to participate in conversations regarding the determination of reasonableness process upon request by the Authority may result in the Authority determining that the cost growth was unreasonable.

(6) As part of the determination of reasonableness process, an entity that exceeds the cost growth target with statistical confidence may submit analyses and supporting documentation to the Authority for any and all potentially acceptable reasons for cost growth as the entity may identify. Such analyses and supporting documentation may include but are not limited to:

(a) the quantified impact of the reasonable cause on the entity’s cost growth with detailed explanation of how the entity calculated the impact;

(b) what the entity’s cost growth would have been had it not been for the reasonable cause, including a detailed explanation of how the entity calculated the cost growth;

(d) the aggregate amount of total compensation using a methodology posted by the Authority in sub-regulatory documentation on the Program website, if a provider organization claims total compensation paid to frontline workers as a reasonable cause, as specified in (2)(h) of this rule and OAR 409-065-0028.

(7) The Authority may request additional information, documents and analyses as the Authority may require to evaluate an entity’s assertation of reasonable cause for exceeding the cost growth target.

(8) No person shall file or cause to be filed with the Authority any statement, report, or other information required or permitted to be filed and known to such person to be false or misleading in any material aspect.

(9) After reviewing information submitted by the entity, the Authority must determine whether the entity’s claim of reasonable cost growth for the measurement period is acceptable.

(a) The Authority must determine that a payer or provider organization’s cost growth is reasonable if all of the cost growth above the cost growth target is due to one or more reasonable causes, as described in this rule.

(b) If the Authority determines that any amount of cost growth above the cost growth target is unreasonable, accountability mechanisms shall apply, as specified in OAR 409-065-0040 and OAR 409-065-0045.

(10) The Authority must issue a notice of intent to impose one of three possible determinations: cost growth is due to an acceptable reason(s), cost growth is not due to an acceptable reason(s), or the reason(s) for cost growth cannot be determined.

(11) The Authority may, subject to OAR 409-065-0030, publish the final outcome of the conversations regarding the determination of reasonableness process.

(12) The Authority must notify the payer or provider organization in writing if a Performance Improvement Plan is required, as per OAR 409-065-0040.

(13) The Authority will deem there is reasonable cause for a provider organization exceeding the cost growth target if its frontline worker cost growth is greater than or equal to the total value of the provider organization’s cost growth above the target across all accountable markets.

(14) A payer or provider organization that has received a determination that cost growth is not due to an acceptable reason may request a contested case hearing pursuant to the procedure outlined in OAR 409-065-0050.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.386
OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024

Or. Admin. R. 409-065-0040 Performance Improvement Plans (PIP)

(1) A payer or provider organization that exceeds the cost growth target with statistical confidence, as such term is described by the Authority in the Statistical Analysis guidance posted on the Program website, and without reasonable cause, in accordance with 409-065-0035, during a measurement year for Medicaid, Medicare Advantage, or the commercial insurance market, must complete the performance improvement plan (PIP) template enumerated in section (2) of this rule.

(2) The Authority must develop and publish on the Program website a PIP template (titled CGT-5), PIP Instructions and Manual (titled CGT-6), and Guidance on Accountability (titled CGT-7).

(a) The PIP is a document written by a payer or provider organization and approved by the Authority that specifies how the certain factors will result in reduced cost growth such that future cost growth does not exceed the cost growth target. These factors must:

(A) Identify key cost growth drivers and the specific actions a payer or provider organization will take to address those key cost growth drivers;

(B) Identify an appropriate timeframe or timeframes by which the payer or provider organization will reduce the cost growth and cost growth drivers; and

(b) A payer or provider organization must use the document titled CGT-5, to describe:

(A) The root cause(s)of cost growth including, but not limited to, any causes identified during discussions with the Authority regarding the determination of a reasonable cause for cost growth;

(B) Strategies developed by the payer or provider organization to address the root cause or causes of cost growth in a specified timeframe, but no more than 24 consecutive months from the date the Authority approves the submitted PIP, unless extended by the Authority as per (10) of this rule;

(D) The strategy developed by the payer or provider organization to avoid negative effects on health care service availability, quality, and health equity;

(E) The plan for adjusting the strategy during the duration of the PIP in response to unmet savings or measures, and any negative effects on quality, access, and health equity; and

(F) The payer or provider organization’s plan for how to apply any generated savings.

(3) The Authority must collaborate with a payer or provider organization required to develop and undertake a PIP by providing technical assistance, which may include sub-regulatory guidance, office hours, a webinar published on the Program website, and consultation with the payer or provider organization at their request.

(4) The Authority may, at its sole discretion, agree to a payer or provider organization combining required PIPs for multiple markets or to a payer and provider organization submitting a PIP jointly developed in the event that the strategies to address the root cause or causes of cost growth would benefit from a collaborative PIP.

(5) The payer or provider organization must submit its PIP to the Authority no later than 90 calendar days from the date the Authority notifies the payer or provider organization in writing that a PIP is required. The payer or provider organization is responsible for completing and submitting a CGT-5 to the Authority.

(6) The notified payer or provider organization may request an extension to complete and submit a PIP by completing and submitting a CGT-3 to the Authority.

(a) The payer or provider organization must request an extension no less than 30 calendar days prior to the PIP submission deadline.

(b) The Authority may grant, at its sole discretion, an extension of no more than 45 calendar days for the payer or provider organization to submit a complete PIP.

(7) Within 30 calendar days of receipt, the Authority must assess the submitted PIP to ensure it is complete and either approve the PIP or, if the PIP is incomplete, return it to the submitting payer or provider organization for revision with a specified deadline for the revised PIP, as determined by the Authority on a case-by-case basis.

(8) Following the Authority’s approval of the PIP, the payer or provider organization must submit progress reports every six months in a manner specified by the Authority and in collaboration with the entity, regarding all progress made in advancing the purpose of the PIP, including qualitative and quantitative data as specified in the PIP. The first report must be due six months from the date the Authority approved the submitted PIP.

(9) The Authority must publish on the Program website all PIPs, progress reports, and relevant materials marked “PUBLIC” pursuant to the requirements of OAR 409-065-0042.

(10) At the request of the payer or provider organization, the Authority may grant one or multiple extensions to a payer or provider organization with an approved PIP to achieve the activities outlined in the PIP. The Authority must publish on the Program website all granted extensions and any new applicable deadlines for activities and milestones in each PIP.

(11) At the full discretion of the Authority, the Authority may waive the requirement for a payer or provider organization to complete a PIP, or undertake an approved PIP that a payer or provider organization has implemented or is in the process of implementing. If waived by the Authority, the payer or provider organization will not be required to submit documents related to a PIP including but not limited to progress reports and other required documentation pertaining to the waived PIP. In contemplating a waiver of an approved PIP, the Authority may take the following into consideration:

(a) The payer or provider organization’s achievement of PIP goals ahead of the schedule specified in the PIP;

(b) Unforeseen market circumstances;

(d) The payer or provider organization is required to develop a subsequent PIP.

(12) If for a given year the Authority determines a payer or provider organization’s cost growth to be acceptable, or indeterminate, which shall be a rare occurrence, in accordance with OAR 409-065-0035, no PIP will be required for that year.

(13) No later than December 31, 2030, the Authority must reassess and, if necessary, revise the PIP process outlined in these rules.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.386
OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024

Or. Admin. R. 409-065-0042 Confidential Information

(1) An entity that submits information to the Authority may claim portions of the information a trade secret and exempt from disclosure under ORS 192.311 to 192.478.

(a) The entity must submit two versions of such materials to the Authority:

(A) One must be marked as “CONFIDENTIAL” and must contain the full unredacted version of the document.

(B) The second must be marked as “PUBLIC” and must contain a redacted version of the document (from which the confidential portions have been removed or obscured) and must be posted on the Program website.

(b) An entity claiming confidentiality must include a redaction log that provides a reasonably detailed statement of the grounds on which confidentiality is claimed and the reasoning for such redaction. This redaction log must be posted on the Program website.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.386
OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024

Or. Admin. R. 409-065-0045 Cost Growth Target Financial Penalties

(1) Pursuant to ORS 442.386, the Authority may impose a financial penalty on a payer or provider organization when:

(a) The cost growth exceeded the target with statistical confidence, as defined by the Authority; and

(b) The payer or provider organization’s cost growth is without reasonable cause, or is not indeterminate, as defined in 409-065-0035, in the Medicaid, Medicare Advantage, or commercial insurance market for at least three out of five calendar years.

(2) The Authority must not impose financial penalties before January 1, 2026, and the cost growth from 2021 to 2022 must serve as the first year of a payer or provider organization’s first five-year period described in section (1)(b) of this rule.

(3) The financial penalty must be paid to consumers or designed to directly benefit consumers.

(4) The size of a payer or provider organization’s financial penalty must be based on how much the payer or provider organization exceeded the cost growth target and must be determined as follows:

(a) A payer or provider organization’s first instance of a financial penalty within a given market must equal 5 percent of the net total cost above and below the cost growth target collectively in the five-year period.

(b) A payer or provider organization’s second instance of a financial penalty within a given market must equal 10 percent of the net total cost above and below the cost growth target in the five-year period.

(c) A payer or provider organization’s third instance of a financial penalty within a given market must equal 15 percent of the net total cost above and below the cost growth target in the five-year period.

(d) Each instance of a financial penalty within a given market must increase by 5 percentage points of the net total cost above the cost growth target in the five-year period.

(e) The total cost above the cost growth target for a given performance period is calculated by the following steps:

(A) First, subtract from the payer or provider organization’s per member per month (PMPM) cost in the second year of the two-year performance period the product of the payer or provider organization’s per member per month (PMPM) cost in the first year of the two-year performance period multiplied by the sum of one plus the cost growth target percent. The Authority must use per member per month costs, as defined by the Authority in CGT-1 data submission template as total medical expenses. The mathematical formula is (PMPM year 2 – (PMPM year 1 * (1 + cost growth target percent))) = x. In this OAR 409-070-0045, the value ”x” equals the calculated value of the mathematical formula in this subsection (4)(e)(A).

(B) Second, multiply “x” times the number of member months (MM) in the second year of the two-year performance period. The mathematical formula is (x * MM) = z.

(C) Repeat the steps in subsection (4)(e)(A) and (4)(e)(B) of this section for all five years of the five-year period. For years in which the payer or provider organization’s cost growth exceeded the cost growth target, the calculated value of “x” and “z” will be a positive number. For years in which the payer or provider organization’s cost growth was less than the cost growth target, the calculated value of “x” and “z” will be a negative number.

(D) Sum all values of ”z” calculated in subsections (4)(e)(A) through (C) in this section. The result is the net total cost above the cost growth target.

(E) Multiply the value in subsection (4)(e)(D) of this section by the appropriate factor, as determined in subsection (4)(a) through (4)(d) in this section.

(F) If the value calculated in subsection (4)(e)(E) in this section is zero or negative, the payer or provider organization will not be penalized for that five-year period.

(5) A payer or provider organization’s performance in a given year will be counted only once towards the calculation of a net total cost above the cost growth target in a five-year period. The five-year period will shift forward every year following payers’ submission of data as outlined in OAR 409-065-0010.

(6) The Authority may reduce the calculated financial penalty amount if the payer or provider organization is subject to one or more other penalties imposed by the State of Oregon or the federal government for the same measurement period or if the penalties threaten the solvency of the payer or provider organization. The Authority must consult with DCBS on every instance of a penalty applying to a payer.

(a) Other penalties imposed by the State of Oregon or the federal government include, but are not limited to, rebates relating to the medical loss ratio. The amount of the other penalty or rebate imposed by the State of Oregon or the federal government must be subtracted from the penalty amount calculated in section (4) of this rule.

(b) The Authority must collaborate with DCBS when determining if a penalty imposed by the Authority will threaten the solvency of a payer and may reference information including but not limited to the payer’s risk-based capital amounts. The Authority must handle confidential information received by DCBS in accordance with ORS 705.137 and may share confidential information with DCBS. Such sharing shall not constitute a waiver of the confidential status of such materials.

(c) The Authority may request financial information from provider organizations when determining if a penalty amount imposed by the Authority will threaten the solvency of a provider organization and may reference information including, but not limited to, audited financial statements.

(7) If the Authority determines a payer or provider is subject to financial penalty under this rule, the Authority must prepare and serve a Notice of Intent to Impose a Financial penalty on the payer or provider organization. A payer or provider organization that has been served a Notice of Intent has 60 calendar days to either provide the Authority with a proposed plan for the financial penalty pursuant to section (8) of this rule or file a written request for a contested case hearing pursuant to the procedures outlined in OAR 409-065-0050.

(8) The Authority must publish sub-regulatory guidance on the Program website outlining allowable financial plans including a template for the proposed plan and the availability of additional technical assistance. Financial penalties must:

(a) Benefit community members who reside in or in close proximity to a geographic area in Oregon that the payer or provider organization serves, and

(b) Not directly and financially benefit the payer or provider organization.

(9) The payer or provider organization must pay the totality of the financial penalty within 60 months after receiving a Final Order Imposing a Financial penalty from the Authority, inclusive of all appeal periods.

(10) The following payer and provider organizations are exempt from OAR 409-065-0045 and will not be subject to a financial penalty:

(a) A Federally Qualified Health Center, as defined in 42 U.S.C. 254b, that is not affiliated with a hospital through ownership, governance, control, or membership.

(b) A pediatric clinic or group of pediatric clinics that predominantly treat individuals under the age of 21, that is not affiliated with a hospital through ownership, governance, control, or membership.

(11) No later than December 31, 2030, the Authority must reassess and, if necessary, revise the financial penalty calculation methodology outlined in this rule.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.386
OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024

Or. Admin. R. 409-065-0050 Cost Growth Target Accountability Request for Consideration and Contested Case Hearings

(1) A payer or provider organization may request that the Authority reconsider any Notice of Intent or determination made under OAR 409-065-0000 through OAR 409-065-0055.

(a) A request for reconsideration must be submitted in writing to OHA, via email to HealthCare.CostTarget@oha.oregon.gov, within 30 days of the date of OHA’s written Notice of Intent or determination. This request must include a detailed explanation of why the payer or provider organization believes OHA’s decision is in error along with any supporting documentation. This request for reconsideration initiates an informal review process.

(b) New information may be provided by the payer or provider organization, or may be requested by the Authority, as part of the reconsideration process.

(c) A reconsideration may result in a modified Notice or in the reaffirmation of the original Notice. A request for reconsideration, supporting documentation and additional information, and OHA’s determination must be posted on the Program website, although any information determined to be a trade secret and confidential under OAR 409-065-0042 must be maintained as confidential.

(2) A payer or provider organization is entitled to an informal conference and contested case hearing as provided in this rule regarding Notices of Intent and determinations made under OAR 409-065-0000 through 409-065-0055.

(3) This section solely applies to informal conferences and contested case hearings requested on notices of intent and determinations made under OAR 409-065-0010 through 409-065-0030.

(a) An entity that wishes to contest a determination of mandatory reporter status or provider organization must submit a request a hearing within 20 calendar days after the Authority issues the determination of mandatory reporter status as outlined in OAR 409-065-0010.

(b) A payer or provider organization that wishes to contest a denial of waiver or extension request must request a hearing within 20 calendar days after the Authority issues its determination pursuant to OAR 409-065-0020.

(c) A payer or provider organization that wishes to contest a notice of intent to impose a civil penalty issued by the Authority regarding data submission or data filing requirements must request a hearing within 20 calendar days after the Authority issues the notice of intent pursuant to OAR 409-065-0025.

(4) This section applies to informal conferences and contested case hearings requested on notices of intent and determinations made under OAR 409-065-0035 through 409-065-0045.

(a) A payer or provider organization that wishes to contest a determination that cost growth is not due to an acceptable reason(s) must request a hearing within 20 calendar days after the Authority issues the determination.

(b) A payer or provider organization that wishes to contest a notice of intent to impose a financial penalty issued by the Authority must request a hearing within 20 calendar days after the Authority issues the notice of intent pursuant to OAR 409-065-0045.

(5) Informal Conference Request.

(a) Upon receipt of a notice of intent and/or determination outlined in section (3) or (4) of this rule, a payer or provider organization may request an informal conference with the Authority via email to HealthCare.CostTarget@oha.oregon.gov.

(b) The Authority will schedule an informal conference with the payer or provider organization. The purposes of this informal conference are to:

(A) Provide an opportunity to settle the matter;

(B) Give the parties and the Authority an opportunity to review the information which is the basis for the action; and

(c) If the payer or provider organization request a contested case hearing, the payer or provider organization may, at any time prior to the hearing date, request an additional informal conference with the Authority, which may be granted if the Authority finds at its sole discretion that the additional informal conference will facilitate the resolution of disputed issues.

(d) An informal conference may result in a modified notice of intent or determination or in the reaffirmation of the original notice of intent or determination.

(6) Contested Case Hearing.

(a) In a contested case conducted pursuant to this rule, an Administrative Law Judge (ALJ) assigned by the Office of Administrative Hearings must conduct the contested case hearing pursuant to ORS 183.411 through 183.497, the Attorney General’s Model Rules at OAR 137-003-0501 to 137-003-0700, and the provisions of these rules.

(b) The Authority’s contested case hearings governed by this rule must be open to the public.

(c) The issues to be considered in a contested case conducted pursuant to this rule must be limited in scope to the facts and conclusions contained in the order or determination.

(7) Proposed and Final Orders. The ALJ is authorized to serve a proposed order on all parties and the Authority unless prior to the hearing, the Authority notifies the ALJ that a final order may be served by the ALJ.

(a) If the ALJ issues a proposed order, and the proposed order is adverse to a party, the party may file written exceptions to the proposed order to be considered by the Authority, or the ALJ when the ALJ is authorized to issue the final order. The exceptions must be in writing and received by the Authority, or the ALJ when the ALJ is authorized to issue the final order, not later than 10 calendar days after the date of the proposed order is issued by the ALJ. No additional evidence may be submitted without prior approval of the Authority.

(b) The Authority must issue a final order within 30 calendar days of receipt of the proposed order, which may adopt some or all of the proposed order, as the Authority must determine in its sole discretion. The final order is effective immediately upon being signed or as otherwise provided in the order.

(c) After receiving the exceptions or argument, if any, the Authority may adopt the proposed order as the final order or may prepare a new order. Prior to issuing the final order, the Authority may issue an amended proposed order.

(8) The time limits established in this rule may be waived or shortened by agreement among the parties and the Authority.

(9) All contested case hearing decisions are subject to judicial review under ORS 183.482 in the Court of Appeals.

History

Statutory/Other Authority: ORS 442.386
Statutes/Other Implemented: ORS 442.386
OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024

Or. Admin. R. 409-065-0055 Annual Public Hearings

(1) The cost growth target program must hold an annual public hearing regarding the growth in total health care expenditures in relation to the health care cost growth in the previous calendar year. The director of the Authority may request any payer or provider organization that is found to be a significant contributor to health care cost growth in the state or exceeds the cost growth target with statistical confidence, as defined by the Authority, and without reasonable cause, as defined in OAR 409-065-0035, during the performance year, to participate in an annual public hearing. If the payer or provider organization does not commit to participating in the annual public hearing, the director of the Authority may require participation. The Authority must notify the payer or provider organization of the requirement to participate. Each such payer or provider organization that is required to participate in such hearing must provide testimony on issues identified by the director of the Authority and provide additional information on actions taken to reduce such payer's or provider organization’s contribution to state-wide and market-level health care costs.

(2) The director of the Authority may request that any other entity, including but not limited to a drug manufacturer or pharmacy benefit manager, that is found to be a significant contributor to health care cost growth in this state during the performance year participate in such hearing. If the entity does not commit to participating in the annual public hearing, the director of the Authority may require participation. Any other entity that is required to participate in such hearing must provide testimony on issues identified by the director of the Authority and provide additional information on actions taken to reduce such other entity's contribution to state-wide health care costs.

History

Statutory/Other Authority: ORS 413.037 & 442.386
Statutes/Other Implemented: ORS 442.386
OHP 4-2024, adopt filed 07/22/2024, effective 07/22/2024

Division 70 HEALTH CARE MARKET OVERSIGHT PROGRAM

Or. Admin. R. 409-070-0000 Scope and Purpose

(1) OAR 409-070-0000 through OAR 409-070-0085 are adopted pursuant to authority in ORS 415.501. OAR 409-070-0000 through OAR 409-070-0085 govern the procedure for filing notices of material change transactions and the criteria and procedure for review of material change transactions.

(2) Pursuant to ORS 415.501(1), the purpose of these rules is to promote the public interest and to advance the goals of the Authority and the Oregon Integrated and Coordinated Care Delivery System described in ORS 414.018 and ORS 414.570.

(3) The Authority and the Department must aim to achieve the following goals when reviewing proposed material change transactions:

(a) Improving health, maintaining and increasing the quality, reliability, availability and continuity of care and reducing the cost of care for people living in Oregon.

(b) Achieving health equity and equitable access to care.

(d) A process that is transparent, robust and informed by the public, including the local community, through meaningful engagement.

(e) Using resources wisely and ensuring the sustainability of the program, in collaboration with the Department, the Oregon Department of Justice, and other state agency programs when applicable.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 413.181 & 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0005 Definitions

When used and not otherwise defined in OAR 409-070-0000 through OAR 409-070-0085, the following terms have the meaning given in this section:

(1) "Administrative services" means support and administration services, outsourced and subcontracted services and other equivalent services and servicing arrangements relating to, supporting or facilitating the provision of patient care and services.

(2) "Authority" means the Oregon Health Authority.

(3) "AVP methodologies" means the advanced value-based payment models (3A and higher) described in the Oregon Value-Based Payment Compact (June 28, 2021).

(4) “Business entity” has the meaning given in ORS 731.116.

(5) "Carrier" means:

(a) A carrier as defined in ORS 743B.005 (but excluding subsection (d) thereof); or

(b) Any person that offers Medicare Advantage plans in this state.

(6) "Charitable organization" has the meaning given in ORS 128.620.

(7) "Comprehensive management services" means a person provides all or substantially all the personnel, or manages all or substantially all the operations, of a health care entity.

(8) "Control" means the direct or indirect power to manage a legal entity or set the legal entity's policies, whether by owning voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position or corporate office.

(9) "Coordinated care organization" has the meaning given in ORS 414.025.

(10) "Corporate affiliation" means a health care entity controls, is controlled by, or is under common control with another legal entity.

(11) "Covered transaction" means a transaction described in OAR 409-070-0010.

(12) "Department" means the Department of Consumer and Business Services.

(13) "Domestic health insurer" means an insurer as defined in ORS 731.106 or a health care service contractor as defined in ORS 750.005 that is formed under the laws of this state and has a certificate of authority from the Department to insure personal health risks, or pay for or provide health care services, whether in the form of indemnity insurance, managed care products or any other form or type of individual or group health insurance or health care service contract.

(14) In accordance with ORS 415.500(2), "essential services" means:

(a) Services that are funded on the prioritized list of health services described in ORS 414.690, as in effect at the time of notice submission; and

(b) Services that are essential to achieve health equity, meaning any service directly related to the treatment of a chronic condition, pregnancy-related services, prevention services including non-clinical services, or health care system navigation and care coordination services.

(15) In accordance with ORS 415.500(3), "health benefit plan" has the meaning given in ORS 743B.005.

(16) In accordance with ORS 415.500(4)(a), "health care entity" includes all of the following:

(a) An individual health professional licensed or certified in this state.

(b) A hospital, as defined in ORS 442.015.

(d) A carrier that offers a health benefit plan or Medicare Advantage plan in this state.

(e) A coordinated care organization or a prepaid managed care health services organization, as the term is defined in ORS 414.025.

(f) Any other person or business entity that has as a primary function the provision of health care items or services, including physical, behavioral or dental health items or services.

(g) Any other person or business entity that is a parent organization of, has control over, is controlled by, or is under common control with, an entity that has as a primary function the provision of health care items or services.

(17) In accordance with ORS 415.500(4)(b), "health care entity" does not include:

(a) Long term care facilities, as defined in ORS 442.015.

(b) Facilities licensed and operated under ORS 443.400 through 443.455.

(18) "Health equity" means a health system that provides all people with the ability to reach their full health potential and well-being and ensures that people are not disadvantaged by their race, ethnicity, language, disability, age, gender, gender identity, sexual orientation, social class, intersections among these communities or identities, or their socially determined circumstances.

(19) "Hospital" has the meaning given in ORS 442.015.

(20) “Hospital system” means:

(a) A parent corporation of one or more hospitals and any entity affiliated with the parent through ownership, governance, control, or membership; or

(b) A hospital and any entity affiliated with the hospital through ownership, governance, control, or membership.

(21) "Independent practice association" has the meaning given in ORS 743B.001.

(22) "Material change transaction" means a covered transaction that is material under the materiality standards set forth in OAR 409-070-0015.

(23) In accordance with ORS 415.500(8), "net patient revenue" means the total amount of income, after allowance for contractual amounts, charity care and bad debt, received for patient care and services, including:

(a) Value-based payments, incentive payments, capitation payments, payments under any similar contractual arrangement for the prepayment or reimbursement of patient care and services; and

(b) Any payment received by a hospital to reimburse a hospital assessment under ORS 414.855.

(24) "Person" means an individual, corporation, association, partnership, limited liability company, limited liability partnership, political subdivision, joint stock company, trust or unincorporated organization, or an entity or combination of entities similar to the entities described in this paragraph.

(25) "Program website" means the Authority's website for the Health Care Market Oversight Program, currently at https://www.oregon.gov/oha/HPA/HP/Pages/health-care-market-oversight.aspx.

(26) "Provider" means a person licensed, certified or otherwise authorized or permitted by laws of Oregon to administer or provide medical or mental health services in the ordinary course of business or practice of a profession.

(27) In accordance with ORS 415.500(9), "revenue" of a party to the transaction means:

(a) Net patient revenue; or

(b) The gross amount of premiums received by a health care entity that are derived from health benefit plans.

(28) "Term sheet" means a memorandum of understanding or letter of intent setting forth the negotiated terms and conditions of the proposed transaction in reasonable detail, signed by the parties to a proposed transaction, or any other equivalent document that sets forth an agreement in principle for a proposed transaction.

(29) "These rules" means the rules set forth in OAR 409-070-0000 through OAR 406-070-0085.

(30) “Timely” means completing a required action within the timeframe identified by the Authority or within the timeframe mutually agreed on between the Authority and parties to a transaction.

(31) "Voting security" means a security that entitles the owner or holder of the security to vote at a meeting of shareholders, a membership interest having voting rights in a limited liability company or nonprofit corporation, a partnership interest having voting rights in a limited or general partnership or any other type of instrument that confers on the holder of the instrument voting rights in the governance of a legal entity. A "voting security" also includes a security that is convertible into a voting security or that is evidence of a right to acquire a voting security.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0010 Covered Transactions

(1) Pursuant to ORS 415.500(6) and (10) and subject to the materiality standards under OAR 409-070-0015, transactions that are subject to review under these rules are the following:

(a) A merger or consolidation of a health care entity with another entity;

(b) An acquisition of a health care entity by another entity;

(c) A transaction to form a new contract, new clinical affiliation or new contracting affiliation between or among health care entities that will eliminate or significantly reduce essential services;

(d) Formation of a corporate affiliation involving at least one health care entity; or

(e) A transaction to form a new partnership, joint venture, accountable care organization, parent organization or management services organization between or among health care entities that will:

(A) Eliminate or significantly reduce essential services;

(B) Consolidate or combine providers of essential services when contracting payment rates with payers, insurers, or coordinated care organizations; or

(2) An acquisition of a health care entity occurs when:

(a) Another person acquires control of the health care entity including acquiring a controlling interest as described in OAR 409-070-0025;

(b) Another person acquires, directly or indirectly, voting control of more than fifty percent (50%) of any class of voting securities of the health care entity other than a domestic insurer as described in OAR 409-070-0025(1)(c);

(d) Another person undertakes to provide the health care entity with comprehensive management services; or

(e) The health care entity merges tax identification numbers or corporate governance with another entity.

(3) A significant reduction of services occurs when the transaction will result in a change of one-third or more of any of the following:

(a) An increase in time or distance for community members to access essential services, particularly for historically or currently underserved populations or community members using public transportation;

(b) A reduction in the number of providers, including the number of culturally competent providers, health care interpreters, or traditional healthcare workers, or a reduction in the number of clinical experiences or training opportunities for individuals enrolled in a professional clinical education program;

(c) A reduction in the number of providers serving new patients, providers serving individuals who are uninsured, or providers serving individuals who are underinsured;

(d) Any restrictions on providers regarding rendering, discussing, or referring for any essential services;

(e) A decrease in the availability of essential services or the range of available essential services;

(f) An increase in appointment wait times for essential services;

(g) An increase in any barriers for community members seeking care, such as new prior authorization processes or required consultations before receiving essential services; or

(h) A reduction in the availability of any specific type of care such as primary care, behavioral health care, oral health care, specialty care, pregnancy care, inpatient care, outpatient care, or emergent care as relates to the provision of essential services.

(4) Any change in the sub-regulatory guidance document pertaining to paragraph (3) of this rule shall be effective no less than 180 calendar days after publication.

(5) The foregoing standards in paragraph (3) of this rule do not alter any regulatory standards that may otherwise apply to a health care entity.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 to 415.900
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0015 Materiality Standard

(1) Pursuant to ORS 415.500(6) and (9) and ORS 415.501(4), a covered transaction under OAR 409-070-0010 is a material change transaction and must be subject to review under these rules if:

(a) At least one party to the transaction had average annual revenue of $25 million or more in the party's three most recent fiscal years; and

(b) Another party to the transaction:

(A) Had average annual revenue of $10 million or more in that party's three most recent three fiscal years; or

(B) If such party is a newly organized legal entity, is projected to have at least $10 million in revenue over its first full year of operation at normal levels of utilization or operation. A party is a newly organized legal entity if the entity is an existing entity whose form of ownership is changed in connection with the transaction. Changes in the form of ownership include but are not limited to a change from physician-owned to private equity-owned and publicly-held to a privately-held form of ownership.

(2) A covered transaction under OAR 409-070-0010 that qualifies as material under paragraph (1) of this rule must be subject to review under these rules notwithstanding that the transaction involves a health care entity in this state and an out-of-state entity if the transaction may increase the price of health care services or limit access to health care services in this state.

(a) For the purpose of these rules, an entity is considered in-state if it:

(A) Is based or domiciled in Oregon;

(B) Owns or operates business locations in Oregon;

(D) Is engaged in profit-seeking activity in Oregon; or

(E) Provides health care services to residents of Oregon.

(b) An entity domiciled outside of Oregon that otherwise meets the criteria in subsection (a) may be considered out-of-state under these rules if:

(A) The entity served no more than 100 Oregon residents annually for each of the three previous fiscal years; or

(B) The entity is a health care insurer, the proposed transaction involves only health care insurers, and the combined market share held by the health care insurer immediately after the completion of the proposed transaction does not exceed five percent in any market.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0020 Excluded Transactions

(1) Pursuant to ORS 415.500(6)(b) and (7), the following transactions are not material change transactions subject to review under these rules:

(a) A clinical affiliation of health care entities formed to collaborate on clinical trials or graduate medical education programs.

(b) A medical services contract or an extension of a medical services contract as described in paragraph (2) of this rule.

(A) Does not impact the corporate leadership, governance or control of a health care entity; and

(B) Is necessary to adopt AVP methodologies to meet the health care cost growth targets under ORS 442.386.

(d) Contracts under which one health care entity, for and on behalf of a second health care entity, provides patient care and related services or provides administrative services relating to, supporting or facilitating the provision of patient care and services, if the second health care entity:

(A) Maintains responsibility, oversight and control over the patient care and related services;

(B) Bills and receives reimbursement for the patient care and related services; and

(e) Transactions in which a participant that is a health center as defined in 42 U.S.C. 254b, while meeting all of the participant's obligations, acquires, affiliates with, partners with or enters into any agreement with another entity unless the transaction would result in the participant no longer qualifying as a health center under 42 U.S.C. 254b.

(f) A transaction that consists solely of a change in the immediate or intermediate ownership of a health care entity but which:

(A) Does not change the ultimate ownership or control of the health care entity,

(B) Does not result in the acquisition of control of the health care entity by any person not previously affiliated with the health care entity, and

(C) Does not involve an agreement between the health care entity and another person that otherwise constitutes a covered transaction and is not excluded from review under subsections (a), (b), (d) or (g) of this section.

(g) Agreements between an affiliate and a health care entity that are subject to ORS 732.574(2)(d)(D).

(2) For purposes of paragraph (1)(b) of this rule:

(a) A "medical services contract" means a contract to provide medical or mental health services, including physical, behavioral or dental health services, entered into by:

(A) A carrier or coordinated care organization and an independent practice association;

(B) A carrier, coordinated care organization, independent practice association or network of providers and one or more providers;

(D) A medical, dental, vision or mental health clinic; or

(E) A medical, dental, vision or mental health clinic and an individual health professional to provide medical, dental, vision or mental health services.

(b) A "medical services contract" does not include a contract of employment or a contract creating a legal entity and ownership of the legal entity that is authorized under ORS chapter 58, 60 or 70 or under any other law authorizing the creation of a professional organization similar to those authorized by ORS chapter 58, 60 or 70.

(3) If a complete notice of material change transaction submitted in accordance with OAR 409-070-0030(1) and OAR 409-070-0045(5) pertains to a transaction excluded under this rule, the Authority must notify the parties and the notice must be deemed withdrawn. All further proceedings in respect of the notice must be terminated and ended. The Authority's written notice to the parties under this paragraph (3) must be accompanied by a refund of the fee, if any, that was paid in connection with the notice of material change transaction.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0022 Emergency and Exempt Transactions

(1) Pursuant to ORS 415.501(8)(a), the Authority, for good cause shown, may exempt an otherwise covered transaction from review if the Authority finds that:

(a) There is an emergency situation, including but not limited to a public health emergency, which immediately threatens health care services; and

(b) The transaction is urgently needed to protect the interest of consumers and to preserve the solvency of an entity other than a domestic health insurer.

(2) If a proposed transaction would otherwise be subject to review because it involves a change in control of a domestic health insurer, the Department, in consultation with the Authority, for good cause shown, may exempt the transaction from review if the Department finds that:

(a) There is an emergency situation, including but not limited to a public health emergency, which immediately threatens health care services; and

(b) The transaction is urgently needed to protect the interest of consumers and to preserve the solvency of the domestic health insurer.

(3) An applicant for emergency exemption under paragraph (1) of this rule must provide the Authority, and an applicant for emergency exemption under paragraph (2) of this rule must provide the Department, with the following:

(a) A detailed explanation of the grounds for the application, including a complete statement of the facts, circumstances and conditions which justify emergency exemption and the conditions necessitating immediate relief;

(b) A detailed explanation of all the terms, conditions and agreements that comprise the transaction and the manner in which such terms, conditions and agreements will respond to the conditions necessitating expedited consideration of the exemption application;

(c) A detailed explanation of the reasons why the transaction is in the public interest and in the interest of those consumers and markets that are or will be served by the parties following closing of the transaction;

(d) If the application for emergency exemption requires or otherwise is based upon, in whole or in part, a disclaimer of a rebuttable presumption of control, the application must include a disclaimer of control meeting the requirements of OAR 409-070-0025;

(e) Such additional information, documents and analysis as the Authority or the Department, as applicable, may require in order to evaluate the application and the asserted grounds for emergency exemption;

(f) An undertaking by the parties to make such further filings with, and submit such further information to, the Authority or the Department, as applicable and to cooperate with and assist the Authority or the Department, as applicable, in conducting such further investigations, hearings and examinations, as may be required following the allowance of emergency exemption for the transaction;

(g) Payment of a fee in accordance with OAR 409-070-0030; and

(h) An undertaking by the parties to reimburse the Authority for expenses described in OAR 409-070-0050.

(4) The Authority with respect to an application filed under paragraph (1) of this rule, and the Department with respect to an application filed under paragraph (2) of the rule, must:

(a) Provide a period for the filing of comments in respect of the application unless the Authority or the Department, as applicable, determines that:

(A) The public interest in providing comments is outweighed by the interest in confidentiality of the applicant for emergency exemption; or

(B) the nature of the emergency situation presented and the urgency of the need for emergency exemption will not allow time for the filing and consideration of comments.

(b) Provide the applicant with three business days' advance notice prior to posting the application for public comment.

(5) The Department must promptly provide an application filed under paragraph (2) of this rule to the Authority, and such an application must be deemed to include an express consent to the sharing between the Authority and the Department of such application and all material in connection therewith.

(6) The Authority will publish from time to time a list of other categories or types of transactions that must be exempt from review under these rules.

(7) An applicant for emergency exemption may contest the Authority's determination as provided in OAR 409-070-0075. Unless otherwise ordered in the course of such proceedings, the time periods for preliminary and comprehensive review of the transaction under OAR 409-070-0055 or OAR 409-070-0060 must remain applicable, without abatement or reduction, in the event a preliminary or comprehensive review of the transaction is thereafter required.

(8) For emergency transactions that the Authority exempts from review, the Authority must publish the entity names and type of the covered transaction the earlier of either (a) or (b) of this section:

(a) No less than six months after the transaction has consummated or closed, or

(b) Immediately after an entity involved in the transaction discloses the nature of the emergency to the public or the nature of the emergency is otherwise publicly known.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0025 Acquisition of Control; Presumptions and Disclaimers

(1) The following presumptions will apply in determining whether a transaction involving a health care entity results in the acquisition of direct or indirect control of that health care entity:

(a) A transaction must be rebuttably presumed to involve an acquisition of control of a health care entity that is a domestic health insurer or a coordinated care organization if a person, directly or indirectly, acquires voting control of ten percent (10%) or more of any class of voting securities of the domestic health insurer or the coordinated care organization.

(b) For a health care entity other than a domestic health insurer or coordinated care organization, a transaction must be rebuttably presumed to involve an acquisition of control of the health care entity if a person, directly or indirectly, acquires voting control of twenty-five percent (25%) or more of any class of voting securities of the health care entity.

(c) For any health care entity, a transaction must be irrebuttably presumed to involve an acquisition of control of the health care entity if a person, directly or indirectly, acquires voting control of more than fifty percent (50%) of any class of voting securities of the health care entity.

(2) A person seeking to rebut the presumption described in paragraph (1)(b) of this rule must apply to the Authority, on a form prescribed by the Authority, for a disclaimer of control determination. Such application must show that the proposed transaction would not result in control of the health care entity, or that control would not be changed by the proposed transaction, and must fully disclose all material relationships and bases for control between the disclaimer applicant and the person(s) to which the disclaimer applies, as well as the basis for disclaiming control or change of control. The Authority may determine, after giving persons that have an interest in the Authority's determination notice and opportunity to be heard and after making specific findings of fact to support the determination, that control would exist or would be changed by a proposed transaction.

(3) A disclaimer application filed under paragraph (2) of this rule is effective unless, within thirty calendar days after the Authority receives the disclaimer application, the Authority notifies the disclaimer applicant that the disclaimer has been disallowed.

(4) Paragraphs (2) and (3) of this rule do not apply to transactions involving a domestic health insurer or a coordinated care organization. For a domestic health insurer, the disclaimer of affiliation procedure is in ORS 732.568. For a coordinated care organization, the disclaimer of affiliation procedure is in OAR 410-141-5315.

(5) Filing a disclaimer application does not relieve a health care entity of the requirement to submit a notice of material change transaction in accordance with OAR 407-070-0030. If a disclaimer application shows that a proposed transaction would not result in control of the health care entity or that control would not be changed by the proposed transaction, then the Authority must discontinue any review of the transaction and refund any fee paid in connection with the notice of material change transaction.

(6) A health care entity that submits a disclaimer application may contest the Authority's determination as provided in OAR 409-070-0075. Unless otherwise ordered in the course of such proceedings, the time periods for preliminary and comprehensive review of the transaction under OAR 409-070-0055 or OAR 409-070-0060 will remain applicable, without abatement or reduction, in the event a preliminary or comprehensive review of the transaction is thereafter required.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0030 Requirement to File a Notice of Material Change Transaction

(1) Any health care entity must:

(a) Submit to the Authority a notice of material change transaction not involving an activity described in ORS 732.521 with respect to a domestic health insurer. The notice must contain the information required under OAR 409-070-0045.

(b) Submit to the Department a notice of material change transaction for an activity described in ORS 732.521 with respect to a domestic health insurer. The notice must be submitted as an addendum to filings required by ORS 732.517 to ORS 732.546 or ORS 732.576. The Department must promptly provide to the Authority the notice submitted under this subsection to enable to the Authority to conduct its review in accordance with OAR 409-070-0035.

(2) The notice of material change transaction required under paragraph (1) of this rule must be filed not fewer than 180 calendar days prior to the proposed effective date of the material change transaction. For purposes of these rules, the effective date of a material change transaction is the date when the proposed transaction will be consummated or closed. If the Authority determines that a health care entity has failed to timely file a notice of material change transaction pursuant to this subsection, the Authority may refer the health care entity to the Oregon Department of Justice.

(3) Effective July 1, 2026 a fee must be paid to the Authority in connection with a complete notice of material change transaction accepted under this rule on or after July 1, 2026.

(a) The fee amount must be $2,000 for an emergency exemption request in accordance with OAR 409-070-0022.

(b) The fee amount must be $30,000 for a preliminary review in accordance with OAR 409-070-0055.

(c) The fee amount for a comprehensive review must be based on the average annual revenue or projected revenue, as applicable, in accordance with OAR 409-070-0015(1), of the following entity (the “smaller entity”):

(A) For transactions between two entities, the entity with smaller revenue; or

(B) For transactions involving more than two entities, the entity with the second largest average annual revenue.

(d) Comprehensive review fees must be determined as follows:

(A) For transactions in which the revenue of the smaller entity is greater than or equal to $10 million and less than $50 million, the fee must be $200,000.

(B) For transactions in which the revenue of the smaller entity is greater than or equal to $50 million and less than $200 million, the fee must be $250,000.

(C) For transactions in which the revenue of the smaller entity is greater than or equal to $200 million and less than $500 million, the fee must be $300,000.

(D) For transactions in which the revenue of the smaller entity is greater than or equal to $500 million, the fee must be $350,000.

(e) The fee amount for a comprehensive review includes the fee associated with the preliminary review.

(f) For purposes of this rule, “revenue” includes projected revenue, if applicable in accordance with OAR 409-070-0015(1)(b)(B).

(4) Fees required under Section (3) must be paid within 30 calendar days following receipt of an invoice for payment. Any decision regarding an emergency exemption or a proposed material change transaction may be conditioned on the payment of fees pursuant to paragraph (3) of this rule. The obligation of the parties to pay the fee to the Authority does not depend on whether the Authority approves the transaction. The obligation to pay fees is an obligation of the person filing the notice of material change transaction and any other parties to the transaction designated by the Authority.

(5) The fee for an emergency exemption request applies regardless of any other review or determination the Authority has started.

History

Statutory/Other Authority: ORS 415.501 & 415.512
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0035 Material Change Transaction Involving a Domestic Health Insurer

(1) The Authority must review a proposed material change transaction for an activity described in ORS 732.521 with respect to a domestic health insurer pursuant to the procedures set forth in OAR 409-070-0055 (preliminary review) and, if applicable, OAR 409-070-0060 (comprehensive review).

(a) At the conclusion of the preliminary review period provided in OAR 409-070-0055, the Authority must report to the Department:

(A) The results of the Authority's review under OAR 409-070-0055; or

(B) That the Authority intends to review the proposed material change transaction under OAR 409-070-0060, including whether the Authority intends to appoint a community review board pursuant to OAR 409-070-0062.

(b) If the Authority reviews the proposed material change transaction under OAR 409-070-0060, it must promptly provide to the Department the results of its review not later than the period specified in OAR 409-070-0060.

(c) The periods for review under OAR 409-070-0055 and OAR 409-070-0060 must begin running upon the Authority's receipt from the Department of a complete notice of material change transaction as required under OAR 409-070-0030(1)(b) and subject to OAR 409-070-0045.

(2) The Department must receive and consider the results of the Authority's review prior to entering its decision on the proposed material change transaction. The Department must coordinate with the Authority to incorporate the results of the Authority's review into the final determination issued by the Department pursuant to ORS 732.528 or ORS 732.542, as applicable. In the event the proposed material change transaction is deemed exempt from review or is otherwise not reviewed by the Department but remains subject to review by the Authority, the Authority must proceed with its review of the transaction pursuant to OAR 409-070-0045, OAR 409-070-0055, and OAR 409-070-0060 and must render the final determination.

(3) The filing of a notice of material change transaction that is subject to review by each of the Authority and the Department under this rule shall be deemed to include an express consent to the sharing between the Authority and the Department of confidential material submitted in connection with such proposed material change transaction. Confidential material provided by any party in connection with such proposed material change transaction must be maintained as confidential material in accordance with ORS 705.137 and ORS 415.103, and OAR 409-070-0070, and may be shared between the Authority and the Department pursuant to ORS 705.137(3)(b) & (c) and (4), and ORS 192.355(1), (9), (10) and (31), as applicable. Such sharing shall not constitute a waiver of the confidential status of such materials.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0040 Material Change Transaction Involving a Charitable Organization or Hospital

(1) The parties must provide a copy of any notice of a material change transaction involving a health care entity that is, controls, or is controlled by a charitable organization to the Charitable Activities Section of the Oregon Department of Justice in addition to the notice submitted to the Authority in accordance with OAR 409-070-0030(1)(a).

(2) To the extent applicable, a health care entity involved in a material change transaction remains subject to the charitable registration and reporting requirements contained in ORS 128.610 et seq. and to the Attorney General notification and other provisions contained in ORS Chapter 65, the Nonprofit Corporations Act, including Attorney General review and approval of hospital transfers within the scope of ORS 65.803.

(3) The filing of a notice of material change transaction that is subject to review by each of the Authority and the Charitable Activities Section of the Oregon Department of Justice under this rule must be deemed to include an express consent to the sharing between the Authority and the Department of Justice of confidential material submitted in connection with such proposed material change transaction. The Authority may consult with the Department of Justice regarding the potential effects of a proposed material change transaction on the charitable organization or its assets or charitable assets held by a health care entity. Confidential material provided by any party in connection with such proposed material change transaction shall be maintained as confidential material in accordance with OAR 409-070-0070. Such sharing shall not constitute a waiver of the confidential status of such materials.

(4) The Authority may condition its approval of a material change transaction involving a health care entity that is, controls, or is controlled by a charitable organization on a required filing with, and approval by, the Charitable Activities Section of the Oregon Department of Justice.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0042 Optional Application for Determination of Covered Transaction Status

(1) Any party to a proposed transaction may, but must not be required to, submit a written application to the Authority requesting a determination whether such transaction is a covered transaction pursuant to these rules. The Authority must notify the applicant in writing of its determination within 30 calendar days following receipt of the application and any additional information requested by the Authority. If the Authority determines that the proposed transaction is a covered transaction, and the parties desire to pursue the transaction, the parties must file a notice in accordance with these rules.

(2) An application for determination pursuant to paragraph (1) of this rule must contain:

(a) A detailed explanation of the transaction, including the parties to such transaction and all relevant terms, conditions and agreements that comprise the transaction;

(b) A detailed explanation of the reasons the parties to the proposed transaction believe such transaction is not a covered transaction pursuant to these rules; and

(c) Such additional information, documents and analyses as the Authority may require in order to evaluate the application and the asserted grounds on which it should not be considered a covered transaction pursuant to these rules.

(3) The submission of an application pursuant to this rule does not toll any timelines or notice requirements under these rules.

(4) No fee shall be required in connection with an optional application filed under this rule. However, if the Authority determines that the transaction is a covered transaction, and if a notice of material change transaction is thereafter filed, a fee in accordance with OAR 409-070-0030 must be payable.

(5) Confidential material provided by any party in connection with an optional determination must be maintained as confidential in accordance with OAR 409-070-0070.

(6) The Authority will publish the letter of determination at the earlier of either (a), (b), or (c) of this section:

(a) No less than six months after the date of the letter of determination in the event that the transaction proceeds, is publicly available, but is not subject to review by the Authority;

(b) Within one business day after receipt of a complete notice of material change transaction;

(c) Within one business day after the letter of determination is sent to the requesting entity if the transaction is otherwise publicly known; or

(d) within one business day after the letter of determination is sent to the requesting entity if the entity consents to such letter being published.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0045 Form and Contents of Notice of Material Change Transaction

(1) A notice of material change transaction required to be filed under OAR 409-070-0030(1)(a) must be made using the form available at the Program website. Unless expressly provided otherwise, if any item is inapplicable or the answer to any item is in the negative, a statement to that effect must be made.

(2) A party or the parties to a material change transaction for which a filing will be made under this rule are encouraged to contact the Authority and arrange for a pre-filing conference. If the Authority decides to conduct a comprehensive review under OAR 409-070-0060, the Authority must offer the party or parties a comprehensive review conference. The pre-filing conference or comprehensive review conference must preview the transaction and filing and the Authority's expectations for the review of the transaction including timing, the use of outside experts, the potential involvement of a community review board in accordance with OAR 409-070-0062, and other relevant issues. As applicable, the Department will participate along with the Authority in any such conference. The party or parties to a material change transaction under review may request a pre-filing conference, a comprehensive review conference, or other conference with the Authority at any time during the preliminary or comprehensive review period.

(3) One complete copy of the notice, including exhibits and all other papers and documents filed as part of the notice, must be filed with the Authority by electronic delivery.

(a) The notice must be signed electronically or otherwise in the manner prescribed in the notice form.

(b) The notice must include only non-confidential public-facing responses on the notice form with all information designated as “CONFIDENTIAL” under OAR 409-070-0070 provided separately as a supplemental attachment to the notice form.

(c) All exhibits, attachments, or other papers and documents filed as part of the notice must be in compliance with the requirements of OAR 409-070-0070.

(4) All copies of any financial statements or exhibits must be clear, easily readable and suitable for printing. Debits in credit categories and credits in debit categories must be designated so as to be clearly distinguishable as such. The notice and statements therein must be in clear, readable, English language and monetary values must be stated in United States currency. If any exhibit or other paper or document filed with the notice is in a foreign language, it must be accompanied by a translation into the English language. Any monetary value shown in a foreign currency must be converted into United States currency.

(5) A notice of material change transaction must include either complete and final executed copies of all the definitive agreements pursuant to which the transaction will be documented and closed, draft definitive agreements, or a term sheet. If a notice is filed on the basis of a term sheet, then:

(a) Unless extended in writing by the Authority, the parties must furnish the Authority with complete and final executed copies of all the definitive agreements pursuant to which the transaction will be documented and closed, or draft definitive agreements in lieu of complete and final executed copies, together with a detailed description of any respect in which the definitive agreements depart from the term sheet, no later than 15 days after the commencement of the preliminary review period. If the parties are unable to furnish complete and final executed copies of all definitive agreements or draft definitive agreements within this time period, then the Authority will either suspend the proposed transaction pursuant to ORS 415.501(10) or notify the entities that the running of the period for review of the notice will be tolled under OAR 409-070-0085 until the parties have furnished copies of such final executed definitive agreements or draft definitive agreements.

(b) To the extent that the definitive agreements materially deviate from the term sheet, the Authority may extend the review period and may withdraw or modify an order based on the term sheet.

(6) If the Authority considers a notice of material change transaction to be incomplete, the Authority must notify the parties of the information or clarification that is required.

(7) Any party that has filed a notice of material change transaction must promptly advise the Authority of any changes in the information so furnished on the notice arising subsequent to the date upon which the information was furnished but prior to disposition of the material change transaction by the Authority.

(8) The Authority may require that statements of revenue and revenue projections be presented in accordance with generally accepted accounting principles or statutory accounting principles, as applicable, and be prepared by a duly qualified and credentialed accounting expert.

(9) The Authority's review of the information provided in a notice of material change must be analyzed using the Analytic Framework, published on the Program website, with standards that:

(a) Are clear, fair, predictable, and consistent;

(b) Use measures of quality and access that can be meaningfully compared to current and past performance across Oregon and, if available, in other states; and

(c) Include equity analyses that stratify cost, quality, and access data by the characteristics specified in the definition of health equity to the greatest extent allowable by data availability.

(10) After submission, any party to a notice of material change transaction may rescind the notice at any time and for any reason. If the Authority has not commenced a preliminary review under OAR 409-070-0055, the fee paid in connection with the notice must be refunded. If the Authority has commenced a preliminary review under OAR 409-070-0055, the fee paid in connection with the notice shall not be refunded, and the parties shall remain obligated to reimburse the Authority for costs and expenses incurred prior to withdrawal in accordance with OAR 409-070-0050.

(11) A health care entity that is a party to an approved material change transaction must notify the Authority, in writing, of the completion of the transaction no more than one business day after the completion of the transaction.

(12) An approved material change transaction must become effective no later than 60 calendar days from the date the Authority issues its final order approving the proposed material change transaction.

(13) A party to an approved material change transaction must notify the Authority, in writing, within seven business days in the event a proposed transaction has failed or has been abandoned.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0050 Retention of Outside Advisors

(1) Pursuant to ORS 415.501(14), the Authority or the Department of Justice may retain at the expense of the parties to a material change transaction any actuaries, accountants, consultants, legal counsel and other advisors not otherwise a part of the Authority's staff as the Authority may reasonably need to assist the Authority in reviewing the proposed material change transaction. The Authority or the Department of Justice, as applicable, must require that the retained advisors:

(a) Are not subject to any conflict of interest associated with reviewing a given transaction; and

(b) Will protect any confidential information disclosed to them in the course of their review of the transaction. Material that is privileged or confidential and therefore exempt or determined by the Authority to be exempt from public disclosure under ORS 415.501(13)(b) may be shared with the retained advisors, and such disclosure shall not constitute a waiver of the privileged or confidential status of the material.

(2) The parties to a material change transaction must reimburse the Authority within 30 calendar days after receipt of an invoice from the Authority, for all reasonable and actual costs incurred by the Authority in connection with its review of the material change transaction. Such costs must include, but are not limited to, the costs and expenses of any advisors retained by the Authority or the Department of Justice pursuant to paragraph (1) of this rule, and other out-of-pocket costs but excluding any unallocated staff or interagency costs of the Authority. Invoices provided by the Authority pursuant to this paragraph (2) must contain a reasonably detailed summary of the costs incurred, provided that in no event must such invoices include any communications protected by the attorney-client or other applicable privilege. Failure to remit payment within 30 calendar days after receipt of an invoice from the Authority may result in additional actions pursuant to ORS 293.231.

(3) Any approval of a material change transaction may be conditioned on the parties reimbursing the Authority pursuant to paragraph (2) of this rule. The obligation of the parties to reimburse the Authority does not depend on whether the Authority approves the transaction. The obligation to reimburse is an obligation of the person filing the notice of material change transaction and any other parties to the transaction designated by the Authority.

(4) The Authority must notify applicants before any costs are incurred when a transaction review requires the use of outside advisors.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0055 Preliminary 30-Day Review of a Notice of Material Change Transaction

(1) Pursuant to ORS 415.501(5) and after receipt of a complete notice of material change transaction in accordance with OAR 409-070-0030(1)(a) and OAR 409-070-0045(5), the Authority must complete a preliminary review to determine whether the proposed material change transaction meets one or more of the criteria set forth in paragraph (2) of this rule. The Authority must, subject to OAR 409-070-0070, publish the notice of material change transaction. For the duration of the preliminary review period, the Authority must accept and publish public comments pertaining to the material change transaction.

(2) At the conclusion of the preliminary review described in paragraph (1) of this rule, the Authority must approve, or approve with conditions as provided in OAR 409-070-0065, a material change transaction, or, in the case of a material change transaction involving a domestic health insurer, recommend to the Department that the transaction be approved, if the Authority determines that the transaction meets one or more of the following criteria:

(a) The material change transaction is in the interest of consumers and is urgently necessary to maintain the solvency of an entity involved in the transaction;

(b) The material change transaction is unlikely to substantially reduce access to affordable health care in Oregon;

(d) The material change transaction is not likely to substantially alter the delivery of health care in Oregon; or

(e) Comprehensive review of the material change transaction is not warranted given the size and effects of the transaction.

(3) If after a preliminary review, the Authority does not approve or recommend for approval, as applicable, a material change transaction in accordance with this paragraph (2), the Authority must notify the parties and must thereafter conduct a comprehensive review pursuant to OAR 409-070-0060.

(4) Unless extended by agreement among the Authority and the parties to a proposed material change transaction, the Authority must complete the preliminary review described in paragraph (1) within 30 calendar days of the Authority's written confirmation of receipt of a complete notice of material change transaction or on the first business day thereafter if the 30th day is a weekend or state-recognized holiday. The Authority must notify the parties at the conclusion of the preliminary review period the results of the preliminary review. If the Authority fails to complete such preliminary review within 30 calendar days of the Authority's receipt of a complete notice of material change transaction, the proposed material change transaction must be subject to the comprehensive review procedure provided in OAR 409-070-0060.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0060 Comprehensive Review of a Notice of a Material Change Transaction

(1) Pursuant to ORS 415.501(7), the Authority must conduct a comprehensive review of a proposed transaction if the Authority determines not to approve the transaction at the conclusion of its preliminary review.

(2) The Authority must notify the entity that submitted the notice of material change transaction if a comprehensive review will occur and must notify the entity that submitted the notice of material change transaction the fee amount associated with the comprehensive review pursuant to OAR 409-070-0030. A party to the transaction must pay the fee amount in full no later than 30 calendar days after receipt of an invoice from the Authority.

(3) The Authority must issue proposed findings of fact and conclusion of law, along with the Authority's proposed order at the conclusion of its comprehensive review and must allow the parties and the public a reasonable opportunity to make written comments to the proposed findings and conclusions and the proposed order. If the comprehensive review includes a community review board, recommendations of the community review board must be in writing and appended to the proposed order. Unless otherwise directed by the Authority, written comments to the proposed findings and conclusions and the proposed order must be filed with the Authority within 30 calendar days following publication. The Authority must make any filed comments available to the public promptly following receipt.

(4) The Authority must consider the parties' and the public's written exceptions and issue a final order setting forth the Authority's findings and conclusions in respect of the proposed transaction. If the comprehensive review included a community review board, the Authority's findings and conclusions must include an explanation of the reasons why the Authority accepted, rejected or modified the recommendations of the community review board.

The final order must include any commitments by the health care entity to continue services currently provided by the health care entity. A party to the proposed transaction may contest the final order as provided in OAR 409-070-0075.

(5) Subject to any conditions prescribed under these rules, the Authority must approve a material change transaction that does not involve a domestic insurer, or in the case of a material change transaction involving a domestic health insurer, recommend to the Department that the transaction be approved, if pursuant to ORS 415.501(9), the Authority determines that the transaction satisfies (a) below and also satisfies either (b) or (c) below:

(a) There is no substantial likelihood that the transaction would:

(A) Have material anticompetitive effects in the region (such as significantly increased market concentration among providers when contracting with payers, carriers, or coordinated care organizations, or among carriers when establishing health benefit premiums that is likely to increase costs for consumers) not outweighed by benefits in increasing or maintaining services to underserved populations;

(B) Be contrary to law;

(D) Otherwise be hazardous or prejudicial to consumers or the public.

(b) The transaction will benefit the public good and communities by:

(A) Reducing the growth in patient costs in accordance with the health care cost growth targets established under ORS 442.386 or maintain a rate of cost growth that exceeds the target that the entity demonstrates is in the best interest of the public;

(B) Increasing access to services in medically underserved areas; or

(6) Unless extended by agreement among the Authority, the Department, as applicable, and the parties to the proposed transaction, the Authority must issue a proposed order, or in the case of a material change transaction involving a domestic health insurer, issue a recommendation to the Department, following its comprehensive review within 180 calendar days of the filing of a complete notice of material change transaction, subject to tolling or extension as provided in these rules. A transaction may be disapproved or suspended under ORS 415.501(10) if the parties do not agree to an extension of time necessary to accomplish a tribal consultation.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0062 Community Review Board

(1) The Authority may appoint and convene a community review board to participate in the comprehensive review of a material change transaction, pursuant to ORS 415.501(11). A community review board must:

(a) Advise the Authority on the impact of the transaction to the community; and

(b) Make recommendations to the Authority on the approval or disapproval of a transaction, or the approval of a transaction subject to certain conditions.

(2) In determining whether to convene a community review board, the Authority must consider the potential impacts of the proposed transaction, including, but not limited to:

(a) The potential loss or change in access to essential services.

(b) The potential to impact a large number of residents in this state.

(3) A community review board must consist of at least three individuals. This community review board must include members of the affected community, including persons who represent populations that experience health disparities, consumer advocates and health care experts. Not more than one-third of the members of the community review board may be representatives of institutional or corporate providers. The Authority may not appoint to a community review board an individual who is employed by an entity that is a party to the transaction that is under review or is employed by a competitor that is of a similar size to an entity that is a party to the transaction. As part of the community review board appointment process, the Authority will notify the coordinated care organization staff who facilitate the community advisory council, as defined in ORS 414.575, representing the affected community.

(4) Community review board members must declare any potential or actual conflict of interest by filing a notice, pursuant to ORS 415.501(11)(b). A notice of conflict of interest for an appointed community review board member will be made public. If the Authority determines that a member of the community review board has an actual conflict of interest, the member must abstain from participating in community review board actions related to the conflict of interest. A conflict of interest exists when a community review board member:

(a) Has a financial stake in an entity that is a party to the transaction under review; or

(b) Has governance or decision-making authority for an entity that is a party to the transaction under review.

(5) As defined by ORS 292.495(4), qualified community review board members must receive per diem compensation and reimbursement of travel or other expenses related to the performance of community review board member’s official duties as determined by the Authority.

(a) Per diem compensation must be equal to the per diem paid to members of the Legislative Assembly under ORS 171.072, for each full or partial day during which the qualified member is engaged in the performance of official duties.

(b) Reimbursement of actual and necessary travel or other expenses incurred in the performance of a qualified member’s official duties must be in the manner and amount provided in ORS 292.495.

(c) A qualified member of a community review board may decline to accept compensation or reimbursement of expenses related to the qualified member’s service on a community review board.

(d) To be considered a qualified member, a member of a community review board must attest by signature that they meet the conditions and income limits specified in ORS 292.495(4).

(e) Non-qualified members of a community review board must be reimbursed for actual and necessary travel and other expenses incurred in the performance of their official duties in the manner and amount provided in ORS 292.495.

(6) A community review board must make written recommendations to the Authority on a proposed transaction based on the criteria listed in section (1) of this rule.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, adopt filed 12/08/2022, effective 12/08/2022

Or. Admin. R. 409-070-0065 Conditional Approval; Suspension of Proposed Material Change Transaction

(1) Following completion of a preliminary review pursuant to OAR 409-070-0055 or a comprehensive review pursuant to OAR 409-070-0060, which may include the appointment of a community review board pursuant to OAR 409-070-0062, the Authority may approve, or recommend for approval, a material change transaction with conditions designed to further the purposes and goals described in OAR 409-070-0000.

(2) If the Authority approves a material change transaction with conditions as set forth in paragraph (1) of this rule, the Authority may suspend, or in the case of transaction involving a domestic insurer recommend that the Department suspend, the effective date of the transaction for such reasonable time as necessary to conduct an examination and complete an analysis of whether the conditions have been satisfied.

(3) The Authority may impose civil penalties against an entity for each failure to comply with a condition that is not resolved within 30 calendar days of written notification. If an entity does not come into compliance within 30 calendar days of written notification, penalties will be assessed in accordance with OAR 409-070-0067.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0067 Violations and Civil Penalties

(1) Pursuant to ORS 415.900, the Authority adopts the following schedule of civil penalties:

(a) For violations of OAR 409-070-0010 and 409-070-0015: Up to $10,000 per offense when an entity fails to submit a material change transaction that was subject to review.

(b) For violations of OAR 409-070-0080:

(A) Up to $10,000 per offense when an entity fails to timely respond to a clarifying question or information request from the Authority.

(B) Up to $10,000 per offense when an entity fails to comply with a condition as specified in the Order.

(A) Up to $10,000 per offense when an entity fails to timely respond to a clarifying question or information request from the Authority.

(B) Up to $10,000 per offense when an entity fails to provide requested documentation.

(d) Up to $10,000 per offense when an entity fails to timely respond to a clarifying questions or information request from the authority in violation of OAR 409-070-0085.

(2) If an entity has made documented efforts to comply with these rules, the Authority may consider this a mitigating factor before imposing civil penalties against the entity.

(3) Every violation of an order, rule or regulation is a separate offense subject to a separate civil penalty.

(4) The provisions of this section are in addition to and not in lieu of any other enforcement provisions imposed by law.

(5) Civil penalties under this section shall be imposed and enforced in accordance with ORS 183.745.

(6) Pursuant to ORS 514.501(22), the director of the Authority may apply to the Circuit Court for Marion County for an order enjoining the person, and any director, officer, employee or agent of the person, from the violation, and for other such equitable relief as the nature of the case and the interest of the public may require.

(7) Moneys received by the Authority under this section shall be paid to the State Treasury and credited to the General Fund.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, adopt filed 06/29/2026, effective 07/01/2026

Or. Admin. R. 409-070-0070 Confidentiality; Permitted Disclosures

(1) An applicant for review of a material change transaction may designate portions of a notice and any documents thereafter submitted by the applicant in support of the notice as confidential. Any portion or portions of a notice of material change transaction designated as confidential must be provided separately as one or more attachments. The entities must not include any confidential information in the notice of material change transaction form itself.

(2) Entities submitting forms, documents, materials, or other information, including an optional application for determination of covered transaction status under OAR 409-070-0042 or a request for emergency exemption under OAR 409-070-0022 must file two versions of the submitted documents. One must be marked as "CONFIDENTIAL" and must contain the full unredacted version of the notice or supporting materials and must be maintained as such by the Authority and the Department. The second must be marked as "PUBLIC" and must contain a redacted version of the notice or supporting materials (from which the confidential portions have been removed or obscured) and must be made available to the public by the Authority. An applicant claiming confidentiality in respect of portions of a notice, or any documents thereafter submitted by the applicant in support of the notice, must include a redaction log, which the Authority will publish, that provides a reasonably detailed statement of the grounds on which confidentiality is claimed, citing the applicable statutory basis for confidentiality of each portion.

(3) The Authority will, in collaboration with the Oregon Department of Justice, review all claims of confidentiality. The Authority or the Oregon Department of Justice may require additional information from an entity to justify their claims of confidentiality. An applicant must timely respond to all inquiries and requests for additional information received by either the Authority or the Oregon Department of Justice.

(4) The failure of an applicant to adequately justify grounds for confidentiality as required in section (1) and timely respond to correspondence from the Authority or the Oregon Department of Justice related to such claim of confidentiality as required in section (3) may result in a denial of the Authority accepting such confidentiality claims. In the event of such an occurrence, the Authority will provide a minimum of five business days advance notification to the Applicant prior to public release.

(5) Confidential materials filed by an applicant in connection with a transaction that is subject to review by each of the Authority and the Department must be maintained as confidential materials in accordance with paragraph (1) of this rule, ORS 415.501(13)(c) and ORS 705.137.

(6) Confidential materials filed by an applicant in connection with a transaction that is subject to review by the Authority under these rules and under the Authority’s CCO Acquisitions and Mergers in OAR 410-141-5255, et seq., must be maintained as confidential materials in accordance with paragraph (1) of this rule and ORS 415.501(13)(c).

(7) The Authority may authorize sharing a confidential document, material or other information as appropriate among the administrative divisions and staff offices of the Authority for the purpose of administering and enforcing the program.

(8) Disclosing or sharing a document, material or other information to the Authority under this rule does not waive an applicable privilege or claim of confidentiality in the document, material or other information.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0075 Contested Case Hearings

(1) Contested case hearings must be conducted pursuant to ORS 183.411 through ORS 183.497 and the Attorney General's Uniform and Model Rules of Procedure for the Office of Administrative Hearings, OAR 137-003-0501 through OAR 137-003-0700, and the provisions of this rule.

(2) A party to a material change transaction that wishes to contest a final order issued by the Authority that fully resolves the notice of material change transaction must request a contested case hearing within 15 calendar days from the date of service of the final order and a notice of right to a hearing.

(3) An applicant for emergency exemption under OAR 409-070-0022 or a disclaimer under OAR 409-070-0025 that wishes to contest a determination issued by the Authority must request a contested case hearing within 15 calendar days from the date of service of the determination and a notice of right to a hearing.

(4) The person or entity to which a civil penalty imposed under OAR 409-070-0067 is addressed will have 20 calendar days from the date of service of the Notice to request a contested case hearing.

(a) If the person or entity fails to request a hearing within the time specified in the Notice, the Authority will issue an Order assessing a civil penalty.

(b) If the Order is not appealed, the amount of penalty is payable within 10 calendar days after the Order is entered.

(c) If the Order is appealed and is sustained, the amount of the penalty is payable within 10 calendar days after the court decision.

(d) The Order, if not appealed or sustained on appeal, will constitute a judgment and may be filed in accordance with the provisions of ORS 18.005 to 18.428. Execution may be issued upon the order in the same manner as execution upon a judgment of a court of record.

(5) All requests for a contested case hearing shall be in writing and submitted to the Authority as provided in the Notice or Final Order. If the written request for a contested case hearing is not received by the required deadline, the Authority will issue a final order.

(6) The Authority's determination:

(a) Not to approve a transaction at the conclusion of the preliminary review period pursuant to OAR 409-070-0055; and

(b) That a transaction is a covered transaction following application under OAR 409-070-0042 shall, in each case, be interlocutory and shall not be reviewable prior to the issuance of the final order that fully resolves the notice of material change transaction.

(7) The issues to be considered in a contested case conducted pursuant to this rule shall be limited in scope to the facts and conclusions contained in the final order or determination.

(8) In a contested case conducted pursuant to this rule, the party requesting the contested case hearing shall have the burden of proof.

(9) In a contested case conducted pursuant to this rule, an administrative law judge assigned by the Office of Administrative Hearings shall serve a proposed order on all parties and the Authority, unless prior to the hearing the Authority notifies the administrative law judge that a final order may be served, within 30 calendar days of the close of the evidentiary record in the contested case.

(10) The Authority must issue a final order within 30 days of receipt of the proposed order, which may adopt some or all of the proposed order, as the Authority must determine in its sole discretion. The final order is effective immediately upon being signed or as otherwise provided in the order.

(11) The time limits established in paragraphs (7) and (8) of this rule may be waived or shortened by agreement among the parties and the Authority.

(12) All contested case hearing decisions are subject to judicial review under ORS 183.482 in the Court of Appeals.

(13) In cases where the decision is to be made by the Department, contested case hearings for a domestic insurer shall be conducted by the Department in accordance with ORS 732.526.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.019 & 415.500-415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0080 Compliance with Conditions

(1) Following approval of a material change transaction, the Authority will verify compliance with any conditions that the Authority included in its approval of the transaction and issue such additional orders, following notice and opportunity for hearing, as may be necessary to enforce compliance with the terms and conditions of the approval of the transaction; provided however, that the Authority may not impose new conditions that are unrelated to, or not reasonably required to enforce compliance with, those conditions, if any, that were included in the Authority's approval of the transaction. Such verification of compliance must occur, at minimum, at the intervals required by ORS 415.501(19).

(2) The Authority may require that the parties provide such information, reports, analyses and documentation as the Authority may require in order to verify compliance with conditions.

(3) The entity or entities must provide all requested information in accordance with OAR 409-070-0070 and may not refuse to provide requested information. Failure to comply with or timely respond to a clarifying question or information request from the Authority may result in the imposition of civil penalties pursuant to OAR 409-070-0067.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 413.037, 415.013, 415.103 & 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022

Or. Admin. R. 409-070-0082 Follow-up Analyses After the Material Change Transaction

(1) Following approval of a material change transaction, the Authority must conduct follow-up analyses one year, two years, and five years after the material change transaction is completed, in accordance with ORS 501.501(19).

(2) The Authority may require that the parties provide such information, reports, analyses and documentation as the Authority may require in order to monitor and assess the impacts and effects of the material change transaction as required in ORS 415.501(19), including specifically, but without limitation, the effects and status of the material change transaction under OAR 409-070-0065 and OAR 409-070-0060(5).

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, adopt filed 12/13/2024, effective 12/16/2024

Or. Admin. R. 409-070-0085 Information Requests

The Authority may request additional information, or clarification of submitted information, from parties to proceed with its review of a material change transaction under these rules. The Authority must notify the parties of the information or clarification that is required to be submitted to the Authority, and the parties must timely reply to such requests. The running of the period for review of the material change transaction will be tolled upon such notification and will resume when the Authority deems the information request to be complete. Failure to comply with or timely respond to a clarifying question or information request from the Authority may result in the imposition of civil penalties pursuant to OAR 409-070-0067.

History

Statutory/Other Authority: ORS 415.501
Statutes/Other Implemented: ORS 415.500 - 415.900
OHP 4-2026, amend filed 06/29/2026, effective 07/01/2026
OHP 6-2024, amend filed 12/13/2024, effective 12/16/2024
OHP 10-2022, amend filed 12/08/2022, effective 12/08/2022
OHP 1-2022, adopt filed 02/22/2022, effective 03/01/2022