Oregon Statutes 414.631 – Mandatory enrollment in coordinated care organization; exemptions
(1) Except as provided in subsections (2), (3), (4) and (5) of this section and ORS § 414.632 (2), a person who is eligible for or receiving health services must be enrolled in a coordinated care organization to receive the health services for which the person is eligible. For purposes of this subsection, Medicaid-funded long term care services do not constitute health services.
Terms Used In Oregon Statutes 414.631
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Coordinated care organization: means an organization meeting criteria adopted by the Oregon Health Authority under ORS § 414. See Oregon Statutes 414.025
- Health services: means at least so much of each of the following as are funded by the Legislative Assembly based upon the prioritized list of health services compiled by the Health Evidence Review Commission under ORS § 414. See Oregon Statutes 414.025
- Person: includes individuals, corporations, associations, firms, partnerships, limited liability companies and joint stock companies. See Oregon Statutes 174.100
- Prepaid managed care health services organization: means a managed dental care, mental health or chemical dependency organization that contracts with the authority under ORS § 414. See Oregon Statutes 414.025
- United States: includes territories, outlying possessions and the District of Columbia. See Oregon Statutes 174.100
(2) Subsections (1) and (4) of this section do not apply to:
(a) A person who is a noncitizen and who is eligible only for labor and delivery services and emergency treatment services;
(b) A person who is an American Indian and Alaska Native beneficiary;
(c) An individual described in ORS § 414.632 (2) who is dually eligible for Medicare and Medicaid and enrolled in a program of all-inclusive care for the elderly; and
(d) A person whom the Oregon Health Authority may by rule exempt from the mandatory enrollment requirement of subsection (1) of this section, including but not limited to:
(A) A person who is also eligible for Medicare;
(B) A woman in her third trimester of pregnancy at the time of enrollment;
(C) A person under 19 years of age who has been placed in adoptive or foster care out of state;
(D) A person under 18 years of age who is medically fragile and who has special health care needs;
(E) A person receiving services under the Medically Involved Home-Care Program created by ORS § 417.345 (1); and
(F) A person with major medical coverage.
(3) Subsection (1) of this section does not apply to a person who resides in an area that is not served by a coordinated care organization or where the organization’s provider network is inadequate.
(4) In any area that is not served by a coordinated care organization but is served by a prepaid managed care health services organization, a person must enroll with the prepaid managed care health services organization to receive any of the health services offered by the prepaid managed care health services organization.
(5) As used in this section, ‘American Indian and Alaska Native beneficiary’ means:
(a) A member of a federally recognized Indian tribe;
(b) An individual who resides in an urban center and:
(A) Is a member of a tribe, band or other organized group of Indians, including those tribes, bands or groups whose recognition was terminated since 1940 and those recognized now or in the future by the state in which the member resides, or who is a descendant in the first or second degree of such a member;
(B) Is an Eskimo or Aleut or other Alaska Native; or
(C) Is determined to be an Indian under regulations promulgated by the United States Secretary of the Interior;
(c) A person who is considered by the United States Secretary of the Interior to be an Indian for any purpose; or
(d) An individual who is considered by the United States Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut or other Alaska Native. [Formerly 414.737; 2021 c.97 § 41]