Oregon Statutes 414.065 – Determination of health care and services covered; quality measures; reimbursement; cost sharing; payments by Oregon Health Authority as payment in full; rules
(1)(a) With respect to health care and services to be provided in medical assistance during any period, the Oregon Health Authority shall determine, subject to such revisions as it may make from time to time and subject to legislative funding and paragraph (b) of this subsection:
Terms Used In Oregon Statutes 414.065
- Coordinated care organization: means an organization meeting criteria adopted by the Oregon Health Authority under ORS § 414. See Oregon Statutes 414.025
- Global budget: means a total amount established prospectively by the Oregon Health Authority to be paid to a coordinated care organization for the delivery of, management of, access to and quality of the health care delivered to members of the coordinated care organization. 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
- Medical assistance: includes any care or services for any individual who is a patient in a medical institution or any care or services for any individual who has attained 65 years of age or is under 22 years of age, and who is a patient in a private or public institution for mental diseases. See Oregon Statutes 414.025
- Person: includes individuals, corporations, associations, firms, partnerships, limited liability companies and joint stock companies. See Oregon Statutes 174.100
(A) The types and extent of health care and services to be provided to each eligible group of recipients of medical assistance.
(B) Standards, including outcome and quality measures, to be observed in the provision of health care and services.
(C) The number of days of health care and services toward the cost of which medical assistance funds will be expended in the care of any person.
(D) Reasonable fees, charges, daily rates and global payments for meeting the costs of providing health services to an applicant or recipient.
(E) Reasonable fees for professional medical and dental services which may be based on usual and customary fees in the locality for similar services.
(F) The amount and application of any copayment or other similar cost-sharing payment that the authority may require a recipient to pay toward the cost of health care or services.
(b) The authority shall adopt rules establishing timelines for payment of health services under paragraph (a) of this subsection.
(2) The types and extent of health care and services and the amounts to be paid in meeting the costs thereof, as determined and fixed by the authority and within the limits of funds available therefor, shall be the total available for medical assistance and payments for such medical assistance shall be the total amounts from medical assistance funds available to providers of health care and services in meeting the costs thereof.
(3) Except for payments under a cost-sharing plan, payments made by the authority for medical assistance shall constitute payment in full for all health care and services for which such payments of medical assistance were made.
(4) Notwithstanding subsections (1) and (2) of this section, the Department of Human Services shall be responsible for determining the payment for Medicaid-funded long term care services and for contracting with the providers of long term care services.
(5) In determining a global budget for a coordinated care organization:
(a) The allocation of the payment, the risk and any cost savings shall be determined by the governing body of the organization;
(b) The authority shall consider the community health assessment conducted by the organization in accordance with ORS § 414.577 and reviewed annually, and the organization’s health care costs; and
(c) The authority shall take into account the organization’s provision of innovative, nontraditional health services.
(6) Under the supervision of the Governor, the authority may work with the Centers for Medicare and Medicaid Services to develop, in addition to global budgets, payment streams:
(a) To support improved delivery of health care to recipients of medical assistance; and
(b) That are funded by coordinated care organizations, counties or other entities other than the state whose contributions qualify for federal matching funds under Title XIX or XXI of the Social Security Act. [1965 c.556 § 5; 1967 c.502 § 12; 1975 c.509 § 5; 1981 c.825 § 4; 1987 c.918 § 4; 1989 c.836 § 21; 1991 c.66 § 13; 1991 c.753 § 3; 1995 c.271 § 1; 1995 c.807 § 3; 1999 c.546 § 1; 2001 c.875 § 1; 2005 c.381 § 14; 2005 c.806 § 1; 2009 c.595 § 276; 2011 c.602 § 22; 2012 c.8 § 19; 2013 c.534 § 1; 2013 c.688 § 70; 2019 c.529 § 5]