Oregon Revised Statutes
As used in this section: “Attachment point” means the threshold dollar amount, adopted by the Oregon Health Authority by rule, for costs incurred by a coordinated care organization in a calendar year for a member, after which threshold the costs are eligible for state reinsurance payments. “Coinsurance rate” means the rate, adopted by the authority by rule…
(Regulation of Financial Solvency)
The Oregon Health Authority may adopt rules to carry out the provisions of ORS 415.012 to 415.430. The authority shall adopt rules for regulating the financial solvency of coordinated care organizations that align with the following provisions of the Insurance Code regulating domestic insurers, to the extent the provisions regarding insurers are applicable …
As used in ORS 415.012 to 415.430: “Coordinated care organization” has the meaning given that term in ORS 414.025. “Medical assistance program” means the Oregon Integrated and Coordinated Health Care Delivery System established in ORS 414.570.
The Oregon Health Authority shall enforce the provisions of ORS 415.012 to 415.430 and 415.501 and rules adopted pursuant to ORS 415.011, 415.012 to 415.430 and 415.501 for the public good. The authority has the powers and authority expressly conferred by or reasonably implied from the provisions of ORS 415.012 to 415.430 and 415.501 and rules adopted pursu…
An officer or employee of the Oregon Health Authority who is delegated responsibilities in the enforcement of ORS 415.012 to 415.430 or rules adopted pursuant to ORS 415.011 may not: Be a director, officer or employee of or be financially interested in any coordinated care organization, except as a member of a coordinated care organization or by reason of r…
The Oregon Health Authority shall hold a contested case hearing upon written request for a hearing by a person aggrieved by any act, threatened act or failure of the authority to act under ORS 415.012 to 415.430 or 415.501 or rules adopted pursuant to ORS 415.011, 415.012 to 415.430 or 415.501. The provisions of ORS chapter 183 govern the hearing procedures…
(Confidential Reports)
A complaint made to the Oregon Health Authority against a coordinated care organization for a violation of ORS 415.012 to 415.430 or rules adopted pursuant to ORS 415.011, and the record of the complaint, is confidential and may not be disclosed except as provided in ORS 413.175 or 414.607. The complaint, and the record of the complaint, may not be used in a…
The Oregon Health Authority may disclose or use a report as considered necessary by the authority in the administration of ORS 415.012 to 415.430, rules adopted pursuant to ORS 415.011 or other law. A report filed with the authority according to requirements established by rule for disclosure of material acquisitions or dispositions of assets is confidentia…
The Oregon Health Authority may use reports and financial plans of action that are made confidential under ORS 415.056 only for the purpose of monitoring the solvency of coordinated care organizations and the need for possible corrective action with respect to coordinated care organizations. The authority may not use reports and financial plans of action re…
(Compliance Audit Documents)
As used in ORS 415.061 to 415.067: “Compliance audit” means a voluntary internal evaluation, review, assessment, audit or investigation that is undertaken to identify or prevent noncompliance with, or promote compliance with, laws, regulations, orders or professional standards, and that is conducted by or on behalf of a coordinated care organization. “Comp…
Except as provided in ORS 415.061 to 415.067: A compliance self-evaluative audit document is privileged information and is not discoverable or admissible as evidence in any civil, criminal or administrative proceeding. Any person who performs or directs the performance of an compliance audit, any officer, employee or agent of a coordinated care organizatio…
ORS 415.062 does not prohibit the Oregon Health Authority from acquiring any compliance self-evaluative audit document or examining any person in connection with the document. If the authority determines that the actions of a coordinated care organization are egregious, the authority may introduce and use the document in any administrative proceeding or civi…
The privilege set forth in ORS 415.062 does not apply to the extent that the privilege is expressly waived by the coordinated care organization that prepared or caused to be prepared the compliance self-evaluative audit document. The privilege set forth in ORS 415.062 does not apply in any civil, criminal or administrative proceeding commenced by the Attorn…
Within 30 days after a district attorney or the Attorney General serves on a coordinated care organization a written request by certified mail for disclosure of a compliance self-evaluative audit document, the coordinated care organization that prepared or caused the document to be prepared may file in circuit court a petition requesting an in camera hearing…
The privilege established under ORS 415.062 does not apply to any of the following: Documents, communications, data, reports or other information expressly required to be collected, developed, maintained or reported to the Oregon Health Authority or other regulatory agency under ORS 415.012 to 415.430, rules adopted pursuant to ORS 415.011 or other state or…
Nothing in ORS 415.061 to 415.067, or in the release of any compliance self-evaluative audit document under ORS 415.061 to 415.067, shall limit, waive or abrogate the scope or nature of any statutory or common law privilege or other limitation on admissibility of evidence including, but not limited to, the work product doctrine, the lawyer-client privilege u…
(Investigations and Examinations)
The Oregon Health Authority may request information from any coordinated care organization or its officers in relation to the activities or condition of the coordinated care organization or any other matter connected with a coordinated care organization’s transactions, and the person of whom the information is requested shall promptly and truthfully reply us…
A person may not file or cause to be filed with the Oregon Health Authority any article, certificate, report, statement, application or other information required or permitted to be filed under ORS 415.012 to 415.430 or 415.501 or rules adopted pursuant to ORS 415.011, 415.012 to 415.430 or 415.501 that is known by the person to be false or misleading in any…
The Oregon Health Authority, whenever the authority deems it advisable in the interest of members of a coordinated care organization or for the public good, shall investigate into the affairs of: A coordinated care organization; A person proposing to form a coordinated care organization; or A person holding the capital stock, membership or other ownership…
The Oregon Health Authority shall examine every coordinated care organization, including an audit of the financial affairs of the coordinated care organization, as often as the authority determines an examination to be necessary but at least once every five years. An examination shall be conducted for the purpose of determining the financial condition of the…
When the Oregon Health Authority determines that an examination should be conducted, the authority shall appoint one or more examiners to perform the examination and instruct them as to the scope of the examination. The authority may prescribe the examiner handbook and employ other guidelines and procedures that the authority determines to be appropriate. T…
Not later than the 60th day after an examination is completed, the examiner in charge of the examination shall submit to the Oregon Health Authority a full and true report of the examination, verified by the oath of the examiner. The report shall comprise only facts appearing upon the books, papers, records, accounts, documents or computers and other recordi…
A coordinated care organization shall have an annual audit conducted by an independent certified public accountant and shall file an audited financial report annually with the Oregon Health Authority by June 30 following the end of the period to which the report applies. The annual audited financial report shall disclose: The financial position of the coord…
Except in the case of malfeasance in office or willful or wanton neglect of duty, a cause of action does not arise and liability may not be imposed against the Oregon Health Authority, an authorized representative of the authority or any examiner appointed by the authority for: Any statements made or conduct performed in good faith pursuant to an examinatio…
(Supervision of Coordinated Care Organization)
Whenever the Oregon Health Authority determines from any showing or statement made to the authority from any examination made by the authority that the assets of a coordinated care organization are less than its liabilities plus required capitalization, the authority may: Proceed immediately to petition for an order of rehabilitation or liquidation or to co…
For any reason stated in subsection (2) of this section, the Oregon Health Authority may order a coordinated care organization to be placed under supervision. The authority may place a coordinated care organization under supervision if upon examination or at any other time the authority determines that: The condition of the coordinated care organization re…
A coordinated care organization placed under supervision must correct, eliminate or remedy the acts, transactions or practices that are the basis for the order of supervision and otherwise comply with the requirements of the Oregon Health Authority within the period of time allowed by the authority, not to exceed 60 days, after the date on which the order is…
The circuit court shall have original jurisdiction of delinquency proceedings, and any court with jurisdiction is authorized to make all necessary or proper orders to carry out the purposes of ORS 415.203 to 415.430. The venue of delinquency proceedings and proceedings under ORS 415.203 to 415.430 against a coordinated care organization shall be in the Circ…
Delinquency proceedings constitute the sole and exclusive method of rehabilitating, liquidating or conserving a coordinated care organization, and a court may not entertain a petition for the commencement of such proceedings, or any other similar procedure, unless the Oregon Health Authority has filed such a petition in the name of the state. A coordinated …
Notwithstanding ORS 37.040, the Oregon Receivership Code does not apply to delinquency proceedings under ORS 415.203 to 415.430.
The Oregon Health Authority shall commence a delinquency proceeding by an application to the court for an order directing the coordinated care organization to show cause why the authority should not have the relief prayed for. The application shall be by petition, verified by the authority, setting forth the ground or grounds for the proceeding and the reli…
An officer, manager, member of the governing board, trustee, owner, employee or agent of a coordinated care organization, and any other person with authority over or in charge of any portion of the coordinated care organization’s affairs, including any person who exercises control directly or indirectly over the activities of the coordinated care organizatio…
Upon application by the Oregon Health Authority for an order to show cause under ORS 415.261, or at any time thereafter, the court may, without notice, issue an injunction restraining a coordinated care organization, its officers, members of its governing board, agents, employees and all other persons from the transaction of its business or the waste or disp…
The Oregon Health Authority may petition the circuit court for an order: Directing the authority to rehabilitate a coordinated care organization on one or more of the following grounds: The coordinated care organization is impaired. The coordinated care organization has failed to submit its books, papers, accounts or affairs for the reasonable inspection …
Upon petition by the Oregon Health Authority under ORS 415.280, the court may issue the requested order immediately, ex parte and without hearing. The court in its order shall specify the duration of the order. The duration of an order shall be a period sufficient to enable the authority to ascertain the condition of the coordinated care organization. On mo…
The Oregon Health Authority, in connection with supervising a coordinated care organization or conducting a delinquency proceeding, may appoint one or more special deputy directors to act for the authority and may employ counsel, clerks and assistants as the authority deems necessary. Unless otherwise provided by the authority, a person so appointed is not a…
An order to rehabilitate a coordinated care organization shall direct the Oregon Health Authority to take possession of the property of the coordinated care organization and to conduct the business of the coordinated care organization, and to take such steps toward removing the causes and conditions that made rehabilitation necessary as directed by the court…
The Oregon Health Authority may apply for an order directing the authority to liquidate the business of a coordinated care organization, regardless of whether there has been a prior order directing the authority to rehabilitate the coordinated care organization, upon any of the grounds specified in ORS 415.280, or if the coordinated care organization: Has c…
The Oregon Health Authority, after taking possession of the property and business of any coordinated care organization, shall: Subject to a court’s direction, immediately conduct the business of the coordinated care organization or take steps authorized by law to rehabilitate, liquidate or conserve the coordinated care organization; Be vested with the coor…
An order to liquidate the business of a coordinated care organization shall direct the Oregon Health Authority to: Take possession of the property of the coordinated care organization; Liquidate the business of the coordinated care organization; Deal with the coordinated care organization’s property and business in the name of the authority or in the name…
Whenever a receiver is to be appointed in delinquency proceedings for a coordinated care organization, the court shall appoint the Oregon Health Authority as the receiver. The court shall direct the receiver to take possession of the property of the coordinated care organization and to administer the property as ordered by the court. Any deed or other instr…
The following persons are entitled to protection under this section: All receivers responsible for the conduct of a delinquency proceeding under ORS 415.203 to 415.430, including present and former receivers. All employees of the receiver described in paragraph (a) of this subsection. For purposes of this section, such employees include all present and for…
The rights and liabilities of the coordinated care organization, its creditors and all other persons interested in its assets shall, unless otherwise directed by the court, be fixed as of the date on which an order directing the liquidation of the coordinated care organization is filed in the office of the clerk of the court that made the order, subject to t…
A court may make an order declaring a coordinated care organization insolvent at the time it grants an order of liquidation or at any time during the liquidation proceedings. When the order is issued, the Oregon Health Authority shall provide notice, in the manner determined by the court, to all persons who may have claims against the coordinated care organi…
All claims against a coordinated care organization against which delinquency proceedings have been begun shall: Set forth in reasonable detail: The amount of the claim or the basis upon which the amount can be ascertained; The facts upon which the claim is based; and The priorities asserted, if any; Be verified by the affidavit of the claimant or someon…
Except as provided in ORS 415.406 for secured claims, the claims to be paid in full in delinquency proceedings against a coordinated care organization prior to the payment of any other claims, and the order of payment, shall be: The expenses of administering the delinquency proceedings; Claims that are legally due and owing by the coordinated care organiza…
All claims that are preferred under the laws of the state, whether owing to residents or nonresidents, shall be given equal priority of payment from the general assets of a coordinated care organization in a delinquency proceeding against the coordinated care organization regardless of where the assets are located.
A contingent claim against a coordinated care organization shall be filed, presented and reported in the same manner and within the same time limitations as provided in ORS 415.400 for a noncontingent claim. Contingent claims shall be allowed to share in a distribution of assets in the same manner as noncontingent claims of the same class and priority, provi…
The owners of special deposit claims against a coordinated care organization for which a receiver is appointed shall be given priority against their several special deposits in accordance with the provisions of the statutes governing the creation and maintenance of the deposits. If there is a deficiency in any deposit so that claims secured by the deposit ar…
The owner of a secured claim against a coordinated care organization for which a receiver has been appointed may surrender the security and file a claim as a general creditor, or the claim may be discharged by resort to the security, in which case the deficiency, if any, shall be treated as a claim against the general assets of the coordinated care organizat…
During the pendency of a delinquency proceeding against a coordinated care organization, an action or proceeding to obtain an attachment, garnishment or execution may not be commenced or maintained in the courts of this state against the delinquent coordinated care organization or its assets. An attachment, garnishment or execution obtained prior to the comm…
A transfer of or lien upon the property of a coordinated care organization, other than as provided in ORS 415.420, is voidable if the transfer or lien is: Made or created within four months prior to the commencement of a delinquency proceeding; Made with the intent of giving to a transferee or lienor or enabling the transferee or lienor to obtain a greater…
Offsets may not be allowed in cases of mutual debts or mutual credits between the coordinated care organization and another person in connection with a delinquency proceeding, except with respect to reinsurance.
For the purpose of this section only, and only in the event of a finding of impairment by the Oregon Health Authority, as described in ORS 415.203, or of a final order of liquidation, any covered health care service furnished within this state by a provider to a member of a coordinated care organization shall be considered to have been furnished pursuant to …
As used in this section and ORS 415.501 and 415.505: “Corporate affiliation” has the meaning prescribed by the Oregon Health Authority by rule, including: Any relationship between two organizations that reflects, directly or indirectly, a partial or complete controlling interest or partial or complete corporate control; and Transactions that merge tax ide…
The purpose of this section is to promote the public interest and to advance the goals set forth in ORS 414.018 and the goals of the Oregon Integrated and Coordinated Health Care Delivery System described in ORS 414.570. In accordance with subsection (1) of this section, the Oregon Health Authority shall adopt by rule criteria approved by the Oregon Health …
An officer or employee of the Oregon Health Authority who is delegated responsibilities in the enforcement of ORS 415.501 or rules adopted pursuant to ORS 415.501 may not: Be a director, officer or employee of or be financially interested in an entity that is a party to a proposed material change transaction except as an enrollee or patient of a health care…
Every four years, the Oregon Health Authority shall commission a study of the impact of health care consolidation in this state. The study must review consolidation occurring during the previous four-year period and include an analysis of: The impact on costs to consumers for health care either to the benefit or the detriment of consumers; and Any increase…
The Oregon Health Authority shall prescribe by rule a fee to be paid under ORS 415.501 (3), proportionate to the size of the parties to the transaction, sufficient to reimburse the costs of administering ORS 415.501. Moneys received by the authority under this section shall be deposited to the Oregon Health Authority Fund established in ORS 413.101 to be us…
In addition to any other penalty imposed by law, the Director of the Oregon Health Authority may impose a civil penalty, as determined by the director, for a violation of ORS 413.037 or 415.501. The amount of the civil penalty may not exceed $10,000 for each offense. The civil penalty imposed on an individual health professional may not exceed $1,000 for eac…
_______________