Oregon Revised Statutes Chapter 414 § 414.065 — Determination of health services covered; quality measures; reimbursement; cost

Determination of health services covered; quality measures; reimbursement; cost sharing; payments by Oregon Health Authority as payment in full; rules. (1)(a) Consistent with ORS 414.690, 414.710, 414.712 and 414.766 and other statutes governing the provision of and payments for health services in medical assistance, the Oregon Health Authority shall determine, subject to such revisions as it may make from time to time and to legislative funding: (A) The types and extent of health 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 services. (C) The number of days of health 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 services. (b) The authority shall adopt rules establishing timelines for payment of health services under paragraph (a) of this subsection. (2) In making the determinations under subsection (1) of this section and in the imposition of any utilization controls on access to health services, the authority may not consider a quality of life in general measure, either directly or by considering a source that relies on a quality of life in general measure. (3) The types and extent of health 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 services in meeting the costs thereof. (4) Except for payments under a cost-sharing plan, payments made by the authority for medical assistance shall constitute payment in full for all health services for which such payments of medical assistance were made. (5) Notwithstanding subsection (1) 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. (6) 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. (7) 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; 2024 c.18 §1]