ORS 415.001
Reinsurance program for coordinated care organizations (CCOs)
(1)
As used in this section:(a)
“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.(b)
“Coinsurance rate” means the rate, adopted by the authority by rule, at which the authority will reimburse a coordinated care organization for costs incurred by the coordinated care organization in a calendar year after the attachment point and before the reinsurance cap.(c)
“Reinsurance” has the meaning given that term in ORS 731.126 (“Reinsurance.”).(d)
“Reinsurance cap” means the maximum dollar amount, adopted by the authority by rule, for costs incurred by a coordinated care organization in a calendar year, after which maximum the costs are no longer eligible for state reinsurance payments.(e)
“Reinsurance payment” means a payment by the reinsurance program described in subsection (2) of this section to cover part of a coordinated care organization’s costs.(2)
The Oregon Health Authority may establish a reinsurance program to:(a)
Make payments to coordinated care organizations that face particularly high costs in caring for members who require new, exceptionally costly drugs or treatments; and(b)
Better manage costs systemically.(3)
The following requirements apply to a reinsurance program established under subsection (2) of this section:(a)
A coordinated care organization becomes eligible for a reinsurance payment when the coordinated care organization’s costs in a calendar year exceed the attachment point. The amount of the payment shall be the product of the coinsurance rate and the coordinated care organization’s costs that exceed the attachment point, up to the reinsurance cap.(b)
After the authority adopts by rule the attachment point, reinsurance cap or coinsurance rate for a calendar year, the authority may not:(A)
Change the attachment point or the reinsurance cap during the calendar year; or(B)
Increase the coinsurance rate during the calendar year.(c)
The authority may adopt rules necessary to carry out the provisions of this section including, but not limited to, rules prescribing:(A)
The amount, manner and frequency of reinsurance payments;(B)
Assessments, if any, necessary to provide funding for the program; and(C)
Financial reporting requirements for coordinated care organizations necessary to administer the program.(d)
The authority shall take into account reinsurance payments received by a coordinated care organization in the determination of a global budget for the coordinated care organization.(4)
The authority shall work with the Centers for Medicare and Medicaid Services in establishing a reinsurance program under subsection (2) of this section to ensure compliance with federal requirements and federal financial participation in the costs of the program. [2019 c.529 §2]
Source:
Section 415.001 — Reinsurance program for coordinated care organizations (CCOs), https://www.oregonlegislature.gov/bills_laws/ors/ors415.html.
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