§ 414.611 — Transfer of 500 or more members of coordinated care organization

Oregon § 414.611

• Jurisdiction: Oregon
• Vol.: 11
• Title 34: Human Services; Juvenile Code; Corrections
• Ch. 414: Medical Assistance

Text

(1) The Oregon Health Authority may approve the transfer of 500 or more members from one coordinated care organization to another coordinated care organization if:
(a) The members’ provider has contracted with the receiving organization and has stopped accepting patients from or has terminated providing services to members of the transferring organization; and
(b) Members are offered the choice of remaining members of the transferring organization.
(2) Members may not be transferred under this section until the authority has evaluated the receiving organization and determined that the organization meets criteria established by the authority by rule, including but not limited to criteria that ensure that the organization meets the requirements of ORS 414.609 (1).
(3) The authority shall provide notice of a transfer under this section to members that will be affected by the transfer at least 90 days before the scheduled date of the transfer.
(4)(a) The authority may not approve the transfer of members under this section if:
(A) The transfer results from the termination of a provider’s contract with a coordinated care organization for just cause; and
(B) The coordinated care organization has notified the authority that the provider’s contract was terminated for just cause.
(b) A provider is entitled to a contested case hearing in accordance with ORS chapter 183, on an expedited basis, to dispute the denial of a transfer of members under this subsection.
(c) As used in this subsection, “just cause” means that the contract was terminated for reasons related to quality of care, competency, fraud or other similar reasons prescribed by the authority by rule.
(5) The provider and the organization shall be the parties to any contested case proceeding to determine whether the provider’s contract was terminated for just cause. The authority may award attorney fees and costs to the party prevailing in the proceeding, applying the factors in ORS 20.075.

Legislative History

Formerly 414.647