Oregon Administrative Rules
Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS
Division 65 - SUSTAINABLE HEALTH CARE COST GROWTH TARGET PROGRAM
Section 409-065-0040 - Performance Improvement Plans (PIP)

(1) A payer or provider organization that exceeds the cost growth target with statistical confidence, as such term is described by the Authority in the Statistical Analysis guidance posted on the Program website, and without reasonable cause, in accordance with 409-065-0035, during a measurement year for Medicaid, Medicare Advantage, or the commercial insurance market, must complete the performance improvement plan (PIP) template enumerated in section (2) of this rule.

(2) The Authority must develop and publish on the Program website a PIP template (titled CGT-5), PIP Instructions and Manual (titled CGT-6), and Guidance on Accountability (titled CGT-7).

(3) The Authority must collaborate with a payer or provider organization required to develop and undertake a PIP by providing technical assistance, which may include sub-regulatory guidance, office hours, a webinar published on the Program website, and consultation with the payer or provider organization at their request.

(4) The Authority may, at its sole discretion, agree to a payer or provider organization combining required PIPs for multiple markets or to a payer and provider organization submitting a PIP jointly developed in the event that the strategies to address the root cause or causes of cost growth would benefit from a collaborative PIP.

(5) The payer or provider organization must submit its PIP to the Authority no later than 90 calendar days from the date the Authority notifies the payer or provider organization in writing that a PIP is required. The payer or provider organization is responsible for completing and submitting a CGT-5 to the Authority.

(6) The notified payer or provider organization may request an extension to complete and submit a PIP by completing and submitting a CGT-3 to the Authority.

(7) Within 30 calendar days of receipt, the Authority must assess the submitted PIP to ensure it is complete and either approve the PIP or, if the PIP is incomplete, return it to the submitting payer or provider organization for revision with a specified deadline for the revised PIP, as determined by the Authority on a case-by-case basis.

(8) Following the Authority's approval of the PIP, the payer or provider organization must submit progress reports every six months in a manner specified by the Authority and in collaboration with the entity, regarding all progress made in advancing the purpose of the PIP, including qualitative and quantitative data as specified in the PIP. The first report must be due six months from the date the Authority approved the submitted PIP.

(9) The Authority must publish on the Program website all PIPs, progress reports, and relevant materials marked "PUBLIC" pursuant to the requirements of OAR 409-065-0042.

(10) At the request of the payer or provider organization, the Authority may grant one or multiple extensions to a payer or provider organization with an approved PIP to achieve the activities outlined in the PIP. The Authority must publish on the Program website all granted extensions and any new applicable deadlines for activities and milestones in each PIP.

(11) At the full discretion of the Authority, the Authority may waive the requirement for a payer or provider organization to complete a PIP, or undertake an approved PIP that a payer or provider organization has implemented or is in the process of implementing. If waived by the Authority, the payer or provider organization will not be required to submit documents related to a PIP including but not limited to progress reports and other required documentation pertaining to the waived PIP. In contemplating a waiver of an approved PIP, the Authority may take the following into consideration:

(12) If for a given year the Authority determines a payer or provider organization's cost growth to be acceptable, or indeterminate, which shall be a rare occurrence, in accordance with OAR 409-065-0035, no PIP will be required for that year.

(13) No later than December 31, 2030, the Authority must reassess and, if necessary, revise the PIP process outlined in these rules.