Current through Register Vol. 63, No. 9, September 1, 2024
As used in OAR
836-053-1500 to
836-053-1510:
(1) The definitions set forth in Section 2,
chapter 575, Oregon Laws 2015 apply to the use of those terms in these
rules.
(2) "Prominent carrier"
means:
(a) A carrier with annual premium
income of $200 million or more in direct health premiums written in Oregon and
is not also licensed as a Coordinated Care Organization;
(b) The Public Employees' Benefit Board;
and
(c) The Oregon Educators
Benefit Board.
(3)
"Non-claims based primary care expenditures" means resources given to a primary
care provider or practice for the following services or arrangements:
(a) Capitation or salaried arrangements with
primary care providers or practices not billed or captured through
claims;
(b) Risk-based
reconciliation for arrangements with primary care providers or practices not
billed or captured through claims;
(c) Payments to Patient-Centered Primary Care
Homes or Patient-Centered Medical Homes based upon that recognition or payments
for participation in proprietary or other multi-payer medical home
initiatives;
(d) Retrospective
incentive payments to primary care providers or practices based on performance
aimed at decreasing cost or improving value for a defined population of
patients;
(e) Prospective incentive
payments to primary care providers or practices aimed at developing capacity
for improving care for a defined population of patients;
(f) Payments for Health Information
Technology structural changes at a primary care practice such as electronic
records and data reporting capacity from those records; or
(g) Workforce expenses including payments or
expenses for supplemental staff or supplemental activities integrated into the
primary care practice (i.e. practice coaches, patient educators, patient
navigators, nurse care managers, etc.).
(4) "Non-claims based total health care
expenditures" means resources given to a provider or practice for the following
services or arrangements:
(a) Capitation or
salaried arrangements with providers or practices not billed or captured
through claims;
(b) Risk-based
reconciliation for arrangements with providers or practices not billed or
captured through claims;
(c)
Payments to Patient-Centered Primary Care Homes, Patient-Centered Medical
Homes, or Patient-Centered Specialty Practices based upon that recognition or
payments for participation in proprietary or other multi-payer medical home or
specialty care initiatives;
(d)
Retrospective incentive payments to providers or practices based on performance
aimed at decreasing cost or improving value for a defined population of
patients;
(e) Prospective incentive
payments to providers or practices aimed at developing capacity for improving
care for a defined population of patients;
(f) Payments for Health Information
Technology structural changes at a practice such as electronic records and data
reporting capacity from those records; or
(g) Workforce expenses including payments or
expenses for supplemental staff or supplemental activities integrated into the
practice (i.e. practice coaches, patient educators, patient navigators, nurse
care managers, etc.).
(5) "Patient-Centered Medical Home" means a
practice or provider who has been recognized as such by the National Committee
for Quality Assurance.
(6)
"Patient-Centered Primary Care Home" means a health care team or clinic as
defined in ORS 414.655, meets the standards
pursuant to OAR 409-055-0040, and has been
recognized through the process pursuant to OAR
409-055-0040.
(7) "Patient-Centered Specialty Practice"
means a practice or provider who has been recognized as such by the National
Committee for Quality Assurance.
(8) "Practice" means an individual, facility,
institution, corporate entity, or other organization which provides direct
health care services or items, also termed a performing provider, or bills,
obligates and receives reimbursement on behalf of a performing provider of
services, also termed a billing provider. The term provider refers to both
performing providers and billing providers unless otherwise
specified.
(9) "Primary care" means
family medicine, general internal medicine, naturopathic medicine, obstetrics
and gynecology, pediatrics or general psychiatry.
(10) "Primary care provider" means:
(a) A physician, naturopath, nurse
practitioner, physician associate or other health professional licensed or
certified in this state, whose clinical practice is in the area of primary
care.
(b) A health care team or
clinic that has been certified by the Oregon Health Authority as a
Patient-Centered Primary Care Home.
Statutory/Other Authority: ORS
731.244 & 2015 OL Ch. 575
Sec. 1
Statutes/Other Implemented: 2015 OL Ch. 575 Sec. 1 &
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