Or. Admin. Code § 410-141-5005

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-141-5005 - FINANCIAL SOLVENCY REGULATION: CCO Financial Solvency Requirements

(1) A CCO shall assume the risk for providing capitated services under its agreements with the Authority.

(2) Each CCO must demonstrate that it is able to provide coordinated care services efficiently, effectively, and economically. CCOs shall maintain sound financial management procedures, maintain protections against insolvency, and generate periodic financial reports as provided in these rules.

(3) A CCO shall comply with the applicable solvency requirements of Division 141 of Chapter 410 and as specified in the CCO's agreements with the Authority. Solvency requirements shall include the following components:

(a) Maintenance of Restricted Reserve Funds as required by OAR 410-141-5285 and by the CCO's agreements with the Authority;

(b) Protection against catastrophic and unexpected loss or expenses related to capitated services for CCOs Loss Protection Program. A CCO's Loss Protection Program:

(A) May include stop loss insurance coverage, reinsurance or such other alternative protection(s) as may be approved by the Authority, and

(B) Shall be subject to the Authority's review and approval.

(c) Any material change to a CCO's Loss Protection Program shall be submitted to the Authority in writing and shall be subject to the Authority's review and approval;

(d) Maintenance of professional liability coverage of not less than $1,000,000 per person per incident and not less than $1,000,000 in the aggregate either through binder issued by an insurance carrier or by self-insurance with proof of same acceptable to the Authority; and

(e) Management systems, practices and procedures that capture, compile, and evaluate information and data concerning financial operations. Such systems shall include, without limitation, the following features and functionalities:

(A) Determination of future budget requirements for the next three quarters.

(B) Determination of incurred but not reported expenses.

(C) Tracking additions and deletions of Members and accounting for capitation payments.

(D) Tracking claims payment.

(E) Tracking all monies collected from third party resources on behalf of Members.

(F) Documentation of, and reports on the use of, incentive payment mechanisms, risk-sharing, and risk-pooling, as applicable.

Or. Admin. Code § 410-141-5005

DMAP 58-2019, adopt filed 12/18/2019, effective 1/1/2020

Statutory/Other Authority: ORS 414.615, 414.625, 414.635, 414.651 & ORS 413.042

Statutes/Other Implemented: ORS 414.610 - 414.685