Or. Admin. Code § 410-141-5015

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

Section 410-141-5015 - FINANCIAL SOLVENCY REGULATION: Financial Statement Reporting

(1) Financial reports to the Authority. A CCO shall submit the following:

(a) On or before April 30 of each year, an unaudited financial statement for the year ending December 31 immediately preceding;

(b) On or before May 31, August 31, and November 30 of each year, an unaudited financial statement for the quarter ending March 31, June 30 and September 30, respectively;

(c) On or before June 30 of each year, an audited financial statement for the year ending December 31 immediately preceding.

(2) Except as otherwise allowed or required by the Authority, all annual and quarterly financial statements filed by a CCO with the Authority shall:

(a) Follow and be presented in accordance with Statutory Accounting Principles;

(b) Use NAIC Forms and Instructions;

(c) Be verified by the oaths of the president and secretary of the CCO or, in their absence, by two other duly authorized and acting principal officers; and

(d) Include the additional information listed in sections (4), (5) and (6) of this rule.

(3) Audited annual financial statements shall be subject to, and shall comply with, the additional requirements set forth in OAR 410-141-5020 through OAR 410-141-5040. NAIC Forms and Instructions are available for inspection at the office of the Authority. Any person interested in inspecting the NAIC Forms and Instructions may contact the Authority at actuarial.services@dhsoha.state.or.us. A CCO shall be responsible for purchasing the current software version of the NAIC Forms and Instructions from the NAIC as required to prepare the financial statement filings required by these rules.

(4) A CCO shall include the following as supplements to the CCO's quarterly and annual financial statement filings, using forms and templates prescribed by the Authority:

(a) A Supplemental Compensation Exhibit, as published by the NAIC, disclosing the salary and benefits of the three officers or employees having the highest total compensation for the period. This exhibit shall be required only with the CCO's annual financial statement filing;

(b) A report of Health-Related Services (as defined by OAR 410-141-5015 and as described in Oregon's Medicaid 1115 Waiver for 2017 - 2022) and additional supplemental information, including care coordination, case management, flexible services, and community benefit expenses. CCOs shall comply with the following additional requirements regarding Health-Related Services (as defined by OAR 410-141-5015 and as described in the CMS section 1115 Waiver):

(A) Health Related Services shall be considered in the rate setting consistent with the current 1115 Waiver;

(B) Health Related Services shall be included as Activities that Improve Health Care Quality in the Minimum Medical Loss Rebate Calculation report.

(c) A certification of compliance with financial and encounter data reporting requirements;

(d) A report of third-party resources collections (CCO contractor);

(e) A report of Corporate Relationships of Contractors and Incentive Plan Disclosure and Detail (CCOs);

(f) CCO-specific utilization reports;

(g) Any other supplemental information deemed necessary by the Authority and specified in Exhibit L to the CCO's contract with the Authority.

(5) A CCO shall report the following information in respect of the CCO's Restricted Reserve, using forms and templates prescribed by the Authority:

(a) Identification of custodians, account balances and assets comprising Restricted Reserve Funds held by a third-party;

(b) A bank statement from each custodian of Restricted Reserve Funds of the account balance or aggregate fair market value of the assets comprising the Restricted Reserve Funds held by the custodian;

(c) Documentation of the liability that would be owed to creditors in the event of the CCO's insolvency;

(d) Documentation of the dollar amount of that liability that is covered by any identified risk-adjustment mechanisms.

(6) A CCO shall report the following information in respect of any Sub-Capitation Arrangements to which the CCO is a party, using forms and templates prescribed by the Authority:

(a) A CCO that sub-capitates any work described in its agreements with the Authority shall require the Sub-Capitated Counterparty to report financial information as specified in the CCO's agreements with the Authority;

(b) CCOs that make sub-capitation payments exceeding an annual amount defined by financial reporting instructions under the CCO's contract shall submit to the Authority on an annual basis the following financial reports with respect to each of the CCO's Sub-Capitated Counterparties:

(A) Statements of revenue, expenses and net income;

(B) Restricted Reserve Account documentation;

(C) Certification of compliance with financial and encounter data reporting requirements;

(D) Any supplemental information deemed necessary by the Authority.

(7) Following termination of the CCO contract, the annual reports described in this rule are due for the last calendar year during which the CCO operated, and its quarterly reports are due until its last annual report has been filed.

(8) The CCO shall make such additional filings with the Authority as are required by the CCO's agreement with the Authority and as otherwise may be determined by the Authority from time to time to be necessary under the circumstances.

Or. Admin. Code § 410-141-5015

DMAP 58-2019, adopt filed 12/18/2019, effective 1/1/2020; DMAP 89-2022, amend filed 12/16/2022, effective 1/1/2023

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

Statutes/Other Implemented: ORS 414.610-414.685