Or. Admin. Code § 836-053-1505

Current through Register Vol. 63, No. 11, November 1, 2024

Section 836-053-1505 - Definitions for OAR 836-053-1500 to 836-053-1510

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.

Or. Admin. Code § 836-053-1505

ID 13-2015(Temp), f. & cert. ef. 10-20-15 thru 4-8-16; ID 4-2016, f. & cert. ef. 4/8/2016; ID 5-2024, minor correction filed 06/27/2024, effective 6/27/2024

Statutory/Other Authority: ORS 731.244 & 2015 OL Ch. 575 Sec. 1

Statutes/Other Implemented: 2015 OL Ch. 575 Sec. 1 & 3