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Oregon Bulletin

October 1, 2013

Oregon Health Authority, Office for Oregon Health Policy and Research, Chapter 409

Rule Caption: Amendments to Patient-Centered Primary Care Home Program Rules

Adm. Order No.: OHP 6-2013

Filed with Sec. of State: 8-23-2013

Certified to be Effective: 9-3-13

Notice Publication Date: 5-1-2013

Rules Amended: 409-055-0030

Subject: The Oregon Health Authority, Office for Oregon Health Policy and Research is proposing to make amendments relating to the application and recognition process for the Primary Care Home (PCPCH) Program.

Rules Coordinator: Zarie Haverkate—(503) 373-1574

409-055-0030

Practice Application and Recognition Process

(1) Practices or other entities on behalf of the practice shall submit a PCPCH Recognition Process Application electronically to the Authority via the Program’s online application system found on the Program website. The application shall include data per OAR 409-055-0040.

(2) The Authority shall review the application for completed data and compliance with the criteria in OAR 409-055-0040.

(3) When the PCPCH applicant meets the criteria requirements, the Authority shall deem the applicant as a Recognized PCPCH Practice and assign a Tier level.

(4) The Authority shall keep instructions and criteria for submitting a PCPCH Recognition Process Application posted on the Program website.

(5) Practices shall be notified in writing or electronically of a PCPCHs Tier score or contacted for additional information within 60 days of application submission.

(6) A practice may be denied PCPCH recognition if it does not meet the criteria in OAR 409-055-0040.

(7) Practices must file a request for review with the Program within 90 days if the practice disagrees with the calculated Tier score.

(8) PCPCHs submitting applications on or after September 3, 2013 must apply to renew their recognition once every two years. Recognition will expire two years from the effective date of recognition that was issued by the Authority. At the Authority’s discretion a 30-day grace period may be allowed for PCPCHs to submit their annual renewal application without having a lapse in recognition status. If during the year, a PCPCH believes that it meets the criteria to be recognized at a higher tier, it may request to have its tier status reassessed by re-submitting an application not more than once every six months. Currently recognized PCPCHs that are due to reapply between September 3, 2013 and December 31, 2013 will be granted a grace period until January 31, 2014 to submit a renewal application without having a lapse in recognition status.

(9) The effective recognition date identified by the Authority shall be the date on which the Authority has completed the application review process.

(10) The Authority reserves the right to identify a recognition date other than the date of application review process completion.

(11) It is the intent of the Program to refine the criteria per OAR 409-055-0040 during the first two years of implementation of the Program based on PCPCH provider and stakeholder feedback. After this time, the Authority intends to move to a recognition renewal process of once every three years.

(12) Recognition requests may be sent electronically or by mail to the address posted on the Program website.

[Tables: Tables reference are available from the agency.]

Stat. Auth: ORS 413.042, 414.655 & 442.210

Stats. Implemented: 413.042, 414.655 & 442.210

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12; OHP 2-2012, f. 2-29-12, cert. ef. 3-1-12; OHP 7-2012(Temp), f. & cert. ef. 10-4-12 thru 4-1-13; OHP 5-2013, f. 3-22-13, cert. ef. 4-1-13; OHP 6-2013, f. 8-23-13, cert. ef. 9-3-13


Rule Caption: Adoption of administrative rules governing the Medicaid Primary Care Provider Loan Repayment Program

Adm. Order No.: OHP 7-2013

Filed with Sec. of State: 9-4-2013

Certified to be Effective: 9-4-13

Notice Publication Date: 8-1-2013

Rules Adopted: 409-037-0000, 409-037-0010, 409-037-0020, 409-037-0030, 409-037-0040, 409-037-0050, 409-037-0060, 409-037-0070, 409-037-0080

Subject: These rules establish standards for the implementation of the new Medicaid Primary Care Loan Repayment Program as mandated by the 2013 Legislature, Senate Bill 440. The Program provides loan repayment supports to primary care providers who commit to serving Medicaid patients in underserved areas of the State. The Program supports the Affordable Care Act and Oregon’s health system transformation efforts to ensure an adequate supply of primary care providers

Rules Coordinator: Zarie Haverkate—(503) 373-1574

409-037-0000

Purpose

The Medicaid Primary Care Loan Repayment Program (Program) is established in the Oregon Health Authority. The purpose of the Program is to provide loan repayment supports to primary care providers who commit to serving Medicaid patients in underserved areas of the State. The Program supports the Affordable Care Act and Oregon’s health system transformation efforts to ensure an adequate supply of primary care providers.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

409-037-0010

Definitions

The following definitions apply to OAR 409-037-0000 through 409-037-0080:

(1) “Authority” means the Oregon Health Authority.

(2) “Clinical Psychologist” means an individual licensed to practice psychology pursuant to ORS 675.010 to 675.090.

(3) “Clinical Social Worker” means an individual licensed to practice clinical social work pursuant to ORS 675.510 to 675.600.

(4) “Dentist” means any individual licensed to practice dentistry pursuant to ORS Chapter 679.

(5) “Eligible provider” means a practitioner in Oregon delivering health care services to patients in Oregon, who meets the provider participation requirements of OAR 409-037-0030 and who is:

(a) A dentist in general or pediatric practice;

(b) An expanded practice dental hygienist;

(c) A physician who practices or intends to practice in the specialties of family medicine, general practice, general internal medicine, geriatrics, pediatrics, or obstetrics and gynecology;

(d) A nurse practitioner who practices or intends to practice in the specialties of adult health, women’s health care; geriatrics; pediatrics; psychiatric mental health; family practice, or nurse midwifery;

(e) A physician assistant who practices or intends to practice in the specialties of family medicine, general practice, general internal medicine, geriatrics, pediatrics or obstetrics and gynecology;

(f) A general, child and adolescent, or geriatric psychiatrist;

(g) A clinical psychologist;

(h) A clinical social worker; or

(i) A Marriage or Family Therapist.

(6) “Expanded Practice Hygienist” means an individual licensed to practice dental hygiene with an expanded practice dental hygienist permit issued under ORS 680.200.

(7) “Marriage and Family Therapist or Professional Counselor” has the meaning given that term in ORS 675.715 to 675.745.

(8) “Nurse Practitioner” means any individual licensed pursuant to ORS 678.375.

(9) “Physician” means any individual licensed pursuant to ORS 677.100 to 677.228.

(10) “Physician Assistant” means any individual licensed pursuant to ORS 677.495 to 677.545.

(11) “Practice full-time” means working at least 40 hours per week, with a minimum of 32 hours per week spent providing direct patient care, averaged over the month for a minimum of 45 weeks per service year. Patient charting is considered a component of offering direct patient care. Telemedicine may be considered direct patient care when both the originating site (location of the patient) and the distant site (the eligible site where the provider works) are located in Oregon.

(12) “Practice part-time” means working at least 20 hours per week, with a minimum of 16 hours per week spent providing direct patient care, averaged over the month for a minimum of 45 weeks per service year. Patient charting is considered a component of offering direct patient care. Telemedicine may be considered direct patient care when both the originating site (location of the patient) and the distant site (the eligible site where the provider works) are located in Oregon.

(13) “Qualifying Loan” means one or more government or commercial loans received solely to cover the cost of post-baccalaureate health professional training, or, in the case of an expanded practice dental hygienist, undergraduate educational training. This does not include credit card loans, lines of credit, and personal loans.

(14) “Qualifying practice site” means:

(a) A rural hospital as defined in ORS 442.470;

(b) A federally certified Rural Health Clinic;

(c) A Federally Qualified Community Health Center;

(d) A site providing primary care services in an area approved as a medical, dental or mental Health Professional Shortage Area(HPSA) as defined by the federal Health Resources and Services Administration; or

(e) Another site providing primary care services to an underserved population, as determined by the Authority.

(15) “Telemedicine” means the provision of health services to patients by physicians and health care practitioners from a distance using electronic communications.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

409-037-0020

Participation and Application Requirements

(1) Program participants must agree to serve Medicaid patients in the same approximate proportion of such patients in the county or other service area, up to a maximum requirement of 15 percent of patient mix.

(2) Program participants must commit to practice either:

(a) Full-time in a qualifying practice site for at least three years. Full-time participants may request, and the Authority may extend the service period to a total of five years, depending on available funds; or

(b) Part-time in a qualifying practice site for at least five years. Part-time participants may request, and the Authority may extend the service period to a total of seven years, depending on the available funds.

(3) To qualify for consideration in the Program, a primary care provider must submit an application that:

(a) Documents the individual having, or having applied for, an unrestricted license to practice in Oregon within their discipline;

(b) Includes a signed and dated statement certifying that the individual is not currently participating in the National Health Services Corps (NHSC), Nursing Corps, or State Loan Repayment Programs or the NHSC Scholarship Program; or

(c) Documents the individual having:

(A) An employment contract with a qualifying practice site that began within the previous 24 months or an agreement to begin practice with a qualifying practice site within 120 days from the date of the application, or

(B) A sole proprietorship, Limited Liability Corporation, Limited Liability Partnership, or Professional Corporation for the purpose of providing health care that meets the definition of a qualifying practice site and that was established within the previous 24 months or will be established with 120 days from the date of application.

(d) Attests that the individual is willing to make a service commitment of at least three years work in a qualifying practice site, during which time the individual agrees to serve Medicaid patients in the same approximate proportion of the patients in the county or other service area, up to a maximum of 15 percent of patient mix; and

(e) Provides all other information required by the Program.

(4) To make a primary care provider’s application complete, the sole proprietor or the qualifying practice site at which the provider works or intends to work must submit a letter of support attesting that the site meets the definition set out in OAR 409-037-0010 (14) and providing other information as requested by the Authority.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

409-037-0030

Application and Review Process

(1) As of the effective date of the filing of this proposed rule, the Program is still developing application processes. When the Authority has finalized the process, the Authority shall provide application format and submission requirements at the Program website.

(2) The Authority shall review completed applications that meet all requirements of OAR 409-037-0020.

(a) The Authority shall return incomplete applications. Completed resubmitted applications shall be processed as of the new date of receipt.

(b) The Authority shall notify applicants of the status of their completed applications within 60 days of application submission.

(3) The following factors may be considered in determining whether to accept an eligible provider for participation in the program, including but not limited to:

(a) Provider type. Providers who may be counted as primary care medical, dental, or mental health providers for federal HPSA designations may be given priority consideration for Program participation.

(b) Determined need of the area. The Authority may prioritize applications from providers who apply to practice at a qualifying practice site with a HPSA score of 10 or higher, or that serves an area or special population with a HPSA score of 10 or higher. The Authority may also prioritize provider applications based on the number of new Medicaid eligibles in the area served by the qualifying practice site as of January 1, 2014.

(c) PCPCH status. The Authority may award priority to eligible providers who will provide services in, or in affiliation with, a Patient Centered Primary Care Home (PCPCH) recognized by the State of Oregon.

(d) Duration of time in practice site, or in Oregon. Priority may be given to providers based on the duration of time they have spent at their practice site or in the state, with a priority for new providers. No more than 20 percent of all awards shall be made to providers already practicing at a qualified practice site.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

409-037-0040

Maximum Award Amounts

Program participants are eligible for a maximum loan repayment award of:

(1) Twenty percent of the balance owed on qualifying loans upon program entry, up to an annual maximum amount of $35,000 for each year of full-time service.

(2) Ten percent of the balance owed on qualifying loans upon program entry, up to an annual maximum amount of $17,500 for each year of part-time service.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

409-037-0050

Transfer of Medicaid Loan Repayment Provider Service Obligation

(1) In the event of a practice failure or other extenuating circumstance, a participating provider may, with Authority approval, transfer his or her service obligation to another qualifying practice site. A written transfer request must be submitted to the Authority documenting the:

(a) Need or reason for the transfer;

(b) Proposed new qualifying practice site; and

(c) The name of the director at the proposed new practice site.

(2) Along with the written transfer request, the participating provider must submit:

(a) A letter from the original practice site releasing the eligible provider from any employment contract (if applicable) and providing an explanation for the termination of employment. The Authority may waive this requirement if the original practice site is in non-compliance with federal requirements, federal or state law, or these rules.

(b) An employment contract with the new qualifying practice site, a letter of intent from the new qualifying practice site to employ the provider, or documentation of the provider having established a sole proprietorship, Limited Liability Corporation, Limited Liability Partnership, or Professional Corporation that meets the definition of a qualifying practice site.

(3) The new practice site, in collaboration with the provider, must:

(a) Submit a letter of support documenting the site meets the definition in OAR 409-037-0010 (14) and providing other information as requested by the Authority.

(b) Provide confirmation that the site will cooperate with the provider to comply with the monitoring and follow-up requirements set forth in these rules.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

409-037-0060

Suspension or Waiver of Minimum Service Obligation

(1) The Authority may agree to suspend a participating provider’s service obligation under circumstances it deems appropriate, including, but not limited to parental leave, medical leave, military service leave, or other factors beyond a provider’s control. During the time of suspension, awards are also suspended.

(2) A participant requesting a suspension of minimum service obligation shall make a written request to the Authority, citing the reasons and providing documentation of the circumstances.

(3) The Authority may waive all or part of the minimum service obligation under the following circumstances:

(a) Upon receipt of written documentation acceptable to the Authority of the death of the participant;

(b) Upon receipt of written documentation acceptable to the Authority of the total and permanent disability of the participant; or

(c) Upon receipt of documentation of other significant changes in life circumstances that are out of the control of the participant and that the Authority determines warrant a waiver of service commitment.

(4) If all or part of the minimum service obligation is waived, the Authority may not impose any penalty for failure to meet the obligation.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

409-037-0070

Failure to Comply; Penalties

(1) A participant who fails to complete the minimum service obligation in a qualifying practice site and does not receive a waiver shall be considered to have breached the terms of the loan repayment program. The Authority shall impose a penalty on any such provider in an amount up to the sum of:

(a) The total paid on behalf of the participant for loan repayments for any periods of obligated service not served;

(b) $7,500 for each month of the minimum service period not completed according to the terms of the obligation; and

(c) Interest on the above amounts at the maximum prevailing rate, as determined by the Oregon Department of Revenue, calculated from the date of breach until full repayment has been made.

(2) Any amount determined to be due under this section shall be collected by the Collections Unit in the Oregon Department of Revenue under ORS 293.250.

(3) A participant may appeal decisions made by the Authority under the provisions of ORS Chapter 183.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

409-037-0080

Monitoring and Follow-up Requirements

To maintain participation in the Program, an eligible provider must:

(1) Notify the Authority immediately upon beginning work at a qualifying practice site.

(2) Promptly submit semi-annual reports signed by the provider and the administrator of the qualifying practice site verifying the provider’s employment, or licensed business, in the case of a sole provider, and providing any additional information as requested by the Authority, including but not limited to:

(a) Provider’s caseload (panel size or equivalent);

(b) Provider’s Medicaid caseload;

(c) Provider full time equivalent (FTE) status; and

(d) Number and percentage of practice site’s patients who are Medicaid beneficiaries.

(3) The first report is due six months after employment begins, and every six months thereafter, until the term of the contract is complete.

(4) Notify the Authority immediately of any change in employment or practice status.

Stat. Auth.: 2013 OL Ch. 177

Stats. Implemented: 2013 OL Ch. 177

Hist.: OHP 7-2013, f. & cert. ef. 9-4-13

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2012.

2.) Copyright 2013 Oregon Secretary of State: Terms and Conditions of Use

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

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