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The Oregon Administrative Rules contain OARs filed through April 15, 2013 
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OREGON HEALTH AUTHORITY, OFFICE FOR OREGON HEALTH POLICY AND RESEARCH
OREGON HEALTH AUTHORITY, OFFICE FOR OREGON HEALTH POLICY AND RESEARCH
OREGON HEALTH AUTHORITY, OFFICE FOR OREGON HEALTH POLICY AND RESEARCH
DIVISION 55
PATIENT-CENTERED PRIMARY CARE HOME PROGRAM
409-055-0000
Scope
These rules (OAR 409-055-0000 to 409-055-0090) establish the Patient-Centered Primary Care Home (PCPCH) Program and define criteria and process that the Authority shall use to recognize and verify status as PCPCHs. The PCPCH is a model of primary care that has received attention in Oregon and across the country for its potential to advance the “triple aim” goals of health reform: a healthy population, extraordinary patient care for everyone, and reasonable costs, shared by all. PCPCHs achieve these goals through a focus on wellness and prevention, coordination of care, active management and support of individuals with special health care needs, and a patient and family-centered approach to all aspects of care. PCPCHs emphasize whole-person care in order to address a patient and family’s physical and behavioral health care needs.
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
409-055-0010
Definitions
The following definitions apply to OAR 409-055-0000 to 409-055-0090:
(1) “Administrator” means the administrator or designee of The Office for Oregon Health Policy and Research as defined in ORS 442.011.
(2) “Authority” means the Oregon Health Authority.
(3) “CHIPRA Core Measure Set” means the initial core set of children's health care quality measures released by the Centers for Medicare and Medicaid Services in 2009 for voluntary use by Medicaid and CHIP programs.
(4) “NCQA” means National Committee for Quality Assurance.
(5) “Office” means the Office for Oregon Health Policy and Research.
(6) “Patient Centered Medical Home (PCMH)” means a practice or provider who has been recognized as such by the National Committee for Quality Assurance.
(7) “Patient-Centered Primary Care Home (PCPCH)” 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.
(8) “Personal Health Information” means demographic information, medical history, test and laboratory results, insurance information and other data that is collected by a health care professional to identify an individual and determine appropriate care.
(9) “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 (BP). The term provider refers to both performing providers and BP(s) unless otherwise specified.
(10) “Program” means Patient-Centered Primary Care Home Program.
(11) “Program website” means www.primarycarehome.oregon.gov.
(12) “Provider” 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 (BP). The term provider refers to both performing providers and BP(s) unless otherwise specified.
(13) “Recognition” means the process through which the Authority determines if a practice has met the Oregon Patient-Centered Primary Care Home Standards.
(14) “Recognized” means that the Authority has affirmed that a practice meets the Oregon Patient-Centered Primary Care Home Standards.
(15) “Tier” means the level of Patient-Centered Primary Care Home at which the Authority has scored a practice.
(16) “Verification” means the process that Office for Oregon Health Policy and Research shall conduct to ensure that a practice has submitted accurate information to the Authority for purposes of Patient-Centered Primary Care Home recognition.
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
409-055-0020
Program Administration
(1) The Program is intended to ensure that there is a uniform process for recognizing PCPCHs throughout the State of Oregon in order to support primary care transformation.
(2) The Authority shall recognize practices as PCPCHs upon meeting defined criteria through the Program.
(3) The Authority shall administer the Program, including data collection and analysis, recognition, and verification that a practice meets the defined PCPCH criteria. The Authority may also provide technical assistance as is feasible.
(4) The Authority may contract for any of the work it deems necessary for efficient and effective administration of the Program.
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
409-055-0030
Practice Application and 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 must renew their recognition annually or at the discretion of the OHA, but no less than 12 months from the effective recognition date identified to the practice 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.
(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
409-055-0040
Recognition Criteria
(1) The PCPCH measures are divided into “Must-Pass” measures and other measures that place the practice on a scale of maturity or ‘tier’ that reflect basic to more advanced PCPCH functions.
(2) Must-Pass and Tier 1 measures focus on foundational PCPCH elements that should be achievable by most practices in Oregon with significant effort, but without significant financial outlay.
(3) Tier 2 and Tier 3 measures reflect intermediate and advanced functions.
(4) Except for the 10 Must-Pass measures, each measure is assigned a point value corresponding to the Tier. For a practice to be recognized as a PCPCH, it must meet the following point allocation criteria:
(a) Tier 1: 30 – 60 points and all 10 Must-Pass Measures
(b) Tier 2: 65 – 125 points and all 10 Must-Pass Measures
(c) Tier 3: 130 points or more and all 10 Must-Pass Measures
(5) A practice’s point score shall be calculated through the recognition process pursuant to OAR 409-055-0030.
(6) See Table 1 for a detailed list of Measures and corresponding point assignment.
(7) See Tables 2.A and 2.B for a detailed list of the PCPCH Quality Measures referred to in Table 1, 2.A) Performance & Clinical Quality Improvement, 4.A) Personal Clinician Assigned, and 4.D) Personal Clinician Continuity.
(8) Data specifications for the measures listed in Table 2 shall be available on the Program website.
(9) Quantitative data shall be aggregated at the practice level, not the individual patient level, and there may not be any transfer of any personal health information from the practice to the Authority during the PCPCH application process.
(10) Measure specification, thresholds for demonstrating improvement, and benchmarks for quantitative data elements shall be developed by the Authority and made available on the Program website.
(11) NCQA recognition will be acknowledged in the Authority’s PCPCH recognition process; however, a practice is not required to use its NCQA recognition to meet the Oregon PCPCH standards. A practice that does not wish to use its NCQA recognition to meet the Oregon PCPCH standards must indicate so during the PCPCH application process and submit a complete PCPCH application.
(12) Depending on the version of NCQA recognition that was used, practices seeking Oregon PCPCH recognition and wish to use their NCQA PCMH status shall attest to being a NCQA recognized PCMH and submit additional information.
(13) Additional required elements for NCQA PCMH recognized practices choosing to use their NCQA status are listed in Table 3 for PCMH practices using 2008 NCQA criteria and Table 4 for PCMH practices using 2011 NCQA criteria.
[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
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
409-055-0050
Data Reporting Requirements for Recognized PCPCHs
(1) In order to be recognized as a PCPCH, a practice must attest to meeting the standards described in Table 1 as well as submit quantitative data elements as described in Tables 1 and 2.
(2) The attestation shall be submitted electronically via the web-based process pursuant to OAR 409-055-0030.
(3) Recognized PCPCHs shall be scored and assigned a Tier level pursuant to OAR 409-055-0040.
(4) Attestation data must be submitted by PCPCHs annually as a part of the recognition renewal process.
(5) Part of the recognition process shall also include submission of quantitative data about the practice or the practice’s patient population.
(6) Quantitative data shall be submitted electronically via the web-based reporting process.
(7) Quantitative data elements selected from Table 2 must be submitted by recognized PCPCHs annually for those practices submitting data to meet standard 2.A.2 or 2.A.3.
(8) If approved by the practice and the Authority, other entities may submit information on behalf of a practice.
(9) Specific data elements required for PCPCH recognition shall be posted on the PCPCH Program website.
(10) The Authority shall have discretion to make exceptions to the reporting requirements above for practices collecting data elements outside of those on Table 2 for the purpose of quality improvement activities.
(11) The Authority shall have discretion to make exceptions to any of the reporting requirements referred to in OAR 409-055.
(12) Practices may request an exception to the reporting requirements on the PCPCH application form.
(13) The Authority will notify the practice within 60 days of complete application submission whether or not the requested exception has been granted.
[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
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
409-055-0060
Verification
(1) The Authority shall conduct at least one verification review of each recognized PCPCH to determine compliance with PCPCH criteria every five years and at such other times as the Authority deems necessary or at the request of the Division of Medical Assistance Programs (DMAP) or any other applicable program within the Authority. The purpose of the review is to verify reported attestation and quantitative data elements for the purposes of confirming recognition and Tier level.
(2) PCPCHs selected for verification shall be notified no less than 30 days prior to the scheduled review.
(3) PCPCHs shall permit Authority staff access to the practice’s place of business during the review.
(4) A verification review may include but is not limited to:
(a) Review of documents and records.
(b) Review of patient medical records.
(c) Review of electronic medical record systems, electronic health record systems, and practice management systems.
(d) Review of data reports from electronic systems or other patient registry and tracking systems.
(e) Interviews with practice management, clinical and administrative staff.
(f) On-site observation of practice staff.
(g) On-site observation of patient environment and physical environment.
(5) Following a review, Authority staff may conduct an exit conference with the PCPCH representative(s). During the exit conference Authority staff shall:
(a) Inform the PCPCH representative of the preliminary findings of the review; and
(b) Give the PCPCH a reasonable opportunity to submit additional facts or other information to the Authority staff in response to those findings.
(6) Following the review, Authority staff shall prepare and provide the PCPCH specific and timely written notice of the findings.
(7) If the findings result in a referral to the Division of Medical Assistance Programs per OAR 409-055-0070, Authority staff shall submit the applicable information to the Division of Medical Assistance Programs for its review and determination of appropriate action.
(8) If no deficiencies are found during a review, the Authority shall issue written findings to the PCPCH indicating that fact.
(9) If the reviewer’s written notice of findings indicates that the PCPCH was in compliance with PCPCH standards and criteria and no deficiencies were cited, the PCPCH representative shall sign and date the written notice and return it to the Authority.
(10) If deficiencies are found, the Authority shall take informal or formal enforcement action in compliance with OAR 409-055-0070.
(11) The Authority may share application information and content submitted by practices and/or verification findings only with managed care plans and/or insurance carriers with which the Authority contracts.
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
409-055-0070
Compliance
(1) If the Authority finds that the practice is not in compliance with processes as attested to, the Authority shall:
(a) Require a waiver with timeline to correct deficiency
(b) Issue a written warning with timeline to correct deficiency
(2) For steps (1)(a) and (1)(b), the Authority will review outcomes in accordance with the waiver or warning, and if remedied, no further action will be taken.
(3) If a practice fails to move into compliance within 90 days of identification of non-compliance with attested information, the Authority may issue a letter of non-compliance and amend the practice’s PCPCH recognition to reflect the appropriate Tier level or revoke its PCPCH status.
(4) If non-compliance is identified, the Authority will make this information available to managed care plans and insurance carriers with which the Authority contracts.
(5) A practice that has had its PCPCH status revoked may be reissued after the Authority determines that compliance with PCPCH Standards has been achieved satisfactorily.
(6) In order for the Authority to receive federal funding for Medicaid clients receiving services through a PCPCH, documentation of certain processes are required by the Centers for Medicare and Medicaid Services. Documentation requirements can be found in OAR 410-141-0860. If non-compliance is due to lack of documentation required per OAR 410-141-0860, a referral may be made to the Division of Medical Assistance Programs’ provider audit unit.
(7) If the Authority finds a lack of documentation per OAR 410-141-0860 to support the authorized tier level, the Authority may conduct an audit pursuant to the standards in OAR 943-120-1505
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
409-055-0080
Insurance Carrier, Managed Care Plan, and Public Stakeholder Communication
(1) The Authority shall develop a system for making recognized PCPCH Tier status recognition information available to insurance carriers and managed care organizations.
(2) The Authority shall maintain and update monthly the recognized PCPCH Tier status lists.
(3) The Authority shall develop a system for making recognized PCPCH practice names available to the general public through the Program website.
(4) Practices who do not wish to have their name listed on the publicly available list should send an e-mail to PCPCH@state.or.us with the title “opt-out” in the subject line within 10 business days of receiving confirmation of Tier status per OAR 409-055-0040.
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
409-055-0090
Reimbursement Objectives
(1) One objective of these standards is to facilitate appropriate reimbursement for PCPCHs consistent with their recognized Tier levels. The standards and Tier recognition process established in this rule are consistent with statutory objectives to align financial incentives to support utilization of PCPCHs, in recognition of the standards that are required to be met at different Tiers.
(2) Managed care plans and insurance carriers may obtain from the Authority the Tier level recognition of any practice.
(3) Within applicable programs, the Authority shall develop and implement reimbursement methodologies that reimburse practices based on recognition of Tier level, taking into consideration incurred practice costs for meeting the Tier criteria.
Stat. Auth: ORS 413.042, 414.655
& 442.210
Stats. Implemented: 413.042,
414.655 & 442.210
Hist.: OHP 2-2012, f. 2-29-12,
cert. ef. 3-1-12
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