Or. Admin. Code § 409-065-0040 - Performance Improvement Plans (PIP)

(1) A payer or provider organization that exceeds the cost growth target with statistical confidence, as such term is described by the Authority in the Statistical Analysis guidance posted on the Program website, and without reasonable cause, in accordance with 409-065-0035, during a measurement year for Medicaid, Medicare Advantage, or the commercial insurance market, must complete the performance improvement plan (PIP) template enumerated in section (2) of this rule.

(2) The Authority must develop and publish on the Program website a PIP template (titled CGT-5), PIP Instructions and Manual (titled CGT-6), and Guidance on Accountability (titled CGT-7).

(a) The PIP is a document written by a payer or provider organization and approved by the Authority that specifies how the certain factors will result in reduced cost growth such that future cost growth does not exceed the cost growth target. These factors must:

(A) Identify key cost growth drivers and the specific actions a payer or provider organization will take to address those key cost growth drivers;

(B) Identify an appropriate timeframe or timeframes by which the payer or provider organization will reduce the cost growth and cost growth drivers; and

(C) Include clear metrics for success to be used for evaluating progress and completeness.

(b) A payer or provider organization must use the document titled CGT-5, to describe:

(A) The root cause(s)of cost growth including, but not limited to, any causes identified during discussions with the Authority regarding the determination of a reasonable cause for cost growth;

(B) Strategies developed by the payer or provider organization to address the root cause or causes of cost growth in a specified timeframe, but no more than 24 consecutive months from the date the Authority approves the submitted PIP, unless extended by the Authority as per (10) of this rule;

(C) Specific and achievable outcome measures to track progress;

(D) The strategy developed by the payer or provider organization to avoid negative effects on health care service availability, quality, and health equity;

(E) The plan for adjusting the strategy during the duration of the PIP in response to unmet savings or measures, and any negative effects on quality, access, and health equity; and

(F) The payer or provider organization's plan for how to apply any generated savings.

(3) The Authority must collaborate with a payer or provider organization required to develop and undertake a PIP by providing technical assistance, which may include sub-regulatory guidance, office hours, a webinar published on the Program website, and consultation with the payer or provider organization at their request.

(4) The Authority may, at its sole discretion, agree to a payer or provider organization combining required PIPs for multiple markets or to a payer and provider organization submitting a PIP jointly developed in the event that the strategies to address the root cause or causes of cost growth would benefit from a collaborative PIP.

(5) The payer or provider organization must submit its PIP to the Authority no later than 90 calendar days from the date the Authority notifies the payer or provider organization in writing that a PIP is required. The payer or provider organization is responsible for completing and submitting a CGT-5 to the Authority.

(6) The notified payer or provider organization may request an extension to complete and submit a PIP by completing and submitting a CGT-3 to the Authority.

(a) The payer or provider organization must request an extension no less than 30 calendar days prior to the PIP submission deadline.

(b) The Authority may grant, at its sole discretion, an extension of no more than 45 calendar days for the payer or provider organization to submit a complete PIP.

(7) Within 30 calendar days of receipt, the Authority must assess the submitted PIP to ensure it is complete and either approve the PIP or, if the PIP is incomplete, return it to the submitting payer or provider organization for revision with a specified deadline for the revised PIP, as determined by the Authority on a case-by-case basis.

(8) Following the Authority's approval of the PIP, the payer or provider organization must submit progress reports every six months in a manner specified by the Authority and in collaboration with the entity, regarding all progress made in advancing the purpose of the PIP, including qualitative and quantitative data as specified in the PIP. The first report must be due six months from the date the Authority approved the submitted PIP.

(9) The Authority must publish on the Program website all PIPs, progress reports, and relevant materials marked "PUBLIC" pursuant to the requirements of OAR 409-065-0042.

(10) At the request of the payer or provider organization, the Authority may grant one or multiple extensions to a payer or provider organization with an approved PIP to achieve the activities outlined in the PIP. The Authority must publish on the Program website all granted extensions and any new applicable deadlines for activities and milestones in each PIP.

(11) At the full discretion of the Authority, the Authority may waive the requirement for a payer or provider organization to complete a PIP, or undertake an approved PIP that a payer or provider organization has implemented or is in the process of implementing. If waived by the Authority, the payer or provider organization will not be required to submit documents related to a PIP including but not limited to progress reports and other required documentation pertaining to the waived PIP. In contemplating a waiver of an approved PIP, the Authority may take the following into consideration:

(a) The payer or provider organization's achievement of PIP goals ahead of the schedule specified in the PIP;

(b) Unforeseen market circumstances;

(c) The payer or provider organization's performance related to the cost growth target; or

(d) The payer or provider organization is required to develop a subsequent PIP.

(12) If for a given year the Authority determines a payer or provider organization's cost growth to be acceptable, or indeterminate, which shall be a rare occurrence, in accordance with OAR 409-065-0035, no PIP will be required for that year.

(13) No later than December 31, 2030, the Authority must reassess and, if necessary, revise the PIP process outlined in these rules.

Notes

Or. Admin. Code § 409-065-0040

OHP 4-2024, adopt filed 07/22/2024, effective 7/22/2024

Statutory/Other Authority: ORS 442.386

Statutes/Other Implemented: ORS 442.386