Or. Admin. Code § 410-120-1380 - Compliance with Federal and State Statutes
(1) When a Provider submits a claim for
medical services or supplies provided to a Division of Medical Assistance
Programs (Division) client, Division will deem the submission as a
representation by the medical Provider to the Medical Assistance Program of the
medical Provider's compliance with the applicable sections of the federal and
state statutes referenced in this rule:
(a)
45 CFR Part 84 which implements Title V, Section 504 of the Rehabilitation Act
of 1973;
(b) 42 CFR Part 493
Laboratory Requirements and ORS 438 (Clinical Laboratories).
(c) Unless exempt under 45CFR Part 87 for
Faith-Based Organizations (Federal Register, July 16, 2004, Volume 69, #136),
or other federal provisions, the Provider must comply and, as indicated, cause
all sub-contractors to comply with the following federal requirements to the
extent that they are applicable to the goods and services governed by these
rules. For purposes of these rules, all references to federal and state laws
are references to federal and state laws as they may be amended from time to
time:
(A) The Provider must comply and cause
all subcontractors to comply with all federal laws, regulations, executive
orders applicable to the goods and services provided under these rules. Without
limiting the generality of the foregoing, the Provider expressly agrees to
comply and cause all subcontractors to comply with the following laws,
regulations and executive orders to the extent they are applicable to the goods
and services provided under these rules:
(i)
Title VI and VII of the Civil Rights Act of 1964, as amended;
(ii) Sections 503 and 504 of the
Rehabilitation Act of 1973, as amended;
(iii) The Americans with Disabilities Act of
1990, as amended;
(iv) Executive
Order 11246, as amended;
(v) The
Health Insurance Portability and Accountability Act of 1996;
(vi) The Age Discrimination in Employment Act
of 1967, as amended, and the Age Discrimination Act of 1975, as
amended;
(vii) The Vietnam Era
Veterans' Readjustment Assistance Act of 1974, as amended, (viii) all
regulations and administrative rules established pursuant to the foregoing
laws;
(viii) All other applicable
requirements of federal civil rights and rehabilitation statutes, rules and
regulations;
(ix) All federal law
governing operation of Community Mental Health Programs, including without
limitation, all federal laws requiring reporting of client abuse. These laws,
regulations and executive orders are incorporated by reference herein to the
extent that they are applicable to the goods and services governed by these
rules and required by law to be so incorporated. No federal funds may be used
to provide services in violation of
42 USC
14402.
(B) Any Provider that receives or makes
annual payments under the Title XIX State Plan of at least $5,000,000, as a
condition of receiving such payments, shall:
(i) Establish written policies for all
employees of the entity (including management), and of any contractor,
subcontractor, or agent of the entity, that provide detailed information about
the False Claims Act established under sections 3729 through 3733 of title 31,
United States Code, administrative remedies for false claims and statements
established under chapter 38 of title 31, United States Code, any Oregon State
laws pertaining to civil or criminal penalties for false claims and statements,
and whistleblowing protections under such laws, with respect to the role of
such laws in preventing and detecting fraud, waste, and abuse in Federal health
care programs (as defined in section 1128B(f));
(ii) Include as part of written policies,
detailed provisions regarding the entity's policies and procedures for
detecting and preventing fraud, waste and abuse; and
(iii) Include in any employee handbook for
the entity, a specific discussion of the laws described in (i), the rights of
the employees to be protected as whistleblowers, and the entity's policies and
procedures for detecting and preventing fraud, waste, and abuse.
(C) If the goods and services
governed under these rules exceed $10,000, the Provider must comply and cause
all subcontractors to comply with Executive Order 11246, entitled "Equal
Employment Opportunity," as amended by Executive Order 11375, and as
supplemented in Department of Labor regulations ( 41 CFR Part 60 );
(D) If the goods and services governed under
these rules exceed $100,000, the Provider must comply and cause all
subcontractors to comply with all applicable standards, orders, or requirements
issued under Section 306 of the Clean Air Act (42 U.S.C. 7606), the
Federal Water Pollution Control Act as amended (commonly known as the Clean
Water Act- 33 U.S.C.
1251 to
1387), specifically including, but
not limited to, Section 508 (33 U.S.C. 1368). Executive Order
11738, and Environmental Protection Agency regulations ( 40 CFR Part 32 ),
which prohibit the use under non-exempt Federal contracts, grants or loans of
facilities included on the EPA List of Violating Facilities. Violations must be
reported to the Authority, the federal Department of Health and Human Services
(DHHS) and the appropriate Regional Office of the Environmental Protection
Agency. The Provider must include and cause all subcontractors to include in
all contracts with subcontractors receiving more than $100,000, language
requiring the subcontractor to comply with the federal laws identified in this
section;
(E) The Provider must
comply and cause all subcontractors to comply with applicable mandatory
standards and policies relating to energy efficiency that are contained in the
Oregon energy conservation plan issued in compliance with the Energy Policy and
Conservation Act, 42 U.S.C.
6201 et seq. (Pub. L. 94-163);
(F) The Provider certifies, to the best of
the Provider's knowledge and belief, that:
(i)
No federal appropriated funds have been paid or will be paid, by or on behalf
of the Provider, to any person for influencing or attempting to influence an
officer or employee of an agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection with the
awarding of any federal contract, the making of any federal grant, the making
of any federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any federal
contract, grant, loan or cooperative agreement;
(ii) If any funds other than federal
appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this federal contract, grant, loan or cooperative
agreement, the Provider must complete and submit Standard Form LLL, "Disclosure
Form to Report Lobbying" in accordance with its instructions;
(iii) The Provider must require that the
language of this certification be included in the award documents for all
sub-awards at all tiers (including subcontracts, sub-grants, and contracts
under grants, loans, and cooperative agreements) and that all sub-recipients
and subcontractors must certify and disclose accordingly;
(iv) This certification is a material
representation of fact upon which reliance was placed when this Provider
agreement was made or entered into. Submission of this certification is a
prerequisite for making or entering into this Provider agreement imposed by
section 1352, Title 31, U.S. Code. Any person who fails to file the required
certification will be subject to a civil penalty of not less than $10,000 and
not more than $100,000 for each such failure.
(G) If the goods and services funded in whole
or in part with financial assistance provided under these rules are covered by
the Health Insurance Portability and Accountability Act or the federal
regulations implementing the Act (collectively referred to as HIPAA), the
Provider agrees to deliver the goods and services in compliance with HIPAA.
Without limiting the generality of the foregoing, goods and services funded in
whole or in part with financial assistance provided under these rules are
covered by HIPAA. The Provider must comply and cause all subcontractors to
comply with the following:
(i) Individually
Identifiable Health Information about specific individuals is confidential.
Individually Identifiable Health Information relating to specific individuals
may be exchanged between the Provider and the Authority for purposes directly
related to the provision to clients of services that are funded in whole or in
part under these rules. However, the Provider must not use or disclose any
Individually Identifiable Health Information about specific individuals in a
manner that would violate Authority Privacy Rules, or Authority Notice of
Privacy Practices, if done by the Authority. A copy of the most recent
Authority Notice of Privacy Practices is posted on the Authority Web site or
may be obtained from the Authority;
(ii) If the Provider intends to engage in
Electronic Data Interchange (EDI) transactions with the Authority in connection
with claims or encounter data, eligibility or enrollment information,
authorizations or other electronic transactions, the Provider must execute an
EDI Trading Partner Agreement with the Authority and must comply with the
Authority EDI rules;
(iii) If a
Provider reasonably believes that the Provider's or the Authority's data
transactions system or other application of HIPAA privacy or security
compliance policy may result in a violation of HIPAA requirements, the Provider
must promptly consult the Authority Privacy Officer. The Provider or Authority
may initiate a request to test HIPAA transactions, subject to available
resources and the Authority testing schedule.
(H) The Provider must comply and cause all
subcontractors to comply with all mandatory standards and policies that relate
to resource conservation and recovery pursuant to the Resource Conservation and
Recovery Act (codified at 42
USC 6901 et. seq.). Section 6002 of that Act
(codified at 42 USC
6962) requires that preference be given in
procurement programs to the purchase of specific products containing recycled
materials identified in guidelines developed by the Environmental Protection
Agency. Current guidelines are set forth in 40 CFR Parts 247;
(I) The Provider must comply and, if
applicable, cause a subcontractor to comply, with the applicable audit
requirements and responsibilities set forth in the Office of Management and
Budget Circular A-133 entitled "Audits of States, Local Governments and
Non-Profit Organizations;"
(J) The
Provider must not permit any person or entity to be a subcontractor if the
person or entity is listed on the non-procurement portion of the General
Service Administration's "List of Parties Excluded from Federal Procurement or
Nonprocurement Programs" in accordance with Executive Orders No. 12,549 and No.
12,689, "Debarment and Suspension". (See 45 CFR part 76 ). This list contains
the names of parties debarred, suspended, or otherwise excluded by agencies,
and Providers and subcontractors declared ineligible under statutory authority
other than Executive Order No. 12549. Subcontractors with awards that exceed
the simplified acquisition threshold must provide the required certification
regarding their exclusion status and that of their principals prior to
award;
(K) The Provider must comply
and cause all subcontractors to comply with the following provisions to
maintain a drug-free workplace:
(i) The
Provider certifies that it will provide a drug-free workplace by publishing a
statement notifying its employees that the unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance, except as may be
present in lawfully prescribed or over-the-counter medications, is prohibited
in the Provider's workplace or while providing services to Authority clients.
The Provider's notice must specify the actions that will be taken by the
Provider against its employees for violation of such prohibitions;
(ii) Establish a drug-free awareness program
to inform its employees about the dangers of drug abuse in the workplace, the
Provider's policy of maintaining a drug-free workplace, any available drug
counseling, rehabilitation, and employee assistance programs, and the penalties
that may be imposed upon employees for drug abuse violations;
(iii) Provide each employee to be engaged in
the performance of services under these rules a copy of the statement mentioned
in paragraph (J)(i) above in this section;
(iv) Notify each employee in the statement
required by paragraph (J)(i) of this section that, as a condition of employment
to provide services under these rules, the employee will abide by the terms of
the statement and notify the employer of any criminal drug statute conviction
for a violation occurring in the workplace no later than five (5) days after
such conviction;
(v) Notify the
Authority within ten (10) days after receiving notice under subparagraph
(J)(iv) of this section from an employee or otherwise receiving actual notice
of such conviction;
(vi) Impose a
sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program by any employee who is so convicted as
required by Section 5154 of the Drug-Free Workplace Act of 1988;
(vii) Make a good-faith effort to continue a
drug-free workplace through implementation of subparagraphs (J)(i) through
(J)(vi) of this section;
(viii)
Require any subcontractor to comply with subparagraphs (J)(i) through (J)(vii)
of this section;
(ix) Neither the
Provider, nor any of the Provider's employees, officers, agents or
subcontractors may provide any service required under these rules while under
the influence of drugs. For purposes of this provision, "under the influence"
means observed abnormal behavior or impairments in mental or physical
performance leading a reasonable person to believe the Provider or Provider's
employee, officer, agent or subcontractor has used a controlled substance,
prescription or non-prescription medication that impairs the Provider or
Provider's employee, officer, agent or subcontractor's performance of essential
job function or creates a direct threat to Authority clients or others.
Examples of abnormal behavior include, but are not limited to hallucinations,
paranoia or violent outbursts. Examples of impairments in physical or mental
performance include, but are not limited to slurred speech, difficulty walking
or performing job activities;
(x)
Violation of any provision of this subsection may result in termination of the
Provider agreement under these rules.
(L) The Provider must comply and cause all
sub-contractors to comply with the Pro-Children Act of 1994 (codified at
20 USC section
6081 et. seq.);
(M) The Provider must comply with all
applicable federal and state laws and regulations pertaining to the provision
of Medicaid Services under the Medicaid Act, Title XIX,
42 USC Section
1396 et. Seq., and CHIP benefits established
by Title XXI of the Social Security Act, including without limitation:
(i) Keep such records as are necessary to
fully disclose the extent of the services provided to individuals receiving
Medicaid assistance and must furnish such information to any state or federal
agency responsible for administering the Medicaid program regarding any
payments claimed by such person or institution for providing Medicaid Services
as the state or federal agency may from time to time request.
42 USC Section
1396a(a)(27);
42 CFR
431.107(b)(1) & (2);
42 CFR
457.950(a)(3);
(ii) Comply with all disclosure requirements
of 42 CFR
1002.3(a) and 42 CFR 455
Subpart (B); 42 CFR
457.950(a)(3);
(iii) Maintain written notices and procedures
respecting advance directives in compliance with
42 USC Section
1396a(a)(57) and (w),
42 CFR
431.107(b)(4), and 42 CFR
489 subpart I;
(iv) Certify when
submitting any claim for the provision of Medicaid Services that the
information submitted is true, accurate and complete. The Provider must
acknowledge Provider's understanding that payment of the claim will be from
federal and state funds and that any falsification or concealment of a material
fact may be prosecuted under federal and state laws.
(2) Hospitals, Nursing
Facilities, Home Health Agencies (including those providing personal care),
Hospices and Health Maintenance Organizations will comply with the Patient
Self-Determination Act as set forth in Section 4751 of OBRA 1991. To comply
with the obligation under the above listed laws to deliver information on the
rights of the individual under Oregon law to make health care decisions, the
named Providers and organizations will give capable individuals over the age of
18 a copy of "Your Right to Make Health Care Decisions in Oregon," copyright
1993, by the Oregon State Bar Health Law Section. Out-of-State Providers of
these services should comply with Medicare, Medicaid and CHIP regulations in
their state. Submittal to the Division of the appropriate billing form
requesting payment for medical services provided to a Medicaid/CHIP eligible
client shall be deemed representation to the Division of the medical Provider's
compliance with the above-listed laws.
(3) Providers described in ORS chapter 419B
are required to report suspected child abuse to their local Authority Children,
Adults and Families office or police, in the manner described in ORS
419.
(4) The Clinical Laboratory
Improvement Act (CLIA), requires all entities that perform even one laboratory
test, including waived tests on, "materials derived from the human body for the
purpose of providing information for the diagnosis, prevention or treatment of
any disease or impairment of, or the assessment of the health of, human beings"
to meet certain federal requirements. If an entity performs tests for these
purposes, it is considered, under CLIA to be a laboratory.
Notes
Publications: Publications referenced are available from the agency.
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
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