Or. Admin. Code § 410-141-5005 - FINANCIAL SOLVENCY REGULATION: CCO Financial Solvency Requirements

(1) A CCO shall assume the risk for providing capitated services under the CCO Contract.

(2) Each CCO must demonstrate that it is able to provide coordinated care services efficiently, effectively, and economically. CCOs shall maintain sound financial management procedures, maintain protections against insolvency, and generate periodic financial reports as provided in these rules.

(3) A CCO shall comply with all applicable laws relating to solvency requirements of CCOs and the terms of the Contract. Solvency requirements shall include the following components:

(a) Maintenance of Restricted Reserve Funds as required by OAR 410-141-5185;

(b) Protection against catastrophic and unexpected loss or expenses related to capitated services for a CCOs Loss Protection Program; A CCO's Loss Protection Program:

(A) May include stop loss insurance coverage, reinsurance or such other alternative protection(s) as may be approved by the Authority, and

(B) Shall be subject to the Authority's review and approval.

(c) Any material change to a CCO's Loss Protection Program shall be submitted to the Authority in writing and shall be subject to the Authority's review and approval;

(d) Maintenance of professional liability coverage of not less than $1,000,000 per person per incident and not less than $1,000,000 in the aggregate either through binder issued by an insurance carrier or by self-insurance with proof of same acceptable to the Authority; and

(e) Management systems, practices and procedures that capture, compile, and evaluate information and data concerning financial operations. Such systems shall include, without limitation, the following features and functionalities:

(A) Determination of future budget requirements for the next three quarters.

(B) Determination of incurred but not reported expenses.

(C) Tracking additions and deletions of Members and accounting for capitation payments.

(D) Tracking claims payment.

(E) Tracking all monies collected from third party resources on behalf of Members.

(F) Documentation of, and reports on the use of, incentive payment mechanisms, risk-sharing, and risk-pooling, as applicable.

Notes

Or. Admin. Code § 410-141-5005

DMAP 58-2019, adopt filed 12/18/2019, effective 1/1/2020; DMAP 143-2024, amend filed 12/29/2024, effective 1/1/2025

Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605

Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430