ORS 442.464, 442.466, 442.993
442.464 Definitions for ORS 442.464 and 442.466. As used in this section and ORS 442.466, “reporting entity” means:
(1) An insurer as defined in ORS 731.106 or fraternal benefit society as described in ORS 748.106 required to have a certificate of authority to transact health insurance business in this state.
(2) A health care service contractor as defined in ORS 750.005 that issues medical insurance in this state.
(3) A third party administrator required to obtain a license under ORS 744.702.
(4) A pharmacy benefit manager or fiscal intermediary, or other person that is by statute, contract or agreement legally responsible for payment of a claim for a health care item or service.
(5) A coordinated care organization as defined in ORS 414.025.
(6) An insurer providing coverage funded under Part A, Part B or Part D of Title XVIII of the Social Security Act, subject to approval by the United States Department of Health and Human Services. [2009 c.595 §1200; 2011 c.602 §54]
Note: 442.464 to 442.468 were enacted into law by the Legislative Assembly but were not added to or made a part of ORS chapter 442 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.
442.466 Health care data reporting by health insurers. (1) The Administrator of the Office for Oregon Health Policy and Research shall establish and maintain a program that requires reporting entities to report health care data for the following purposes:
(a) Determining the maximum capacity and distribution of existing resources allocated to health care.
(b) Identifying the demands for health care.
(c) Allowing health care policymakers to make informed choices.
(d) Evaluating the effectiveness of intervention programs in improving health outcomes.
(e) Comparing the costs and effectiveness of various treatment settings and approaches.
(f) Providing information to consumers and purchasers of health care.
(g) Improving the quality and affordability of health care and health care coverage.
(h) Assisting the administrator in furthering the health policies expressed by the Legislative Assembly in ORS 442.025.
(i) Evaluating health disparities, including but not limited to disparities related to race and ethnicity.
(2) The Administrator of the Office for Oregon Health Policy and Research shall prescribe by rule standards that are consistent with standards adopted by the Accredited Standards Committee X12 of the American National Standards Institute, the Centers for Medicare and Medicaid Services and the National Council for Prescription Drug Programs that:
(a) Establish the time, place, form and manner of reporting data under this section, including but not limited to:
(A) Requiring the use of unique patient and provider identifiers;
(B) Specifying a uniform coding system that reflects all health care utilization and costs for health care services provided to Oregon residents in other states; and
(C) Establishing enrollment thresholds below which reporting will not be required.
(b) Establish the types of data to be reported under this section, including but not limited to:
(A) Health care claims and enrollment data used by reporting entities and paid health care claims data;
(B) Reports, schedules, statistics or other data relating to health care costs, prices, quality, utilization or resources determined by the administrator to be necessary to carry out the purposes of this section; and
(C) Data related to race, ethnicity and primary language collected in a manner consistent with established national standards.
(3) Any third party administrator that is not required to obtain a license under ORS 744.702 and that is legally responsible for payment of a claim for a health care item or service provided to an Oregon resident may report to the Administrator of the Office for Oregon Health Policy and Research the health care data described in subsection (2) of this section.
(4) The Administrator of the Office for Oregon Health Policy and Research shall adopt rules establishing requirements for reporting entities to train providers on protocols for collecting race, ethnicity and primary language data in a culturally competent manner.
(5) The Administrator of the Office for Oregon Health Policy and Research shall use data collected under this section to provide information to consumers of health care to empower the consumers to make economically sound and medically appropriate decisions. The information must include, but not be limited to, the prices and quality of health care services.
(6) The Administrator of the Office for Oregon Health Policy and Research may contract with a third party to collect and process the health care data reported under this section. The contract must prohibit the collection of Social Security numbers and must prohibit the disclosure or use of the data for any purpose other than those specifically authorized by the contract. The contract must require the third party to transmit all data collected and processed under the contract to the Office for Oregon Health Policy and Research.
(7) The Administrator of the Office for Oregon Health Policy and Research shall facilitate a collaboration between the Department of Human Services, the Oregon Health Authority, the Department of Consumer and Business Services and interested stakeholders to develop a comprehensive health care information system using the data reported under this section and collected by the office under ORS 442.120 and 442.400 to 442.463. The administrator, in consultation with interested stakeholders, shall:
(a) Formulate the data sets that will be included in the system;
(b) Establish the criteria and procedures for the development of limited use data sets;
(c) Establish the criteria and procedures to ensure that limited use data sets are accessible and compliant with federal and state privacy laws; and
(d) Establish a time frame for the creation of the comprehensive health care information system.
(8) Information disclosed through the comprehensive health care information system described in subsection (7) of this section:
(a) Shall be available, when disclosed in a form and manner that ensures the privacy and security of personal health information as required by state and federal laws, as a resource to insurers, employers, providers, purchasers of health care and state agencies to allow for continuous review of health care utilization, expenditures and performance in this state;
(b) Shall be available to Oregon programs for quality in health care for use in improving health care in Oregon, subject to rules prescribed by the Administrator of the Office for Oregon Health Policy and Research conforming to state and federal privacy laws or limiting access to limited use data sets;
(c) Shall be presented to allow for comparisons of geographic, demographic and economic factors and institutional size; and
(d) May not disclose trade secrets of reporting entities.
(9) The collection, storage and release of health care data and other information under this section is subject to the requirements of the federal Health Insurance Portability and Accountability Act. [2009 c.595 §1201]
Note: See note under 442.464.
442.993 Civil penalties for failure to report health care data of health insurers. (1) Any reporting entity that fails to report as required in ORS 442.466 or rules of the Office for Oregon Health Policy and Research adopted pursuant to ORS 442.466 may be subject to a civil penalty.
(2) The Administrator of the Office for Oregon Health Policy and Research shall adopt a schedule of penalties not to exceed $500 per day of violation, determined by the severity of the violation.
(3) Civil penalties under this section shall be imposed as provided in ORS 183.745.
(4) Civil penalties imposed under this section may be remitted or mitigated upon such terms and conditions as the administrator considers proper and consistent with the public health and safety.
(5) Civil penalties incurred under any law of this state are not allowable as costs for the purpose of rate determination or for reimbursement by a third-party payer. [2009 c.595 §1202]
Note: 442.993 was enacted into law by the Legislative Assembly but was not added to or made a part of ORS chapter 442 or any series therein by legislative action. See Preface to Oregon Revised Statutes for further explanation.