Or. Admin. Code § 410-141-5015

Current through Register Vol. 64, No. 1, January 1, 2025

Section 410-141-5015 - FINANCIAL SOLVENCY REGULATION: Financial Statement Reporting

(1) Financial reports to the Authority. A CCO shall submit the following to the Authority:

(a) On or before April 30 of each year, an unaudited financial statement for the 12-month period ending the 31st day of December immediately preceding;

(b) Unaudited quarterly financial statements each year according to the following schedule:

(A) On or before May 31 for the quarter ending the 31st day of March immediately preceding;

(B) On or before August 31 for the quarter ending the 30th day of June immediately preceding;

(C) On or before November 30 of each year for the quarter ending the 30th day of September immediately preceding.

(c) On or before June 30 of each year, an audited financial statement for the year ending the 31st of December immediately preceding.

(2) Except as otherwise allowed or required by the Authority, all annual and quarterly financial statements filed by a CCO with the Authority shall:

(a) Follow and be presented in accordance with Statutory Accounting Principles;

(b) Use a form established by the NAIC, including the instructions, and must complete the form according to the instructions:

(A) For the 2024 reporting year, on the annual statement approved for the 2024 reporting year by the NAIC, according to the applicable instructions published for that year by the NAIC;

(B) For the 2025 reporting year, on the annual statement approved for the 2025 reporting year by the NAIC, according to the applicable instructions published for that year by the NAIC;

(C) For the 2026 reporting year, on the annual statement approved for the 2026 reporting year by the NAIC, according to the applicable instructions published for that year by the NAIC;

(D) For the 2027 reporting year, on the annual statement approved for the 2027 reporting year by the NAIC, according to the applicable instructions published for that year by the NAIC.

(c) Be verified by the oaths of the president and secretary of the CCO or, in their absence, by two other duly authorized and acting principal officers; and

(d) Include the additional information listed in sections (4), (5) and (6) of this rule.

(3) Audited annual financial statements shall be subject to, and shall comply with, the requirements set forth in OAR 410-141-5020 through OAR 410-141-5040. Additional instructions for the filing of financial statements and reports are posted on the Authority's website at https://www.oregon.gov/oha/hsd/ohp/pages/cco-contract-forms.aspx.

(4) A CCO shall include the following as supplements to the CCO's quarterly and annual financial statement filings, using forms and templates prescribed by the Authority:

(a) An Annual Disclosure of Compensation Exhibit, disclosing the salary and benefits of the three officers or employees having the highest total compensation for the period. This exhibit shall be required only with the CCO's annual Exhibit L filing;

(b) A report of Health-Related Services (as defined by OAR 410-141-3500 and 410-141-3845) and additional supplemental information, including care coordination, case management, flexible services, and community benefit expenses. CCOs shall comply with the following additional requirements regarding Health-Related Services:

(A) Health-Related Services shall be considered in the rate setting consistent with the State 1115 Waiver;

(B) Health-Related Services shall be included as Activities that Improve Health Care Quality in the Minimum Medical Loss Ratio Rebate Calculation report.

(c) A certification of compliance with financial and encounter data reporting requirements;

(d) A report of third-party resources collections (CCO contractor);

(e) A report of Corporate Relationships of Contractors and Incentive Plan Disclosure and Detail (CCOs);

(f) CCO-specific utilization reports;

(g) Any other supplemental information deemed necessary by the Authority and specified in Exhibit L to the CCO Contract.

(5) A CCO shall report the following information in respect of the CCO's Restricted Reserve, using forms and templates prescribed by the Authority:

(a) Identification of custodians, account balances and assets comprising Restricted Reserve Funds held by a third-party;

(b) A bank statement from each custodian of Restricted Reserve Funds of the account balance or aggregate fair market value of the assets comprising the Restricted Reserve Funds held by the custodian;

(c) Documentation of the liability that would be owed to creditors in the event of the CCO's insolvency;

(d) Documentation of the dollar amount of that liability that is covered by any identified risk-adjustment mechanisms.

(6) A CCO shall report the following information in respect of any Sub-Capitation Arrangements to which the CCO is a party, using forms and templates prescribed by the Authority:

(a) A CCO that sub-capitates any work described in its agreements with the Authority shall require the Sub-Capitated Counterparty to report financial information as specified in the CCO's agreements with the Authority;

(b) CCOs that make sub-capitation payments exceeding an annual amount defined by financial reporting instructions under the CCO Contract shall submit to the Authority on an annual basis the following financial reports with respect to each of the CCO's Sub-Capitated Counterparties:

(A) Statements of revenue, expenses and net income;

(B) Restricted Reserve Account documentation;

(C) Certification of compliance with financial and encounter data reporting requirements;

(D) Any supplemental information deemed necessary by the Authority.

(7) Following termination of the CCO Contract, the annual reports described in this rule are due for the last calendar year during which the CCO operated, and its quarterly reports are due until its last annual report has been filed.

(8) The CCO shall make such additional filings with the Authority as are required by the CCO's agreement with the Authority and as otherwise may be determined by the Authority from time to time to be necessary under the circumstances.

Or. Admin. Code § 410-141-5015

DMAP 58-2019, adopt filed 12/18/2019, effective 1/1/2020; DMAP 89-2022, amend filed 12/16/2022, effective 1/1/2023; DMAP 143-2024, amend filed 12/29/2024, effective 1/1/2025

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

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