Or. Admin. Code § 410-141-5000

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-141-5000 - FINANCIAL SOLVENCY REGULATION: Definitions

When used and not otherwise defined in OAR 410-141-5005 through OAR-141-5380, the following terms shall have the meaning given in this section:

(1) "AICPA" means the American Institute of Certified Public Accountants.

(2) "Applicable Law" means,

(a) S.B. 1041;

(b) OAR 410-141-5000 to OAR-141-5380 and;

(c) Any other state or federal laws, rules, regulations or regulatory guidance applicable to the operations of CCOs in this state.

(3) "Assumption Reinsurance Agreement" means a contract that:

(a) Transfers obligations or risks of existing or in-force Member Contracts from a cedent CCO to a reinsurer that acquires the obligations or risks from the cedent; and

(b) Is intended to affect a novation of the transferred Member Contracts with the result that the reinsurer becomes directly liable to the Members of the transferor and the transferor's contract obligations to the Members are extinguished.

(4) "Board" means the board of directors or other equivalent governing body of a company that is vested by the company's organizational document(s) with responsibility and authority for the governance and overall management of the affairs of the company, irrespective of the name by which the governing body or the members of that governing body are designated, except that:

(a) An individual or a group of individuals is not the board of directors because of powers delegated to the individual or group by provisions in the articles of incorporation or other equivalent organizational documents authorizing the individual or group to exercise some or all of the powers which would otherwise be exercised by a board; and

(b) A coordinated care organization may have a governing body as required by ORS 414.625(2)(o) that is not the board of the CCO entity.

(5) "Capitated Subcontractor" means a third-party provider that enters into a Sub-capitation Arrangement with a CCO for any portion of the health care services covered by the CCO's agreement with the Authority.

(6) "CGAD Report" means the corporate governance annual disclosure report described at OAR 410-141-5045.

(7) "DCBS" means the Department of Consumer and Business Services.

(8) "Delinquency proceeding" means any proceeding commenced against a CCO for the purpose of liquidating, rehabilitating or conserving the CCO.

(9) "Director" means, as context requires;

(a) A member of the board of directors or other equivalent governing body of a company that is vested by the company's organizational document(s) with the responsibility and authority for the governance and overall management of the affairs of the company; or

(b) The Director of the Authority.

(10) "Impaired" with respect to a CCO means that the CCO's assets do not exceed its liabilities and its required capitalization.

(11) "Loss Protection Program" means a program or set of arrangements maintained by a CCO that collectively are designed and operate to protect the CCO against catastrophic and unexpected loss or expenses related to capitated services the CCO is obligated to provide to its Members.

(12) "Member" means an individual covered by, and entitled to managed health care services under, a CCO's contract with the Authority.

(13) "Member Contract" means the CCO's agreement to provide managed health care services to a Member pursuant to the CCO's contract with the Authority.

(14) "NAIC" means the National Association of Insurance Commissioners.

(15) "NAIC Forms and Instructions" means the current financial statement blanks, forms and instructions for health insurers as published and as revised by the NAIC from time to time.

(16) "Qualified United States Financial Institution" means an institution that:

(a) Is organized, or, in the case of a United States branch or agency office of a foreign banking organization, is licensed, under the laws of the United States or any state thereof and has been granted authority to operate with fiduciary powers; and

(b) Is regulated, supervised and examined by federal or state authorities having regulatory authority over banks and trust companies.

(17) "Political subdivision" means, consistent with ORS 192.005, any city, county, district or any other municipal or public corporation in the State of Oregon.

(18) "Primary Reserve" means the primary Restricted Reserve Fund required by OAR 410-141-5285.

(19) "Receiver" means a receiver, rehabilitator, liquidator or conservator, as the contract may require.

(20) "Restricted Reserve Account" means the reserve account required by OAR 410-141-5285.

(21) "Restricted Reserve Funds" means the funds required to be deposited and maintained in the Restricted Reserve Account under OAR 410-141-5285.

(22) "Restricted Reserve" means the Restricted Reserve Account, the Primary Reserve, the Secondary Reserve and the Restricted Reserve Funds required by OAR 410-141-5285.

(23) "Secondary Reserve" means the secondary Restricted Reserve Fund required by OAR 410-141-5285.

(24) "S.B. 1041" means 2019 Oregon Laws Ch. 478 (Enrolled S.B. 1041), as approved and enacted on June 20, 2019.

(25) "Statutory Accounting Principles" means generally accepted statutory accounting principles for health insurers as prescribed, adopted or otherwise approved by DCBS for the financial and solvency regulation of health insurers under Oregon law, as supplemented by generally accepted statutory accounting principles prescribed, adopted or otherwise approved by the NAIC, including without limitation, those accounting practices, principles and procedures set forth in the NAIC's Accounting Practices and Procedures Manual.

(26) "Sub-Capitated Arrangement" means a contract or other arrangement between the CCO and a Sub-Capitated Counterparty under which the Sub-Capitated Counterparty agrees to provide, as subcontractor to the CCO, certain of the health care services required of the CCO under its agreement with the Authority in return for a fixed capitation payment, the effect of which is to transfer claim frequency and utilization risk to the third-party provider.

(27) "Sub-Capitated Counterparty" means the third-party provider under a Sub-Capitated Arrangement with a CCO.

(28) "SVO" means the Securities Valuation Office of the NAIC.

Or. Admin. Code § 410-141-5000

DMAP 58-2019, adopt filed 12/18/2019, effective 1/1/2020; DMAP 3-2020, temporary amend filed 02/12/2020, effective 02/12/2020 through 08/09/2020; DMAP 38-2020, amend filed 08/05/2020, effective 8/7/2020; DMAP 56-2021, amend filed 12/30/2021, effective 1/1/2022

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651

Statutes/Other Implemented: ORS 414.610 - 414.685