ORS 414.631: Mandatory enrollment in coordinated care organization; exemptions.
Edition: 2025 EditionEffective: 2026-01-01Last verified: 2026-09-07
(1) Except as provided in subsections (2), (3), (4) and (5) of this section and ORS 414.632 (2), a person who is eligible for or receiving health services must be enrolled in a coordinated care organization to receive the health services for which the person is eligible. For purposes of this subsection, Medicaid-funded long term care services do not constitute health services. (2) Subsections (1) and (4) of this section do not apply to: (a) A person who is a noncitizen and who is eligible only for labor and delivery services and emergency treatment services; (b) A person who is an American Indian and Alaska Native beneficiary; (c) An individual described in ORS 414.632 (2) who is dually eligible for Medicare and Medicaid and enrolled in a program of all-inclusive care for the elderly; and (d) A person whom the Oregon Health Authority may by rule exempt from the mandatory enrollment requirement of subsection (1) of this section, including but not limited to: (A) A person who is also eligible for Medicare; (B) A woman in her third trimester of pregnancy at the time of enrollment; (C) A person under 19 years of age who has been placed in adoptive or foster care out of state; (D) A person under 18 years of age who is medically fragile and who has special health care needs; (E) A person receiving services under the Medically Involved Home-Care Program created by ORS 417.345 (1); and (F) A person with major medical coverage. (3) Subsection (1) of this section does not apply to a person who resides in an area that is not served by a coordinated care organization or where the organization’s provider network is inadequate. (4) In any area that is not served by a coordinated care organization but is served by a prepaid managed care health services organization, a person must enroll with the prepaid managed care health services organization to receive any of the health services offered by the prepaid managed care health services organization. (5) As used in this section, “American Indian and Alaska Native beneficiary” means: (a) A member of a federally recognized Indian tribe; (b) An individual who resides in an urban center and: (A) Is a member of a tribe, band or other organized group of Indians, including those tribes, bands or groups whose recognition was terminated since 1940 and those recognized now or in the future by the state in which the member resides, or who is a descendant in the first or second degree of such a member; (B) Is an Eskimo or Aleut or other Alaska Native; or (C) Is determined to be an Indian under regulations promulgated by the United States Secretary of the Interior; (c) A person who is considered by the United States Secretary of the Interior to be an Indian for any purpose; or (d) An individual who is considered by the United States Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut or other Alaska Native. [Formerly 414.737; 2021 c.97 §41]
Administrative rules citing this section
- OAR 410-115-0040: Service Authorization. — implements
- OAR 410-120-1260: Provider Enrollment — implements
- OAR 410-141-3501: Administration of Oregon Integrated and Coordinated Health Care Delivery System Regulation; Rule Precedence — implements
- OAR 410-141-3505: Use of Subcontractors — implements
- OAR 410-141-3515: Network Adequacy — implements
- OAR 410-141-3520: Record Keeping and Use of Health Information Technology — implements
- OAR 410-141-3525: Outcome and Quality Measures — implements
- OAR 410-141-3540: Member Protections — implements
- OAR 410-141-3555: Resolving Disputes between Health Care Entities and CCOs that Concern CCO Contact Award — implements
- OAR 410-141-3560: Resolving Contract Disputes Between Health Care Entities and CCOs — implements
- OAR 410-141-3570: Managed Care Entity Encounter Claims Data Reporting — implements
- OAR 410-141-3575: MCE Member Relations: Marketing — implements
- OAR 410-141-3580: MCE Member Relations: Potential Member Information — implements
- OAR 410-141-3590: MCE Member Relations: Member Rights and Responsibilities — implements
- OAR 410-141-3700: CCO Application and Contracting Procedures — implements
- OAR 410-141-3705: Criteria for CCOs — implements
- OAR 410-141-3725: CCO Contract Renewal Notification — implements
- OAR 410-141-3730: Community Health Assessment and Community Health Improvement Plans — implements
- OAR 410-141-3735: Social Determinants of Health and Equity; Health Equity — implements
- OAR 410-141-3740: Traditional Health Workers — implements
- OAR 410-141-3800: CCO Enrollment for Children Receiving Health Services — implements
- OAR 410-141-3815: CCO Enrollment for Temporary Out-of-Area Behavioral Health Treatment Services — implements
- OAR 410-141-3815: CCO Enrollment for Temporary Out-of-Area Behavioral Health Treatment Services — authority
- OAR 410-141-3840: Emergency and Urgent Care Services — implements
- OAR 410-141-3855: Temporary rule language in effect until 10/27/2026. Pharmaceutical Services — implements
- OAR 410-141-3865: Care Coordination: Identification of Member Needs — implements
- OAR 410-141-3870: Care Coordination: Service Coordination — implements
- OAR 410-141-3880: Grievances & Appeals: Grievance Process Requirements — implements
- OAR 410-141-3900: Grievances & Appeals: Contested Case Hearings — implements
- OAR 410-141-3910: Grievances & Appeals: Continuation of Benefits — implements
- OAR 410-141-5000: FINANCIAL SOLVENCY REGULATION: Definitions — implements
- OAR 410-141-5005: FINANCIAL SOLVENCY REGULATION: CCO Financial Solvency Requirements — implements
- OAR 410-141-5010: FINANCIAL SOLVENCY REGULATION: Procedure for General Financial Reporting and for Determining Financial Solvency Matters — implements
- OAR 410-141-5015: FINANCIAL SOLVENCY REGULATION: Financial Statement Reporting — implements
- OAR 410-141-5020: FINANCIAL SOLVENCY REGULATION: Annual Audited Financial Statements and Auditor’s Report — implements
- OAR 410-141-5025: FINANCIAL SOLVENCY REGULATION: Qualifications of Independent Certified Public Accountant — implements
- OAR 410-141-5030: FINANCIAL SOLVENCY REGULATION: Notification of Adverse Financial Condition — implements
- OAR 410-141-5035: FINANCIAL SOLVENCY REGULATION: Accountant's Letter of Qualifications — implements
- OAR 410-141-5040: FINANCIAL SOLVENCY REGULATION: Independent Certified Public Accountants Workpapers — implements
- OAR 410-141-5045: FINANCIAL SOLVENCY REGULATION: Corporate Governance Annual Disclosure Filing — implements
- OAR 410-141-5050: FINANCIAL SOLVENCY REGULATION: Requirements for Reinsurance — implements
- OAR 410-141-5055: FINANCIAL SOLVENCY REGULATION: Requirements for Obtaining Credit for Reinsurance — implements
- OAR 410-141-5060: FINANCIAL SOLVENCY REGULATION: Qualified Trust Agreements — implements
- OAR 410-141-5065: FINANCIAL SOLVENCY REGULATION: Letters of Credit; Other Security — implements
- OAR 410-141-5070: FINANCIAL SOLVENCY REGULATION: Assets, Liabilities, Reserves — implements
- OAR 410-141-5075: FINANCIAL SOLVENCY REGULATION: Disallowance of Certain Reinsurance Transactions — implements
- OAR 410-141-5080: FINANCIAL SOLVENCY REGULATION: Transparency — implements
- OAR 410-141-5085: ASSET VALUATION AND PERMITTED INVESTMENTS: Definitions — implements
- OAR 410-141-5090: ASSET VALUATION AND PERMITTED INVESTMENTS: Calculation of Value; Books and Records — implements
- OAR 410-141-5095: ASSET VALUATION AND PERMITTED INVESTMENTS: Assets Other Than Securities; Bonds; Real Property; Mortgages; Compensating Balances — implements
- OAR 410-141-5100: ASSET VALUATION AND PERMITTED INVESTMENTS: Investments Used to Provide Compensating Balances — implements
- OAR 410-141-5105: ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Required Capitalization — implements
- OAR 410-141-5110: ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Mortgage Loans — implements
- OAR 410-141-5115: ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Real Property — implements
- OAR 410-141-5120: ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Corporate Stocks — implements
- OAR 410-141-5125: ASSET VALUATION AND PERMITTED INVESTMENTS: Loans; Security; Limitations — implements
- OAR 410-141-5130: ASSET VALUATION AND PERMITTED INVESTMENTS: Investments; Certain Obligations, Property, Loans and Other Specified Items — implements
- OAR 410-141-5135: ASSET VALUATION AND PERMITTED INVESTMENTS: Personal Property; Protection of Investment Property; Custom — implements
- OAR 410-141-5140: ASSET VALUATION AND PERMITTED INVESTMENTS: “Prudent Investor” Standard — implements
- OAR 410-141-5145: ASSET VALUATION AND PERMITTED INVESTMENTS: Prohibited Conduct by Directors, Trustees, Officers, Agents or Employees — implements
- OAR 410-141-5150: ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Funds in Obligations That Are Not Investment Quality; Percentage of Assets — implements
- OAR 410-141-5155: ASSET VALUATION AND PERMITTED INVESTMENTS: Approval by Board — implements
- OAR 410-141-5160: ASSET VALUATION AND PERMITTED INVESTMENTS: Record of Investments — implements
- OAR 410-141-5165: ASSET VALUATION AND PERMITTED INVESTMENTS: Prohibited Investments — implements
- OAR 410-141-5170: CAPITALIZATION: Capital and Surplus — implements
- OAR 410-141-5175: CAPITALIZATION: Impaired Capital and Surplus — implements
- OAR 410-141-5180: CAPITALIZATION: Dividend and Distribution Restrictions — implements
- OAR 410-141-5185: CAPITALIZATION: Restricted Reserve Account — implements
- OAR 410-141-5186: CAPITALIZATION: Restricted Reserve Account—Permitted Investments in Obligations with Political Subdivisions; Public Supported Housing — implements
- OAR 410-141-5190: CAPITALIZATION: Surplus Notes — implements
- OAR 410-141-5195: CAPITALIZATION: Risk-based Capital (RBC) Definitions — implements
- OAR 410-141-5200: CAPITALIZATION: RBC Reports — implements
- OAR 410-141-5205: CAPITALIZATION: Company Action Level Event — implements
- OAR 410-141-5210: CAPITALIZATION: Regulatory Action Level Event — implements
- OAR 410-141-5215: CAPITALIZATION: Authorized Control Level Event — implements
- OAR 410-141-5220: CAPITALIZATION: Mandatory Control Level Event — implements
- OAR 410-141-5225: REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Extraordinary Dividends and Other Distributions — implements
- OAR 410-141-5230: REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Reports of Material Acquisitions And Dispositions Of Assets, and Changes to Ceded Reinsurance Agreements; Assumption Reinsurance — implements
- OAR 410-141-5235: REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Reports of Material Materiality and Reporting Standards for Asset Acquisitions and Dispositions — implements
- OAR 410-141-5240: REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Materiality and Reporting Standards for Changes in Ceded Reinsurance Agreements — implements
- OAR 410-141-5245: EXAMINATIONS: CCO Production of Books and Records — implements
- OAR 410-141-5250: EXAMINATIONS: Authority Examinations of CCOs — implements
- OAR 410-141-5255: CCO ACQUISITIONS AND MERGERS: Purpose; Definitions — implements
- OAR 410-141-5260: CCO ACQUISITIONS AND MERGERS: Activities Prohibited Unless Certain Provisions Satisfied — implements
- OAR 410-141-5265: CCO ACQUISITIONS AND MERGERS: Procedure For Acquiring Controlling Interest — implements
- OAR 410-141-5270: CCO ACQUISITIONS AND MERGERS: Information to Be Included in Form A — implements
- OAR 410-141-5275: CCO ACQUISITIONS AND MERGERS: Hearing, Request, Notice — implements
- OAR 410-141-5278: CCO ACQUISITIONS AND MERGERS: Confidentiality — implements
- OAR 410-141-5280: CCO ACQUISITIONS AND MERGERS: Determination Concerning Proposed Activity, Time For Decision, Grounds For Refusal — implements
- OAR 410-141-5283: CCO ACQUISITIONS AND MERGERS: Compliance with Conditions — implements
- OAR 410-141-5285: CCO HOLDING COMPANY REGULATION: Definitions — implements
- OAR 410-141-5290: CCO HOLDING COMPANY REGULATION: Members of Holding Company Systems; Registration Requirements — implements
- OAR 410-141-5295: CCO HOLDING COMPANY REGULATION: Form and Contents of Registration Statement — implements
- OAR 410-141-5300: CCO HOLDING COMPANY REGULATION: Registration Statement Filing — implements
- OAR 410-141-5305: CCO HOLDING COMPANY REGULATION: Information Required to Be Disclosed — implements
- OAR 410-141-5310: CCO HOLDING COMPANY REGULATION: Presumption of Control; Rebuttal — implements
- OAR 410-141-5315: CCO HOLDING COMPANY REGULATION: Disclaimer of Affiliation — implements
- OAR 410-141-5318: CCO Holding Company Regulation: Group Capital Calculation — implements
- OAR 410-141-5320: CCO HOLDING COMPANY REGULATION: Transactions Within Holding Company — implements
- OAR 410-141-5323: CCO HOLDING COMPANY REGULATION: Transaction Types Within Holding Company for Disclosure — implements
- OAR 410-141-5325: CCO HOLDING COMPANY REGULATION: Director and Officer Liability; Effect of Control of CCO Subject to Registration; Board of Directors — implements
- OAR 410-141-5330: CCO HOLDING COMPANY REGULATION: Annual Enterprise Risk Report — implements
- OAR 410-141-5335: CCO HOLDING COMPANY REGULATION: Disclaimers and Termination of Registration — implements
- OAR 410-141-5340: CCO HOLDING COMPANY REGULATION: Forms; General Requirements — implements
- OAR 410-141-5345: CCO HOLDING COMPANY REGULATION: Forms; Incorporation by Reference, Summaries, And Omissions — implements
- OAR 410-141-5350: CCO HOLDING COMPANY REGULATION: Forms; Information Unknown or Unavailable and Extension of Time to Furnish — implements
- OAR 410-141-5355: CCO HOLDING COMPANY REGULATION: Forms; Additional Information; Amendments — implements
- OAR 410-141-5360: CCO INSOLVENCY AND DISSOLUTION: Access to Funds and Transition of Members and Records — implements
- OAR 410-141-5365: CCO INSOLVENCY AND DISSOLUTION: Hazardous Operations — implements
- OAR 410-141-5370: CCO INSOLVENCY AND DISSOLUTION: Recovery From Parent Corporation Or Holding Company In The Event Of Liquidation Or Rehabilitation — implements
- OAR 410-141-5375: CCO INSOLVENCY AND DISSOLUTION: Voluntary Dissolution; Approval of Plan — implements
- OAR 410-141-5380: CIVIL PENALTIES — implements
This rule cites
- ORS 414.632 — resolved
- ORS 417.345 — resolved
Cited by
- ORS 192.395: Health services costs.
- ORS 414.329: Prescription drug benefits for certain persons who are eligible for Medicare Part D prescription drug coverage; rules.
- ORS 414.428: Coverage for American Indian and Alaska Native beneficiaries.
- ORS 414.654: Persons served by prepaid managed care health services organizations; funding of health information technology.
- ORS 414.712: Health services for certain eligible persons.
- ORS 414.735: Reduction in scope of health services in event of insufficient resources; approval of Legislative Assembly or Emergency Board; notice to providers.
- ORS 414.743: Payment to noncontracting hospital by coordinated care organization; rules.
- ORS 414.745: Liability of health care providers and plans.
- ORS 414.855: Hospital assessment; rates; rules.
- ORS 414.869: Establishment of Hospital Quality Assurance Fund.
- OAR 410-141-3800: CCO Enrollment for Children Receiving Health Services
- OAR 410-141-3805: Mandatory MCE Enrollment Exceptions
Official source: https://www.oregonlegislature.gov/bills_laws/ors/ors414.html