Go Back To Oars 410-141-0000 Through 410-141-0860

Link to law: http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_141_3000-3430.html
Published: 2015

The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 

DIVISION 141
OREGON HEALTH PLAN
SCROLL DOWN TO VIEW OARs 410-141-3000 through 410-141-3430
GO BACK TO OARs 410-141-0000 through 410-141-0860

410-141-3000
Definitions
The
Oregon Health Authority adopts and incorporates by reference the definitions in
the following administrative rules and applies them to Health System Transformation
and the use of Coordinated Care Organizations:
(1)
OAR 309-012-0140, 309-016-0605, 309-032-0860, 309-032-1505, 309-033-0210, applicable
to mental health services;
(2)
OAR 410-120-0000, definitions of the Oregon Health Plan’s General Rules; and
(3)
OAR 410-141-0000, definitions of the Oregon Health Plan’s rules generally
applicable to prepaid managed health care organizations and coordinated care organizations.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 11-2012(Temp), f. & cert. ef. 3-16-12 thru 9-11-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3010
CCO
Application, Certification, and Contracting Procedures
(1) The following definitions apply
to this rule:
(a) “Applicant”
means the entity submitting an application to be certified as a CCO or to enter
into or amend a contract for coordinated care services;
(b) “Application”
means an entity’s written response to a Request for Application (RFA);
(c) “Award Date”
means the date on which the Authority acts on the applications by issuing or denying
certification and by awarding or not awarding contracts;
(d) “Certification”
means the Authority’s determination that an entity meets the criteria in OAR
410-141-3015 and the standards set forth in the RFA for being a CCO through initial
certification or recertification;
(e) “Coordinated Care
Services” means fully integrated physical health services, Substance Use Disorder
(SUD) treatment, and mental health services and shall include dental health services
as provided in ORS 414.625(3) no later than July 1, 2014;
(f) “CMS Medicare/Medicaid
Alignment Demonstration” means a demonstration proposal by the Authority to
CMS that will align and integrate Medicare and Medicaid benefits and financing to
the greatest extent feasible for individuals who are eligible for both programs.
The Authority and CMS shall jointly establish its timelines and requirements for
participation in the demonstration;
(g) “Entity”
means a single legal entity capable of entering into a risk contract that covers
coordinated care services with the state and conducting the business of a coordinated
care organization;
(h) “Request for Applications
(RFA)” means the document used for soliciting applications for certification
as a CCO, award of or amendment of a CCO services contract, or other objectives
as the Authority may determine appropriate for procuring coordinated care services.
(2) The Authority shall establish
an application process for entities seeking certification and contracts as CCOs.
(3) The Authority shall use
the following RFA processes for CCO certification and contracting:
(a) The Authority shall provide
public notice of every RFA on its website. The RFA shall indicate how prospective
applicants will be made aware of addenda by posting notice of the RFA on the electronic
system for notification to the public of Authority procurement opportunities or,
upon request, by mailing notice of the availability of the RFA to persons that have
expressed interest in the RFA;
(b) The RFA process begins
with a public notice that shall be communicated using the Authority’s website.
A public notice of an RFA shall identify the certification requirements for the
contract, the designated service areas where coordinated care services are requested,
and a sample contract;
(c) The RFA may specify that
applicants must submit a letter of intent to the Authority within the specified
time period. The letter of intent does not commit any applicant to apply. If a letter
of intent is required, the Authority may not consider applications from applicants
who fail to submit a timely letter of intent except as provided in the RFA;
(d) The RFA may request applicants
to appear at a public meeting to provide information about the application;
(e) The RFA will request
information from applicants in order to allow the Authority to engage in appropriate
state supervision necessary to promote state action immunity under state and federal
antitrust laws;
(f) The Authority shall consider
only applications that are responsive, completed as described in the RFA, and submitted
in the time and manner described in the RFA. The RFA may require submission of the
application on its web portal in accordance with OAR 137-047-0330 (Electronic Procurements).
If electronic procurement is used, applications shall be accepted only from applicants
who accept the terms and conditions for use of the Authority’s web portal.
(4) At recertification the
Authority may permit a current CCO contractor to submit an abbreviated application
that focuses only on additional or different requirements specific to the recertification
and new contract or the new addenda or capacity or other purposes within the scope
of the RFA.
(5) The Authority shall evaluate
applications for certification on the basis of criteria in OAR 410-141-3015, information
contained in the RFA, the application, and any additional information that the Authority
obtains. Application evaluations shall be based on RFA criteria;
(a) The Authority may enter
into negotiation with applicants concerning potential capacity and enrollment in
relation to other available or potentially available capacity, the number of potential
enrollees within the service area, and other factors identified in the RFA;
(b) The Authority shall notify
each applicant that applies for certification of its certification status;
(c) Applicants that meet
the RFA criteria shall be certified to contract as a CCO.
(6) Review for certification:
(a) The Authority shall issue
certification only to applicants that meet the criteria in OAR 410-141-3015, meet
the requirements, and provide the assurances specified in the RFA. The Authority
determines whether the applicant qualifies for certification based on the application
and any additional information and investigation that the Authority may require;
(b) The Authority determines
an applicant is eligible for certification when the applicant meets the requirements
of the RFA including written assurances satisfactory to the Authority that the applicant:
(A) Provides or will provide
the coordinated care services in the manner described in the RFA and the Authority’s
rules;
(B) Is responsible and meets
or will meet standards established by the Authority and DCBS for financial reporting
and solvency;
(C) Is organized and operated
and shall continue to be organized and operated in the manner required by the contract
and described in the application; and
(D) Shall comply with any
assurances it has given the Authority.
(7) The Authority shall certify
CCOs for a period of six years from the date the certification application is approved,
unless the Authority certifies a CCO for a shorter period.
(8) The Authority may determine
that an applicant is potentially eligible for certification in accordance with section
(9). The Authority is not obligated to determine whether an applicant is potentially
eligible for certification if, in its discretion, the Authority determines that
sufficient applicants eligible for certification are available to attain the Authority’s
objectives under the RFA.
(9) The Authority may determine
that an applicant is potentially eligible for certification if:
(a) The Authority finds that
the applicant is reasonably capable of meeting the operational and solvency requirements
of the RFA within a specified period of time; and
(b) The applicant enters
into discussions with the Authority about areas of qualification that must be met
before the applicant is operationally and financially eligible for certification.
The Authority shall determine the date and required documentation and written assurances
required from the applicant;
(c) If the Authority determines
that an applicant potentially eligible for certification cannot become certified
within the time announced in the RFA for contract award, the Authority may:
(A) Offer certification at
a future date when the applicant demonstrates to the Authority’s satisfaction
that the applicant is eligible for certification within the scope of the RFA; or
(B) Inform the applicant
that it is not eligible for certification.
(10) The Authority may award
contracts to certified CCOs for administering the Oregon Integrated and Coordinated
Health Care Delivery System.
(11) The Authority shall
enter into or renew a contract with a CCO only if the CCO has been certified and
the Authority determines that the contract would be within the scope of the RFA
and consistent with the purposes and effective administration of the Oregon Integrated
and Coordinated Health Care Delivery System that includes, but is not limited to:
(a) The capacity of any existing
CCO in the region compared to the capacity of an additional CCO for the number of
potential enrollees in the addenda;
(b) The number of CCOs in
the region.
(12) The application is the
applicant’s offer to enter into a contract and is a firm offer for the period
specified in the RFA. The Authority’s award of the contract constitutes acceptance
of the offer and binds the applicant to the contract:
(a) Except to the extent
the applicant is authorized to propose certain terms and conditions pursuant to
the RFA, an applicant may not make its offer contingent on the Authority’s
acceptance of any terms or conditions other than those contained in the RFA;
(b) Only an entity that the
Authority has certified to contract as a CCO may enter into a contract as a CCO.
Certification to contract as a CCO does not assure the CCO that it will be offered
a contract;
(c) The Authority may award
multiple contracts or make a single award or limited number of awards to all certified
or potentially certified applicants in order to meet the Authority’s needs
including, but not limited to, adequate capacity for the potential enrollees in
the service area, maximizing the availability of coordinated care services, and
achieving the objectives in the RFA;
(d) Subject to any limitations
in the RFA, the Authority may renew a contract for CCO services by amending an existing
contract or issuing a replacement contract without issuing a new RFA;
(e) The suspension or termination
of a CCO contract issued under an RFA due to noncompliance with contract requirements
or by a CCO’s voluntary suspension or termination shall also be a suspension
or termination of certification.
(13) Disclosure of application
contents and release of information:
(a) Except for the letter
of intent to apply and the technical application (with the exception of information
that has been clearly identified and labeled confidential in the manner specified
in the RFA), information may not be disclosed to any applicant or the public until
the award date. No information may be given to any applicant or the public relative
to its standing with other applicants before the award date except under the following
circumstances:
(A) The information in the
application may be shared with the Authority, DCBS, CMS, and those individuals involved
in the application review and evaluation process; and
(B) Information may be provided
by the applicant to the public as part of a public review process.
(b) Application information
may be disclosed on the award date (with the exception of information that has been
clearly identified and labeled confidential in the manner specified in the RFA)
if the Authority determines it meets the disclosure exemption requirements.
(14) CCOs may apply to participate
in the CMS Medicare/Medicaid Alignment Demonstration, but participation is not required.
This rule does not replace the CMS requirements related to the Medicare/Medicaid
Alignment Demonstration, such as the CMS notice of intent to apply and required
components for Part D coverage. The RFA provides information about the demonstration
requirements. Upon approval of the demonstration by CMS, the Authority shall conduct
jointly with CMS the evaluation for certification for the Medicare/Medicaid Alignment
Demonstration and the award of three-way contracts between CMS, the state, and applicants
who have been certified to contract as a CCO and participate in the demonstration.
(15) The Authority shall
interpret and apply this rule to satisfy federal procurement and contracting requirements
in addition to state requirements applicable to contracts with CCOs. The Authority
must seek and receive federal approval of CCO contracts.
(16) Except where inconsistent
with the preceding sections of this rule, the Authority adopts the following Department
of Justice (DOJ) Model Public Contract Rules (as in effect on January 1, 2012) to
govern RFAs and certification and contracting with CCOs:
(a) OAR 137-046 — General
Provisions Related to Public Contracting: 137-046-0100, 137-046-0110, and 137-046-0400
through 137-046-0480;
(b) OAR 137-047 — Public
Procurements for Goods or Services: 137-047-0100, 137-047-0260 through 137-047-0670,
137-047-700 to 137-047-0760 (excluding provisions governing judicial review), and
137-047-0800;
(c) In applying the DOJ Model
Rules to RFAs under this rule:
(A) An application is a proposal
under the DOJ Model Rules;
(B) An RFA is an RFP under
the DOJ Model Rules;
(C) Certification as a CCO
is pre-qualification under the DOJ Model Rules;
(D) Provisions of the Public
Contracting Code referenced in the DOJ Model Rules are considered to be incorporated
therein;
(E) Definitions in the DOJ
Model Rules govern this rule except where a term is defined in section (1) of this
rule.
(17) Judicial review of the
Authority’s decisions relating to a solicitation protest, certification, or
contract award is governed by the Oregon Administrative Procedures Act (APA). The
RFA may establish when an Authority decision may be considered a final order for
purposes of APA review.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 11-2012(Temp),
f. & cert. ef. 3-16-12 thru 9-11-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 45-2014, f. 7-15-14, cert. ef. 8-1-14
410-141-3015
Certification Criteria for Coordinated
Care Organizations
(1) Applicants shall submit applications
to the Authority describing their capacity and plans for meeting the goals and requirements
established for the Oregon Integrated and Coordinated Health Care Delivery System
including being prepared to enroll all eligible individuals within the CCO’s
proposed service area. The Authority shall use the RFA procurement process described
in OAR 410-141-3010.
(2) In addition to the requirements
for CCOs expressed in the laws establishing Health System Transformation, the Authority
interprets the qualifications and expectations for CCO certification within the
context of the Oregon Health Policy Board’s report, Coordinated Care Organizations
Implementation Proposal: HB 3650 Health System Transformation (Jan. 24, 2012).
(3) Applicants shall describe
their demonstrated experience and capacity for:
(a) Managing financial risk
and establishing financial reserves;
(b) Meeting the following
minimum financial requirements:
(A) Maintaining restricted
reserves of $250,000 plus an amount equal to 50 percent of the entity’s total
actual or projected liabilities above $250,000;
(B) Maintaining a net worth
in an amount equal to at least 5 percent of the average combined revenue in the
prior two quarters of the participating health care entities.
(c) Operating within a fixed
global budget;
(d) Developing and implementing
alternative payment methodologies that are based on health care quality and improved
health outcomes;
(e) Coordinating the delivery
of physical health care, mental health and Substance Use Disorder (SUD) services,
oral health care, and covered long-term care services;
(f) Engaging community members
and health care providers in improving the health of the community and addressing
regional, cultural, socioeconomic, and racial disparities in health care that exist
among the entity’s enrollees and in the entity’s community.
(4) In selecting one or more
CCOs to serve a geographic area, the Authority shall:
(a) For members and potential
members, optimize access to care and choice of providers;
(b) For providers, optimize
choice in contracting with CCOs; and
(c) Allow more than one CCO
to serve the geographic area if necessary to optimize access and choice under this
subsection.
(5) Evaluation of CCO applications
shall account for the developmental nature of the CCO system. The Authority recognizes
that CCOs and partner organizations will need time to develop capacity, relationships,
systems, and experience to fully realize the goals envisioned by the Oregon Integrated
and Coordinated Health Care Delivery System. The Authority shall thoroughly review
how the application describes community involvement in the governance of the CCO
and the CCO’s strategic plan for developing its community health assessment
and community health improvement plan:
(a) In all cases, CCOs shall
have plans in place to meet the criteria laid out in these rules and the application
process and to make sufficient progress in implementing plans and realizing the
goals established in contract;
(b) Each criterion will be
listed followed by the elements that shall be addressed during the initial certification
described in this rule without limiting the information that is requested in the
RFA concerning these criteria.
(6) Each CCO shall have a
governance structure that meets the requirements of ORS 414.625. The applicant shall:
(a) Clearly describe how
it meets governance structure criteria from ORS 414.625, how the governance structure
makeup reflects community needs and supports the goals of health care transformation,
how the criteria is used to select governance structure members, and how it will
assure transparency in governance;
(b) Identify key leaders
who are responsible for successful implementation and sustainable operation of the
CCO;
(c) Describe how its governance
structure will reflect the needs of members with severe and persistent mental illnesses
and members receiving DHS Medicaid-funded, long-term care services and supports.
(7) Each CCO shall convene
a community advisory council (CAC) that meets the requirements of ORS 414.625. The
applicant shall clearly describe how it meets the requirements for selection and
implementation of a CAC consistent with ORS 414.625, how the CAC will be administered
to achieve the goals of community involvement, and the development, adoption, and
updating of the community health assessment and community health improvement plan.
(8) CCOs shall partner with
their local public health authority, hospital system, type B AAA, APD field office,
and local mental health authority to develop a shared community health assessment
that includes a focus on health disparities in the community:
(a) Since community health
assessments will evolve over time as relationships develop and CCOs learn what information
is most useful, initial CCO applicants may not have time to conduct a comprehensive
community assessment before becoming certified;
(b) The applicant shall describe
how it will develop its health assessment, meaningfully and systematically engaging
representatives of critical populations and community stakeholders and its community
advisory council to create a health improvement plan for addressing community need
that builds on community resources and skills and emphasizes innovation.
(9) The CCO shall describe
its strategy to adopt and implement a community health improvement plan consistent
with OAR 410-141-3145.
(10) Dental care organizations:
On or before July 1, 2014, each CCO shall have a contractual relationship with any
DCO in its service area.
(11) CCOs shall have agreements
in place with publicly funded providers to allow payment for point-of-contact services
including immunizations, sexually transmitted diseases and other communicable diseases,
family planning, and HIV/AIDS prevention services. Applicants shall confirm that
these agreements have been developed unless good cause can be shown:
(a) CCOs shall also have
agreements in place with the local mental health authority consistent with ORS 414.153.
Applicants shall confirm that these agreements have been developed unless good cause
can be shown;
(b) The Authority shall review
CCO applications to ensure that statutory requirements regarding county agreements
are met unless good cause is shown why an agreement is not feasible.
(12) CCOs shall provide integrated,
person‐centered care and services designed to provide choice, independence,
and dignity:
(a) The applicant shall describe
its strategy to assure that each member receives integrated, person‐centered
care and services designed to provide choice, independence, and dignity;
(b) The applicant shall describe
its strategy for providing members the right care at the right place and the right
time and to integrate and coordinate care across the delivery system.
(13) CCOs shall develop mechanisms
to monitor and protect against underutilization of services and inappropriate denials,
provide access to qualified advocates, and promote education and engagement to help
members be active partners in their own care. Applicants shall:
(a) Describe their planned
or established policies and procedures that protect member rights including access
to qualified peer wellness specialists, personal health navigators, and qualified
community health workers where appropriate;
(b) Describe planned or established
mechanisms for a complaint, grievance, and appeals resolution process, including
how that process shall be communicated to members and providers.
(14) CCOs shall operate in
a manner that encourages patient engagement, activation, and accountability for
the member’s own health. Applicants shall describe how they plan to:
(a) Actively engage members
in the design and, where applicable, implementation of their treatment and care
plans;
(b) Ensure that member choices
are reflected in the development of treatment plans, and member dignity is respected.
(15) CCOs shall assure that
members have a choice of providers within the CCO’s network, including providers
of culturally and linguistically appropriate services and their providers participating
in the CCO and shall:
(a) Work together to develop
best practices for care and service delivery to reduce waste and improve health
and well‐being of all members;
(b) Are educated about the
integrated approach and how to access and communicate within the integrated system
about a member’s treatment plan and health history;
(c) Emphasize prevention,
healthy lifestyle choices, evidence-based practices, shared decision-making, and
communication;
(d) Are permitted to participate
in the networks of multiple CCOs;
(e) Include providers of
specialty care;
(f) Are selected by the CCO
using universal application and credentialing procedures, objective quality information,
and are removed if the providers fail to meet objective quality standards.
(g) Describe how they will
work with their providers to develop the partnerships necessary to allow for access
to and coordination with medical, mental health and Substance Use Disorder (SUD)
service providers, and dental care when the CCO includes a dental care organization
and facilitate access to community social and support services including DHS Medicaid-funded
long-term care services, mental health crisis services, and culturally and linguistically
appropriate services;
(h) Describe their planned
or established tools for provider use to assist in the education of members about
care coordination and the responsibilities of both parties in the process of communication.
(16) CCOs shall assure that
each member has a consistent and stable relationship with a care team that is responsible
for providing preventive and primary care and for comprehensive care management
in all settings. The applicant shall demonstrate how it will support the flow of
information, identify a lead provider or care team to confer with all providers
responsible for a member’s care, and use a standardized patient follow-up
approach.
(17) CCOs shall address the
supportive and therapeutic needs of each member in a holistic fashion using patient‐centered
primary care homes and individualized care:
(a) Applicants shall describe
their model of care or other models that support patient-centered primary care,
adhere to ORS 414.625 requirements regarding individualized care plans particularly
for members with intensive care coordination needs, and screen for all other issues
including mental health;
(b) Applicants shall describe
how its implementation of individualized care plans reflects member or family and
caregiver preferences and goals to ensure engagement and satisfaction.
(18) CCOs shall assure that
members receive comprehensive transitional health care including appropriate follow‐up
care when entering or leaving an acute care facility or long-term care setting.
Applicants shall:
(a) Describe their strategy
for improved transitions in care so that members receive comprehensive transitional
care, and members’ experience of care and outcomes are improved;
(b) Demonstrate how hospitals
and specialty services will be accountable to achieve successful transitions of
care and establish service agreements that include the role of patient-centered
primary care homes;
(c) Describe their arrangements,
including memorandum of understanding, with Type B Area Agencies on Aging or the
Department’s offices of Aging and People with Disabilities concerning care
coordination and transition strategies for members.
(19) CCOs shall provide members
with assistance in navigating the health care delivery system and accessing community
and social support services and statewide resources including the use of certified
or qualified health care interpreters, community health workers, and personal health
navigators. The applicant shall describe its planned policies for informing members
about access to personal health navigators, peer wellness specialists where appropriate,
and community health workers.
(20) Services and supports
shall be geographically located as close to where members reside as possible and
are, when available, offered in non-traditional settings that are accessible to
families, diverse communities, and underserved populations. Applicants shall describe:
(a) Delivery system elements
that respond to member needs for access to coordinated care services and supports;
(b) Planned or established
policies for the delivery of coordinated health care services for members in long-term
care settings;
(c) Planned or established
policies for the delivery of coordinated health care services for members in residential
treatment settings or long term psychiatric care settings.
(21) Each CCO shall prioritize
working with members who have high health care needs, multiple chronic conditions,
mental illness, or Substance Use Disorder (SUD) services including members with
severe and persistent mental illness covered under the State’s 1915(i) State
Plan Amendment. The CCO shall involve those members in accessing and managing appropriate
preventive, health, remedial, and supportive care and services to reduce the use
of avoidable emergency department visits and hospital admissions. The applicant
shall describe how it will:
(a) Use individualized care
plans to address the supportive and therapeutic needs of each member, particularly
those with intensive care coordination needs;
(b) Reflect member or family
and caregiver preferences and goals to ensure engagement and satisfaction.
(22) Each CCO shall participate
in the learning collaborative described in ORS 442.210. Applicants shall confirm
their intent to participate.
(23) Each CCO shall implement
to the maximum extent feasible patient‐centered primary care homes including
developing capacity for services in settings that are accessible to families, diverse
communities, and underserved populations:
(a) The applicant shall describe
its plan to develop and expand capacity to use patient-centered primary care homes
to ensure that members receive integrated, person-centered care and services and
that members are fully informed partners in transitioning to this model of care;
(b) The applicant shall require
its other health and services providers to communicate and coordinate care with
patient‐centered primary care homes in a timely manner using health information
technology.
(24) CCOs’ health care
services shall focus on achieving health equity and eliminating health disparities.
Applicants shall:
(a) Describe their strategy
for ensuring health equity (including interpretation and cultural competence) and
elimination of avoidable gaps in health care quality and outcomes, as measured by
gender, race, ethnicity, language, disability, sexual orientation, age, mental health
and addictions status, geography, and other cultural and socioeconomic factors;
(b) Engage in a process that
identifies health disparities associated with race, ethnicity, language, health
literacy, age, disability (including mental illness and substance use disorders),
gender, sexual orientation, geography, or other factors through community health
assessment;
(c) Collect and maintain
race, ethnicity, and primary language data for all members on an ongoing basis in
accordance with standards jointly established by the Authority and the Division.
(25) CCOs are encouraged
to use alternative payment methodologies consistent with ORS 414.653. The applicant
shall describe its plan to move toward and begin to implement alternative payment
methods alone or in combination with delivery system changes to achieve better care,
controlled costs, and better health for members.
(26) Each CCO shall use health
information technology (HIT) to link services and care providers across the continuum
of care to the greatest extent practicable. The applicant shall describe:
(a) Its initial and anticipated
levels of electronic health record adoption and health information exchange infrastructure
and capacity for collecting and sharing patient information electronically and its
HIT improvement plan for meeting transformation expectations;
(b) Its plan to ensure that
each network provider participates in a health information organization (HIO) or
is registered with a statewide or local direct-enabled health information service
provider.
(27) Each CCO shall report
on outcome and quality measures identified by the Authority under ORS 414.638 and
participate in the All Payer All Claims (APAC) data reporting system. The applicant
shall provide assurances that:
(a) It has the capacity to
report and demonstrate an acceptable level of performance with respect to Authority-identified
metrics;
(b) It will submit APAC data
in a timely manner according to program specifications.
(28) Each CCO shall be transparent
in reporting progress and outcomes. Applicants shall:
(a) Describe how it will
assure transparency in governance;
(b) Agree to provide timely
access to certain financial, outcomes, quality, and efficiency metrics that will
be transparent and publicly reported and available on the Internet.
(29) Each CCO shall use best
practices in the management of finances, contracts, claims processing, payment functions,
and provider networks. The applicant shall describe:
(a) Its planned or established
policies for ensuring best practices in areas identified by ORS 414.625;
(b) Whether the CCO will
use a clinical advisory panel (CAP) or other means to ensure clinical best practices;
(c) Plans for an internal
quality improvement committee that develops and operates under an annual quality
strategy and work plan that incorporates implementation of system improvements and
an internal utilization review oversight committee that monitors utilization against
practice guidelines and treatment planning protocols and policies.
(30) Each CCO shall demonstrate
sound fiscal practices and financial solvency and shall possess and maintain resources
needed to meet their obligations:
(a) Initially, the financial
applicant shall submit required financial information that allows the DCBS Insurance
Division on behalf of the Authority to confirm financial solvency and assess fiscal
soundness;
(b) The applicant shall provide
information relating to assets and financial and risk management capabilities.
(31) Each CCO may provide
coordinated care services within a global budget. Applicants shall submit budget
cost information consistent with its proposal for providing coordinated care services
within the global budget.
(32) A CCO shall operate,
administer, and provide for integrated and coordinated care services within the
requirements of the medical assistance program in accordance with the terms of the
contract and rule. The applicant shall provide assurances about compliance with
requirements applicable to the administration of the medical assistance program.
(33) Each CCO shall provide
covered Medicaid services, other than DHS Medicaid-funded long-term care services,
to members who are dually eligible for Medicare and Medicaid. The applicant may
participate in the CMS Medicare/Medicaid Alignment Demonstration if the Authority
obtains necessary federal approvals.
Stat. Auth.: ORS 413.042,
414.615, 414.625, 414.635 & 414.651
Stats. Implemented: ORS 414.610 - 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 45-2014, f. 7-15-14, cert. ef. 8-1-14
410-141-3020
Administration
of Oregon Integrated and Coordinated Health Care Delivery System Regulation and
Rule Precedence
(1)
The Authority and its Division of Medical Assistance Programs (Division) and Addictions
and Mental Health Division (AMH) may adopt reasonable and lawful policies, procedures,
rules and interpretations to promote the orderly and efficient administration of
the Oregon Integrated and Coordinated Health Care Delivery System and medical assistance
programs. This includes the Oregon Health Plan (OHP) pursuant to ORS Chapter 414,
subject to the rulemaking requirements of Oregon Revised Statutes and Oregon Administrative
Rule (OAR) procedures.
(2)
In applying its policies, procedures, rules and interpretations, the Authority shall
construe them as much as possible to be consistent. In the event that Authority
policies, procedures, rules, and interpretations are inconsistent, the Authority
shall apply the following order of precedence:
(a)
For purposes of the provision of covered coordinated care services to Authority
clients, including but not limited to authorizing and delivering service, or denials
of authorization or services, the Authority, clients, enrolled providers, and the
CCOs shall apply the following order of precedence:
(A)
Consistent with ORS 413.071 and notwithstanding any other provision of state law,
those federal laws and regulations governing the operation of the medical assistance
program and any waivers granted the Authority by the Centers for Medicare and Medicaid
Services (CMS) shall govern the administration of the medical assistance programs;
(B)
Oregon Revised Statutes governing medical assistance programs;
(C)
Generally for CCOs, requirements applicable to providing coordinated care services
to members are provided in this rule, the Division's General Rules, OAR 410-120-0000
through 410-120-1980 and the provider rules applicable to the category of health
service;
(D)
Generally for enrolled fee-for-service providers, requirements applicable to the
provision of covered medical assistance to clients are provided in the Division's
General Rules, OAR 410-120-0000 through 410-120-1980, the Prioritized List and program
coverage set forth in OAR chapter 410 division 141 and the provider rules applicable
to the category of health service;
(E)
Any other applicable properly promulgated rules adopted by the Division, AMH and
other offices or units within the Authority necessary to administer medical assistance
programs, such as Electronic Data Transaction rules in OAR 943-120-0100 through
943-120-0200; and
(F)
The basic framework for provider enrollment in OAR chapter 943 division120 and chapter
410 division 120 generally applies to providers enrolled with the Authority, subject
to more specific requirements applicable to the administration of medical assistance
programs. For purposes of this rule, “more specific” means the requirements,
laws, and rules applicable to the provider type and covered health services.
(b)
For purposes of contract administration solely between the Authority and its CCOs,
the contract terms and the requirements in section (2)(a) of this rule governing
the provision of covered coordinated health services to clients.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3030
Implementation
and Transition
Implementation
of the Oregon Integrated and Coordinated Health Care Delivery System through CCOs
is essential to achieve the objectives of health transformation and cost savings.
The ability of CCOs to meet transformation expectations will be phased in over time
to allow CCOs to develop the necessary organizational infrastructure. During this
initial implementation period, the Authority holds the following expectations:
(1)
Contract provisions, including an approved CCO strategy or plan for implementing
health services transformation, shall describe how the CCO must comply with transformation
requirements under these rules.
(2)
Local and community involvement is required, and the Authority will work with CCOs
to achieve flexibilities that may be appropriate to achieve community-directed objectives,
including addressing health care for diverse populations.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3040
Service Area Change (SAC) for Existing
Coordinated Care Organizations (CCOs)
(1) For purposes of this rule, the following
definitions apply:
(a) “Applicant”
means a certified coordinated care organization (CCO) that submits an application
seeking recertification and a contract amendment for a SAC. The CCO is described,
for this use, as the applicant, upon its submission of the CCO Letter of Intent
to Apply;
(b) “Capacity”
means the sum of enrollment limits for CCOs in a service area;
(c) “Certified”
means the Authority's determination that an entity meets the criteria in OAR 410-141-3015
for being a CCO through initial certification;
(d) “Document Review”
means the review conducted by the Authority, occurring after the receipt of the
completed SAC packet and before the effective date of the contract amendment, to
determine applicant’s ability to serve Medicaid beneficiaries in the requested
service areas. Successful meeting of the requirements of the document review entitles
the applicant to receive a contract amendment for the SAC and to be recertified
as a CCO in the delivery of Medicaid services;
(e) “Enrollment Limit”
means a CCO’s maximum enrollment by service area, as specified in the Authority’s
contract with the CCO;
(f) “Letter of intent
to apply (LOIA)” means a letter from a CCO to the Authority stating the CCO’s
intent to submit a SAC packet in response to a service area need. A LOIA may be
binding or non-binding, as specified in the Authority’s announcement of the
service area need;
(g) “Recertification”
means the process outlined in this rule, allowing the CCO contractor to submit an
abbreviated application to apply as an existing CCO for a new CCO service area;
(h) “Service Area Change
(SAC)” means a change in a CCO’s service area or enrollment limits,
as specified in the Authority’s contract with the CCO;
(i) “Service area need”
means when the Authority identifies a need, as defined in section (3), for existing
CCOs to apply to the Authority for a SAC to serve a service area;
(j) “SAC packet”
means the packet of application documents that the Authority provides to CCOs applying
for a SAC.
(2) A CCO shall make every
effort to provide the Authority with a Letter of Intent to Exit the Service Area
not less than150 calendar days prior to the CCO’s proposed withdrawal from
all or a portion of its service area. The Authority shall work with each CCO for
a workable exit transition.
(3) The Authority may determine
whether a service area need exists under the following circumstances:
(a) If a CCO withdraws from
all or a portion of its service area; or
(b) If the Authority identifies
an actual or prospective deficiency in capacity that may negatively impact enrollees’
health or safety.
(4) After identifying a service
area need, the Authority shall announce, in letters to the existing CCOs, its intent
to accept LOIAs from CCOs for SACs in stated service areas. The announcement shall
specify the date on which LOIA is due.
(5) By the due date specified
in the Authority’s announcement of service area need, interested CCOs shall
submit their LOIA. In the LOIA, the CCO shall designate a sole point of contact
for this process.
(6) CCOs shall be sent a
SAC packet for their completion. It consists of SAC guidance documents. Interested
CCOs shall complete the Authority’s SAC process for application, review, and
recertification on the schedule prescribed by the Authority.
(7) By the due date set forth
in the Authority’s announcement of service area need, the applicant’s
SAC packet shall be completed in its entirety and returned to the Authority’s
contract administration unit. The recertification application is the applicant's
offer to enter into a contract amendment for the period specified in the SAC packet.
(8) The Authority shall review
packets from all CCOs who apply, considering only packets that are responsive, completed
as described in the SAC guidance document, and submitted in the time and manner
described in this rule.
(9) After the final submission
of the SAC packet and all additional requested information received by the Authority,
the Authority shall complete the document review of submitted packets. The applicants
are eligible for recertification based on criteria specified in the SAC guidance
document, the application, written assurances, and any additional information that
the Authority obtains and deems satisfactory. The applicant shall be responsible
for and meet standards established by the Authority and the current CCO contract.
(10) If two or more CCOs
meet the requirements to expand into a service area, then the Authority shall allow
all the qualified CCOs to serve that service area. The Authority shall certify all
CCOs who apply for the service area change and meet the specified standards as supported
in OAR 410-141-3010.
(11) Applicants who wish
to dispute any Authority actions or decisions pertaining to the SAC process may
engage in dispute resolution as provided for in OAR 410-141-3267.
Stat. Auth: ORS 413.042, 414.645, 414.625
Stats. Implemented: ORS 413.042
Hist.: DMAP 38-2015(Temp),
f. & cert. ef. 7-1-15 thru 12-27-15; DMAP 67-2015(Temp), f. & cert. ef.
11-6-15 thru 12-27-15

410-141-3050
CCO
Enrollment for Children Receiving Health Services
Pursuant to OAR 410-141-3060, the Authority
or Oregon Youth Authority (OYA) shall select CCOs for a child receiving services
in an area where a CCO is available. If a CCO is not available in an area, the Authority
shall enroll the child in accordance with 410-141-0050.
(1) The Authority shall to
the maximum extent possible ensure that all children are enrolled in CCOs at the
next available enrollment date following eligibility determination, redetermination,
or upon review by the Authority unless the Authority authorizes disenrollment from
a CCO:
(a) Except as provided in
OAR 410-141-3060 (Coordinated Care Enrollment Requirements), 410-141-3080 (Disenrollment
from Coordinated Care Health Plans), or ORS 414.631(2), children are not exempt
from mandatory enrollment in a CCO on the basis of third party resources (TPR) coverage;
(b) The Authority shall review
decisions to use fee-for-service (FFS) open card for a child if the child’s
circumstances change and at the time of redetermination consider whether the Authority
shall enroll the child in a CCO.
(2) When a child is transferred
from one CCO to another CCO or from FFS or a PHP to a CCO, the CCO shall facilitate
coordination of care consistent with OAR 410-141-3160:
(a) CCOs shall work closely
with the Authority to ensure continuous CCO enrollment for children;
(b) If the Authority determines
that it should disenroll a child from a CCO, the CCO shall continue to provide health
services until the Authority’s established disenrollment date to provide for
an adequate transition to the next CCO.
(3) When a child experiences
a change of placement that may be permanent or temporary, the Authority shall verify
the address change information to determine whether the child no longer resides
in the CCO’s service area:
(a) A temporary absence as
a result of a temporary placement out of the CCO’s service area does not represent
a change of residence if the Authority determines that the child is reasonably likely
to return to the CCO’s service area at the end of the temporary placement;
(b) A CAF child receiving
behavioral rehabilitation services (BRS) is considered a temporary placement;
(c) Children in OYA custody
enroll with the CCO serving the geographic area of placement. OYA representatives
may request a service area exemption (SAE) to maintain CCO coverage on a placement
they consider temporary.
(4) If the Authority enrolls
the child in a CCO on the same day the child is admitted to psychiatric residential
treatment services (PRTS), the CCO shall pay for covered health services during
that placement even if the location of the facility is outside the CCO’s service
area:
(a) The child is presumed
to continue to be enrolled in the CCO with which the child was most recently enrolled.
The Authority considers an admission to a PRTS facility a temporary placement for
purposes of CCO enrollment;
(b) Any address change associated
with the placement in the PRTS facility is not a change of residence for purposes
of CCO enrollment and may not be a basis for disenrollment from the CCO unless the
provisions in OAR chapter 410, division 141 apply;
(c) If the Authority determines
that a child was disenrolled for reasons not consistent with these rules, the Authority
shall re-enroll the child with the appropriate CCO and assign an enrollment date
that provides for continuous coverage with the appropriate CCO. If the child was
enrolled in a different CCO in error, the Authority shall disenroll the child from
that CCO and recoup the CCO payments.
(5) Except for OAR 410-141-3060
and 410-141-3080, if a child is enrolled in a CCO after the first day of an admission
to PRTS, the enrollment effective date shall be immediately upon discharge.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 45-2014, f. 7-15-14, cert. ef. 8-1-14
410-141-3060
Enrollment Requirements in a CCO
(1) For the purposes of this rule, the
following definitions apply:
(a) Client means an individual
found eligible to receive OHP health services. “Client” is inclusive
of members enrolled in PHPs and CCOs as stated in OAR 410-120-0000;
(b) Eligibility Determination
means an approval or denial of eligibility and a renewal or termination of eligibility
as stated in OAR 410-200-0015;
(c) Member means a client
enrolled with a pre-paid health plan or coordinated care organization as stated
in OAR 410-120-0000;
(d) Newly Eligible means
recently determined, through the eligibility determination process, as having the
right to obtain state health benefits, satisfying the appropriate conditions;
(e) Redetermination means
a review of eligibility outside of regularly scheduled renewals. Redeterminations
that result in the assignment of a new renewal date or a change in program are considered
renewals as stated in OAR 410-200-0015;
(f) Renewal means a regularly
scheduled periodic review of eligibility resulting in a renewal or change of program
benefits, including the assignment of a new renewal date or a change in eligibility
status.
(2) The following populations
may not be enrolled into a CCO for any type of health care coverage including:
(a) Persons who are non-citizens
and are Citizen/Alien Waivered-Emergency Medical program eligible for labor and
delivery services and emergency treatment services;
(b) Clients receiving premium
assistance through the Specified Low-Income Medicare Beneficiary, Qualified Individuals,
Qualified Disabled Working Individuals and Qualified Medicare Beneficiary programs
without other Medicaid;
(c) Persons who are dually
eligible for Medicare and Medicaid and enrolled in a program of all-inclusive care
for the elderly.
(3) The following populations
may not be enrolled into a CCO under the following circumstances:
(a) Newly eligible clients
are exempt from enrollment with a CCO but not exempt from enrollment in a DCO if
they became eligible when admitted as an inpatient in a hospital. The client shall
receive health care services on a fee-for-service (FFS) basis only until the hospital
discharges the client. The individual will receive dental services through the DCO;
(b) The client is covered
under a major medical insurance policy or other third party resource (TPR) that
covers the cost of services to be provided by a PHP as specified in ORS 414.631
and except as provided for children in Child Welfare through the BRS and PRTS programs
outlined in OAR 410-141-3050. A client shall be enrolled with a DCO even if they
have a dental TPR.
(4) Persons who are documented
American Indian and Alaskan Native (AI/AN) beneficiaries are exempt mandatory enrollment
into a managed care plan, as specified in 42 USC 1932, 2 (C), but may elect to be
manually enrolled.
(5) Populations specified
below are exempt from mandatory enrollment into a physical health CCO but are subject
to mandatory enrollment into both dental and mental health plans as available in
the member’s service area. The member may be manually enrolled into a physical
health plan as deemed appropriate by the Authority. These populations are as follows:
(a) Children in the legal
custody of the Department or where the child is expected to be in a substitute care
placement for less than 30 calendar days unless:
(A) Access to health care
on a FFS basis is not available; or
(B) Enrollment would preserve
continuity of care;
(b) Clients who are dually
eligible for Medicare and Medicaid but not enrolled in a program of all-inclusive
care for the elderly. The following apply to these:
(A) A client has the option
to enroll in a CCO regardless of whether they are enrolled in Medicare Advantage;
(B) A client enrolled in
Medicare Advantage, whether or not they pay their own premium, has the option to
enroll in a CCO even if the CCO does not have a corresponding Medicare Advantage
plan;
(C) A client has the option
to enroll with a CCO, even if the client withdrew from that CCO’s Medicare
Advantage plan. The CCO shall accept the client’s enrollment if the CCO has
adequate health access and capacity;
(D) A client has the option
to enroll with a CCO even if the client is enrolled in Medicare Advantage with another
entity.
(6) The Authority may temporarily
exempt clients for other just causes as determined by the Authority through medical
review. The Authority may set an exemption period on a case-by-case basis for those
as follows:
(a) Children under 19 years
of age who are medically fragile and who have special health care needs. The Authority
may enroll these children in CCOs on a case-by-case basis. Children not enrolled
in a CCO shall continue to receive services on a FFS basis;
(b) Until December 31, 2017,
women who are pregnant and meet the qualifications in sub-sections A through E below
may receive OHP benefits on a FFS basis for physical health only until 60 days after
the birth of her child. Women meeting the criteria for the pregnancy enrollment
exemption for their physical health plan coverage will continue to be enrolled in
the appropriate MCO or CCO plan in their service area for dental and mental health
coverage. After the 60-day period the member shall enroll in a plan as appropriate.
Those women under consideration for a pregnancy enrollment exemption for their physical
health enrollment shall receive a response from the Authority within 30 working
days of request. Upon approval of the FFS pregnancy exemption for physical health
enrollment only, the client shall remain FFS for as long as she continues to meet
the requirements in A through E below. In order to qualify for the FFS pregnancy
exemption for physical health only, there must be no home birth option available
to the client through her plan and the client must:
(A) Be pregnant;
(B) State that her intention
is to have a home birth;
(C) Have an established relationship
for the purpose of home birth with a licensed, qualified practitioner who is not
a participating provider with the client’s CCO; and
(D) Make a request to change
to FFS. This request can be made at any point in the pregnancy prior to delivery;
and
(E) Meet all administrative
rules including, but not limited to, OAR 410-130-0240 and statutory requirements
that define when a home birth is eligible for reimbursement by the Authority:
(i) Should a woman become
unable to meet any of the requirements specified in OAR 333-076-0650(1) Table 1
either upon initial evaluation or once the exemption is granted, the exemption shall
be withdrawn and the client will be subject to CCO enrollment requirements as stated
in OAR 410-141-3060.
(ii) Conditions arising during
the pregnancy as listed in subsections (I) through (V) below shall be reviewed by
the Authority on a case-by-case basis for continuation of the FFS enrollment exemption:
(I) Fetal presentation other
than vertex, when known;
(II) Abnormal Bleeding;
(III) Low–lying placenta
within 2 cm. or less of cervical os;
(IV) Genital herpes, primary;
secondary uncoverable at onset of labor; and
(V) Current substance abuse
that has the potential to adversely affect labor and the infant;
(c) The following apply to
clients and exemptions relating to organ transplants:
(A) Newly eligible clients
are exempt from enrollment with a CCO if the client is newly diagnosed and under
the treatment protocol for an organ transplant;
(B) Newly eligible clients
with existing transplants shall enroll into the appropriate CCO for their service
area;
(d) Other just causes to
preserve continuity of care include the following considerations:
(A) Enrollment would pose
a serious health risk; and
(B) The Authority finds no
reasonable alternatives.
(7) Unless stated above,
CCO enrollment is mandatory in all areas served by a CCO. A client who is eligible
for or receiving health services must enroll in a CCO as required by ORS 414.631,
except as provided in ORS 414.631(2), (3), (4), and (5) and this rule.
(8) Enrollment is voluntary
in service areas without adequate access and capacity to provide health care services
through a CCO or PHP.
(9) Enrollment is mandatory
in service areas with adequate health care access and capacity to provide health
care services through a CCO or PHP. If upon application or redetermination, a client
does not select a CCO, the Authority shall auto-assign the client and the client’s
household to a CCO that has adequate health care access and capacity. The following
outlines the priority of enrollment in service areas where enrollment is mandatory
and a PHP remains available for enrollment:
(a) Priority 1: The client
shall enroll in a CCO that serves that area and has adequate health care access
and capacity;
(b) Priority 2: The client
has the option to enroll in a PHP through a manual process if:
(A) The client has an established
relationship with a provider who is only contracted with the PHP; or
(B) The PHP serves an area
that a CCO serves, but the CCO has inadequate health care services capacity to accept
new members. Clients will be FFS unless already established with a PHP’s provider;
(c) Priority 3: The client
shall receive services on a FFS basis.
(10) If a service area changes
from mandatory enrollment to voluntary enrollment, the member shall remain with
the PHP for the remainder of their eligibility period or until the Authority or
Department redetermines eligibility, whichever comes sooner, unless otherwise eligible
to disenroll pursuant to OAR 410-141-3080.
(11) Clients who are exempt
from physical health services or who are enrolled with a PHP for physical health
services will receive managed or coordinated mental health and oral health services
as follows:
(a) The client shall be enrolled
with a CCO if the CCO offers mental health and oral health services; or
(b) The client shall be enrolled
with an MHO for mental health services and with a DCO for oral health services if
the CCO does not offer those services; or
(c) The client shall be enrolled
with a DCO for oral health services and remain FFS for mental health services if
an MHO is not available; or
(d) The client shall remain
FFS for both mental health and oral health services if an MHO or DCO is unavailable.
(12) The following pertains
to the effective date of the enrollment. If the enrollment occurs:
(a) On or before Wednesday,
the date of enrollment shall be the following Monday; or
(b) After Wednesday, the
date of enrollment shall be one week from the following Monday.
(13) Coordinated care services
shall begin as of the effective date of enrollment with the CCO except for:
(a) A newborn’s date
of birth when the mother was a member of a CCO at the time of birth;
(b) For persons other than
newborns who are hospitalized on the date enrolled, the date of enrollment shall
be the first possible enrollment date after the date the client is discharged from
inpatient hospital services;
(c) For members who are re-enrolled
within 30 calendar days of disenrollment, the date of enrollment shall be the date
specified by the Authority and may be earlier than the effective date outlined above.
(d) For adopted children
or children placed in an adoptive placement, the date of enrollment shall be the
date specified by the Authority.
Stat. Auth.: ORS 413.042,
414.615, 414.625, 414.635 & 414.651
Stats. Implemented: ORS 414.610 - 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 62-2012(Temp), f. 12-27-12, cert. ef. 1-1-13 thru 6-29-13; DMAP 4-2013(Temp),
f. & cert. ef. 2-7-13 thru 6-29-13; DMAP 33-2013, f. & cert. ef. 6-27-13;
DMAP 38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 65-2013, f. &
cert. ef. 11-29-13; DMAP 35-2014(Temp), f. 6-25-14, cert. ef. 7-1-14 thru 12-27-14;
DMAP 69-2014(Temp), f. 12-8-14, cert. ef. 12-27-14 thru 12-31-14; DMAP 70-2014,
f. 12-8-14, cert. ef. 1-1-15; DMAP 72-2014(Temp), f. 12-9-14, cert. ef. 1-1-15 thru
6-29-15; DMAP 8-2015, f. 2-26-15, cert. ef. 3-1-15; DMAP 56-2015(Temp), f. 9-30-15,
cert. ef. 10-1-15 thru 2-4-16
410-141-3066
CCO Enrollment Requirements for Temporary
Out-of-Area Behavioral Health Treatment Services
(1) For purposes of this rule, the following
definitions apply:
(a) “Behavioral Health”
means mental health, mental illness, addiction disorders, and substance use disorders;
(b) “Home CCO”
means enrollment in a Coordinated Care Organization (CCO) in a given service area,
based upon a client’s most recent permanent residency, determined at the time
of original eligibility determination or most current point of CCO enrollment prior
to hospitalization;
(c) “Temporary Placement”
means hospital, institutional, and residential placement only, including those placements
occurring inside or outside of the service area with the expectation to return to
the Home CCO service area.
(2) The Authority has determined
that, to the maximum extent possible, all individuals shall be enrolled at the next
available enrollment date following eligibility, redetermination, or upon review
by the Authority. This rule implements and further describes how the Authority administers
its authority under OAR 410-141-3060 and OAR 410-141-3080 for purposes of making
enrollment decisions for adult and young adult individuals, 14 through and including
17 years of age, receiving temporary out-of-area behavioral health treatment services:
(a) For program placements
in Child Welfare, Behavioral Rehabilitative Services, Oregon Youth Authority, and
Psychiatric Residential Treatment Services, see OAR 410-141-3050 for program specific
rules;
(b) For program placements
in Secure Children’s In-Patient (SCIP) and Secure Adolescent In-Patient (SAIP),
CCOs shall work with the Authority in managing admissions and discharges;
(c) The member shall remain
enrolled with the CCO for delivery of SCIP and SAIP services. The CCO shall bear
care coordination responsibility for the entire length of stay, including admission,
determination, and planning.
(3) Specific to residential
settings specializing in the treatment of Substance Use Disorders (SUD), if the
individual is enrolled in a CCO on the same day the individual is admitted to the
residential treatment services, the CCO shall be responsible for the covered services
during that placement even if the location of the facility is outside of the CCO’s
service area. The individual is presumed to continue to be enrolled in the CCO with
which the individual was most recently enrolled.
(4) CCO assignment is based
on the member’s residence and referred to as Home CCO. Home CCO enrollment
for temporary out-of-area placement shall:
(a) Meet Oregon residency
requirements defined in OAR 410-200-0200;
(b) Be eligible for enrollment
into a CCO as specified in OAR 410-141-3060;
(c) Be based on most recent
permanent residency and related CCO enrollment history prior to hospital, institutional,
and residential placement. If the client has no enrollment history, new enrollment
shall reflect most recent permanent residence prior to hospital, institutional,
and residential placement; and
(d) Be consistent with OAR
410-141-3080 when the client exercises recipient choice, where the client is able
to actively participate in their own recovery and direct their own care. If the
client is unable to designate county of residence, as indicated in OAR 410-200-0200,
the Authority shall designate the Home CCO as the geographic location of the client
at the most recent residency and CCO enrollment prior to hospitalization.
(5) Home CCO enrollment policy
for State Hospital discharges shall be implemented as follows:
(a) Upon State Hospital discharge,
the Authority and the State Hospital Benefit Coordination Unit shall consult and
coordinate with the Home CCO for client placement;
(b) If the client has no
residency or enrollment history or no recent pre-hospitalization enrollment history,
but the client’s permanent residency is indicated other than temporary placement
location, the Authority shall enroll pursuant to section (3) (c) of this rule Home
CCO enrollment;
(c) If the client has no
residency or enrollment history prior to hospitalization, the Authority shall enroll
in placement service area.
(6) For new and existing
temporary residential placements, CCOs shall coordinate all behavioral health care
and needs including, but not limited to, medication assisted treatment, routine
non-emergent physical health care, dental, and transportation when within the scope
of the CCO’s contract, including when member’s temporary placements
are outside the CCO service area. CCO’s shall coordinate care for members
receiving behavioral health treatment while in temporary placement and discharge
planning for the return to the Home CCO. Additionally, CCO’s shall coordinate
all care for accompanying dependent members.
(7) Enrollment shall follow
the Home CCO enrollment policy outlined in this rule, except when:
(a) The Home CCO enrollment
hinders access to care or puts the client at potential harm, or the Home CCO is
unable to provide needed unique services, a change in enrollment may be requested
for the member to a CCO serving the service area of the temporary out-of-area placement;
(b) Home CCO enrollment may
create a continuity of care concern, as specified in OAR 410-141-3080. If a continuity
interruption to a client’s care is indicated, the Authority shall align enrollment
with the care and claims history.
(8) Pursuant to OAR 410-141-3080,
if the Authority determines that an individual was disenrolled for reasons not consistent
with these rules, the Authority shall re-enroll the individual with the appropriate
CCO and assign an enrollment date that provides for continuous CCO coverage with
the appropriate CCO. If the individual was enrolled in a different CCO in error,
the Authority shall disenroll the individual from the incorrect CCO and recoup the
capitation payments, pursuant to OAR 410-120-1395. Re-enrollment to the correct
CCO shall occur as specified in OAR 410-141-3060.
(9) For consideration of
disenrollment decisions other than specified in this rule, OAR 410-141-3080 shall
apply. If the Authority determines that disenrollment should occur, the CCO shall
continue to provide covered services until the disenrollment date established by
the Authority, pursuant to 410-141-3160. This shall provide for an adequate transition
to the next responsible coordinated care organization.
Stats. Auth.: ORS 413.042, 414.610 -
414.685
Stats. Implemented: ORS 413.042,
414.610 - 414.685
Hist.: DMAP 48-2015, f. 8-28-15,
cert. ef. 9-1-15
410-141-3070
Pharmaceutical
Drug List Requirements
(1) Prescription drugs are a covered
service based on the funded Condition/Treatment Pairs. CCOs shall pay for prescription
drugs except:
(a) As otherwise provided,
mental health drugs that are in Class 7 & 11 (based on the National Drug Code
(NDC)) as submitted by the manufacturer to First Data Bank);
(b) Depakote, Lamictal, and
those drugs that the Authority specifically carved out from capitation according
to sections (8) and (9) of this rule;
(c) Any applicable co-payments;
(d) For drugs covered under
Medicare Part D when the client is fully dual eligible.
(2) CCOs may use the statewide
Practitioner-Managed Prescription Drug Plan under ORS 414.330 to 414.337. CCOs may
use a restrictive drug list as long as it allows access to other drug products not
on the drug list through some process such as prior authorization (PA). The drug
list shall:
(a) Include Federal Drug
Administration (FDA) approved drug products for each therapeutic class sufficient
to ensure the availability of covered drugs with minimal prior approval intervention
by the provider of pharmaceutical services;
(b) Include at least one
item in each therapeutic class of over-the-counter medications; and
(c) Be revised periodically
to assure compliance with this requirement.
(3) CCOs shall provide their
participating providers and their pharmacy subcontractor with:
(a) Their drug list and information
about how to make non-drug listed requests;
(b) Updates made to their
drug list within 30 days of a change that may include but are not limited to:
(A) Addition of a new drug;
(B) Removal of a previously
listed drug; and
(C) Generic substitution.
(4) If a drug cannot be approved
within the 72-hour time requirement for prior authorization and the medical need
for the drug is immediate, CCOs must provide, within 24 hours of receipt of the
drug prior authorization request, for the dispensing of at least a 72-hour supply
of a drug that requires prior authorization.
(5) CCOs shall authorize
the provision of a drug requested by the Primary Care Provider or referring provider
if the approved prescriber certifies medical necessity for the drug such as:
(a) The equivalent of the
drug listed has been ineffective in treatment; or
(b) The drug listed causes
or is reasonably expected to cause adverse or harmful reactions to the member.
(6) Prescriptions for Physician
Assisted Suicide under the Oregon Death with Dignity Act are excluded. Payment is
governed by OAR 410-121-0150.
(7) CCOs may not authorize
payment for any Drug Efficacy Study Implementation (DESI) Less Than Effective (LTE)
drugs which have reached the FDA Notice of Opportunity for Hearing (NOOH) stage,
as specified in OAR 410-121-0420 (DESI)(LTE) Drug List. The DESI LTE drug list is
available at: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/12 LTEIRSDrugs.asp.
(8) A CCO may seek to add
drugs to the list contained in section (1) of this rule by submitting a request
to the Authority no later than March 1 of any contract year. The request must contain
all of the following information:
(a) The drug name;
(b) The FDA approved indications
that identifies the drug may be used to treat a severe mental health condition;
and
(c) The reason that the Authority
should consider this drug for carve out.
(9) If a CCO requests that
a drug not be paid within the global budget, the Authority shall exclude the drug
from the global budget for the following January contract cycle if the Authority
determines that the drug has an approved FDA indication for the treatment of a severe
mental health condition such as major depressive, bi-polar or schizophrenic disorders.
(10) The Authority shall
pay for a drug that is not included in the global budget pursuant to the Pharmaceutical
Services Program rules (chapter 410, division 121). A CCO may not reimburse providers
for carved-out drugs.
(11) CCOs shall submit quarterly
utilization data within 60 days of the date of service as part of the CMS Medicaid
Drug Rebate Program requirements pursuant to Section 2501 of the Affordable Care
Act.
(12) CCOs are encouraged
to provide payment only for outpatient and physician administered drugs produced
by manufacturers that have valid rebate agreements in place with the CMS as part
of the Medicaid Drug Rebate Program. CCOs may continue to have some flexibility
in maintaining formularies of drugs regardless of whether the manufacturers of those
drugs participate in the Medicaid Drug Rebate Program.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610–414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 21-2014(Temp), f. & cert. ef. 4-1-14 thru 9-28-14; DMAP 32-2014, f. 5-30-14,
cert. ef. 7-1-14
410-141-3080
Disenrollment
from Coordinated Care Organizations
(1) All member-initiated requests for
disenrollment from a Coordinated Care Organization (CCO) or Dental Care Organization
(DCO) shall be initiated orally or in writing by the primary person in the benefit
group enrolled with a CCO or DCO, where primary person and benefit group are defined
in OAR 461-001-0000, 461-001-0035, and 461-110-0750, respectively. For members who
are not able to request disenrollment on their own, the request may be initiated
by the member's representative.
(2) In accordance with 42
CFR 438.56(c)(2), the Authority, CCO, or DCO shall honor a member or representative
request for disenrollment for the following:
(a) Without cause:
(A) Newly eligible members
may change their CCO or DCO assignment within 12 months following the date of initial
enrollment. The effective date of disenrollment shall be the first of the month
following the Division’s approval of disenrollment;
(B) At least once every 12
months;
(C) Existing members may
change their CCO or DCO assignment within 30 days of the Authority’s automatic
assignment or reenrollment in a CCO or DCO;
(D) In accordance with ORS
414.645, members may disenroll from a CCO or DCO during their redetermination (enrollment
period) or one additional time during their enrollment period based on the member’s
choice and with Authority approval. The disenrollment shall be considered “recipient
choice.”
(b) With cause:
(A) At any time;
(B) Due to moral or religious
objections, the CCO or DCO does not cover the service the member seeks;
(C) When the member needs
related services (for example a cesarean section and a tubal ligation) to be performed
at the same time, not all related services are available within the network, and
the member’s primary care provider or another provider determines that receiving
the services separately would subject the member to unnecessary risk; or
(D) Other reasons including,
but not limited to, poor quality of care, lack of access to services covered under
the contract, or lack of access to participating providers who are experienced in
dealing with the member's health care needs. Examples of sufficient cause include,
but are not limited to:
(i) The member moves out
of the CCO or DCO's service area;
(ii) The member is a Native
American or Alaskan Native with Proof of Indian Heritage who wishes to obtain primary
care services from his or her Indian Health Service facility, tribal health clinic/program,
or urban clinic and the Fee-For-Service (FFS) delivery system;
(iii) Continuity of care
that is not in conflict with any section of OAR 410-141-3060 or this rule. Participation
in OHP, including coordinated care or dental care, does not guarantee that any OHP
member has a right to continued care or treatment by a specific provider. A request
for disenrollment based on continuity of care shall be denied if the basis for this
request is primarily for the convenience of an OHP member or a provider of a treatment,
service, or supply, including, but not limited to, a decision of a provider to participate
or decline to participate in a CCO or DCO;
(iv) As specified in ORS
414.645, the Authority may approve the transfer of 500 or more members from one
CCO or DCO to another CCO or DCO if:
(I) The member’s provider
has contracted with the receiving CCO or DCO and has stopped accepting patients
from or has terminated providing services to members in the transferring CCO or
DCO; and
(II) Members are offered
the choice of remaining enrolled in the transferring CCO or DCO; and
(III) The member and all
family (case) members shall be transferred to the provider’s new CCO or DCO;
and
(IV) The transfer shall take
effect when the provider’s contract with their current CCO or DCO contractual
relationship ends, or on a date approved by the Division; and
(V) Members may not be transferred
under section (2)(E)(vi) until the Division has evaluated the receiving CCO or DCO
and determined that the CCO or DCO meets criteria established by the Division as
stated in rule including, but not limited to, ensuring that the CCO or DCO maintains
a network of providers sufficient in numbers, areas of practice and geographically
distributed in a manner to ensure that the health services provided under the contract
are reasonably accessible to members; and
(VI) The Division shall provide
notice of a transfer to members that will be affected by the transfer at least 90
days before the scheduled date of the transfer.
(E) If a member’s disenrollment
is denied, notice of denial shall be sent to the member pursuant to OAR 410-141-0263
and 410-141-3263 of their right to file a grievance or request a hearing.
(c) If the following conditions
are met:
(A) The applicant is in the
third trimester of pregnancy and has just been determined eligible for OHP, or the
OHP client has just been re-determined eligible and was not enrolled in a CCO or
DCO within the past three months; and
(B) The new CCO or DCO the
member is enrolled with does not contract with the member's current OB provider
and the member wishes to continue obtaining maternity services from that non-participating
OB provider; and
(C) The request to change
CCO or DCO or return to FFS is made prior to the date of delivery.
(d) For purposes of a member’s
right to file a grievance or request a hearing, disenrollment does not include the
following:
(A) Transfer of a member
from a PHP to a CCO or DCO.
(B) Involuntary transfer
of a member from a CCO or DCO to another CCO or DCO; or
(C) Automatic enrollment
of a member in a CCO or DCO.
(e) Member disenrollment
requests are subject to the following requirements:
(A) The member shall join
another CCO or DCO, unless the member resides in a service area where enrollment
is voluntary, or the member meets the exemptions to enrollment set forth in OAR
410-141-3060(4) or 410-141-0060(4), the member meets disenrollment criteria state
in 42 CFR 438.56(c)(2), or there is not another CCO or DCO in the service area;
(B) The effective date of
disenrollment shall be the end of the month in which disenrollment was requested
unless the Division approves retroactively;
(C) If the Authority fails
to make a disenrollment determination by the first day of the second month following
the month in which the member files a request for disenrollment, the disenrollment
is considered approved.
(3) The CCO or DCO may not
disenroll members solely for the following reasons:
(a) Because of a physical,
intellectual, developmental, or mental disability;
(b) Because of an adverse
change in the member's health;
(c) Because of the member's
utilization of services, either excessive or lack thereof;
(d) Because the member requests
a hearing;
(e) Because the member exercises
their option to make decisions regarding their medical care with which the CCO or
DCO disagrees;
(f) Because of uncooperative
or disruptive behavior resulting from the member’s special needs.
(4) Subject to applicable
disability discrimination laws, the Division may disenroll members for cause when
the CCO or DCO requests it for cause, which includes, but is not limited to, the
following:
(a) The member commits fraudulent
or illegal acts related to the member’s participation in the OHP, such as:
permitting the use of their medical ID card by others, altering a prescription,
theft, or other criminal acts. The CCO or DCO shall report any illegal acts to law
enforcement authorities and, if appropriate, to DHS Fraud Investigations Unit at
888-Fraud01 (888-372-8301) or http://www.oregon.gov/DHS/aboutdhs/fraud/ as appropriate,
consistent with 42 CFR 455.13.;
(b) The member became eligible
through a hospital hold process and placed in the Adults and Couples category as
required under OAR 410-141-3060(4)
(c) Requests by the CCO for
routine disenrollment of specific members shall include the following procedures
to be followed and documented prior to requesting disenrollment of a member:
(A) A request shall be submitted
in writing to the Coordinated Account Representative (CAR). The CCO or DCO shall
document the reasons for the request, provide written evidence to support the basis
for the request, and document that attempts at intervention were made as described
below. The procedures cited below shall be followed and documented prior to requesting
disenrollment of a member;
(B) There shall be notification
from the provider to the CCO or DCO at the time the problem is identified. The notification
shall describe the problem and allow time for appropriate resolution by the CCO
or DCO. Such notification shall be documented in the member's clinical record. The
CCO or DCO shall conduct provider education or training regarding the need for early
intervention, disability accommodation, and the services available to the provider;
(C) The CCO or DCO shall
contact the member either verbally or in writing, if it is a severe problem, to
inform the member of the problem that has been identified and attempt to develop
an agreement with the member regarding the issue. Any contact with the member shall
be documented in the member's clinical record. The CCO or DCO shall inform the member
that their continued behavior may result in disenrollment from the CCO or DCO;
(D) The CCO or DCO shall
provide individual education, disability accommodation, counseling, or other interventions
with the member in a serious effort to resolve the problem;
(E) The CCO or DCO shall
contact the member’s care team regarding the problem and, if needed and with
the agreement of the member, involve the care team and other appropriate individuals
working with the member in the resolution, within the laws governing confidentiality;
(F) If the severity of the
problem warrants, the CCO or DCO shall develop a care plan that details how the
problem is going to be addressed and coordinate a care conference with the member,
their care team, and other individuals chosen by the member. If necessary, the CCO
or DCO shall obtain an authorization for release of information from the member
for the providers and agencies in order to involve them in the resolution of the
problem. If the release is verbal, it shall be documented in the member's record;
(G) The CCO or DCO shall
submit any additional information or assessments requested by the Division CAR;
(H) The Authority shall notify
the member in writing of a disenrollment made as defined in the section above;
(I) If the member's behavior
is uncooperative or disruptive including, but not limited to, threats or acts of
physical violence as the result of his or her special needs or disability, the CCO
or DCO shall also document each of the following:
(i) A written description
of the relationship of the behavior to the special needs or disability of the individual
and whether the individual's behavior poses a direct threat to the health or safety
of others. Direct threat means a significant risk to the health or safety of others
that cannot be eliminated by a modification of policies, practices, or procedures.
In determining whether a member poses a direct threat to the health or safety of
others, the CCO or DCO shall make an individualized assessment, based on reasonable
judgment that relies on current medical knowledge or best available objective evidence
to ascertain the nature, duration, and severity of the risk to the health or safety
of others; the probability that potential injury to others shall actually occur;
and whether reasonable modifications of policies, practices, or procedures shall
mitigate the risk to others;
(ii) A CCO or DCO-staffed
interdisciplinary team review that includes a mental health professional or behavioral
specialist and other health care professionals who have the appropriate clinical
expertise in treating the member's condition to assess the behavior, the behavioral
history, and previous history of efforts to manage behavior;
(iii) If warranted, a clinical
assessment of whether the behavior will respond to reasonable clinical or social
interventions;
(iv) Documentation of any
accommodations that have been attempted and why the accommodations haven’t
worked;
(v) Documentation of the
CCO or DCO's rationale for concluding that the member's continued enrollment in
the CCO or DCO seriously impairs the CCO’s or DCO’s ability to furnish
services to either this particular member or other members.
(vi) If a Primary Care Provider
(PCP) terminates the provider/patient relationship, the CCO or DCO shall attempt
to locate another PCP on their panel who will accept the member as their patient.
If needed, the CCO or DCO shall obtain an authorization for release of information
from the member in order to share the information necessary for a new provider to
evaluate whether they can treat the member. All terminations of provider/patient
relationships shall be according to the CCO or DCO's policies and shall be consistent
with CCO or DCO or PCP's policies for commercial members and with applicable disability
discrimination laws. The CCO or DCO shall determine whether the PCP’s termination
of the provider/patient relationship is based on behavior related to the member’s
disability and shall provide education to the PCP about disability discrimination
laws.
(d) In addition to the requirements
in subsection (c), requests by the CCO or DCO for an exception to the routine disenrollment
process shall include the following:
(A) In accordance with 42
CFR 438.56 the CCO or DCO shall submit a request in writing to the CAR for approval.
An exception to the disenrollment process may only be requested for members who
have committed an act of or made a credible threat of physical violence directed
at a health care provider, the provider’s staff, other patients, or the CCO
or DCO’s staff so that it seriously impairs the CCO or DCO’s ability
to furnish services to either this particular member or other members. A credible
threat means that there is a significant risk that the member will cause grievous
physical injury to others (including but not limited to death) in the near future,
and that risk cannot be eliminated by a modification of policies, practices, or
procedures. The CCO or DCO shall document the reasons for the request and provide
written evidence to support the basis for the request prior to requesting an exception
to the disenrollment process of a member;
(B) Providers shall immediately
notify the CCO or DCO about the incident with the member. The notification shall
describe the problem and be maintained for documentation purposes;
(C) The CCO or DCO shall
attempt and document contact with the member and their care team regarding the problem
and, if needed, involve the care team and other appropriate individuals in the resolution,
within the laws governing confidentiality;
(D) The CCO or DCO shall
provide any additional information requested by the CAR, the Authority, or Department
of Human Services assessment team;
(E) If the member’s
behavior could reasonably be perceived as the result of their special needs or disability,
the CCO or DCO shall also document each of the following:
(i) A written description
of the relationship between the behavior to the special needs or disability of the
individual and whether the individual’s behavior poses a credible threat of
physical violence as defined in section (2)(b)(C)(i) of this rule;
(ii) In determining whether
a member poses a credible threat to the health or safety of others, the CCO or DCO
shall make an individualized assessment, based on reasonable judgment that relies
on current medical knowledge or best available objective evidence to ascertain the
nature, duration, and severity of the risk to the health or safety of others; the
probability that potential injury to others will actually occur; and whether reasonable
modifications of policies, practices, or procedures will mitigate the risk to others;
(F) Documentation shall exist
that verifies the provider or CCO or DCO immediately reported the incident to law
enforcement. The CCO or DCO shall submit a copy of the police report or case number.
If a report is not available, submit a signed entry in the member’s clinical
record documenting the report to law enforcement or other reasonable evidence;
(G) Documentation shall exist
that verifies what reasonable modifications were considered and why reasonable modifications
of policies, practices, or procedures will not mitigate the risk to others;
(H) Documentation shall exist
that verifies any past incidents and attempts to accommodate similar problems with
this member;
(I) Documentation shall exist
that verifies the CCO or DCO’s rationale for concluding that the member’s
continued enrollment in the CCO or DCO seriously impairs the CCO or DCO’s
ability to furnish services to either this particular member or other members.
(e) Approval or denial of
disenrollment requests shall include the following:
(A) If there is sufficient
documentation, the request shall be evaluated by the CCO or DCO’s CAR or a
team of CARs who may request additional information from Ombudsman Services, AMH,
or other agencies as needed. If the request involves the member's mental health
condition or behaviors related to substance abuse, the CAR shall also confer with
the AMH’s substance use disorder specialist;
(B) In cases where the member
is also enrolled in the CCO or DCO’s Medicare Advantage plan, the CCO or DCO
shall provide proof to the Division of CMS’ approval to disenroll the member.
If approved by the Division, the date of disenrollment from both plans shall be
the disenrollment date approved by CMS;
(C) If there is insufficient
documentation, the CAR shall notify the CCO or DCO within two business days of initial
receipt what supporting documentation is needed for final consideration of the request;
(D) The CARs shall review
the request and notify the CCO or DCO of the decision within ten working days of
receipt of sufficient documentation from the CCO or DCO.
(E) Written decisions shall
be sent to the CCO or DCO within 15 working days from receipt of request and sufficient
documentation from the CAR.
(5) The following procedures
apply to all denied disenrollment requests:
(a) The CAR shall send the
member a notice within five days after the decision for denial with a copy to the
CCO or DCO and the member’s care team.
(b) The notice shall give
the disenrollment date, the reason for disenrollment, and the notice of the member's
right to file a complaint (as specified in 410-141-0260 through 410-141-0266) and
to request an administrative hearing and the option to continue enrollment in the
PHP pending the outcome of the hearing, in accordance with 42 CFR 438.420. If the
member requests a hearing, the disenrollment will proceed unless the member requests
continued enrollment, pending a decision:
(c) If disenrollment is approved,
the CAR shall contact the member's care team to arrange enrollment in a different
plan. The Division may require the member to obtain services from FFS providers
or a PCM until such time as they can be enrolled with another CCO or DCO;
(d) If no other CCO or DCO
is available to the member, the member will be exempt from enrollment in that type
of managed care plan for 12 months. If a member who has been disenrolled for cause
is re-enrolled in the CCO or DCO, the CCO or DCO may request a disenrollment review
by the CAR. A member may not be involuntarily disenrolled from the same CCO or DCO
for a period of more than 12 months. If the member is re-enrolled after the 12-month
period and the CCO or DCO again requests disenrollment for cause, the request shall
be referred to the OHA assessment team for review.
(6) The following procedures
apply to all approved disenrollment requests:
(a) The CAR shall send the
member a notice within five days after the request was approved with a copy to the
CCO or DCO and the member's care team.
(b) The notice shall give
the disenrollment date, the reason for disenrollment, and the notice of member's
right to file a complaint (as specified in OAR 410-141-3260 through 410-141-3266)
and to request an administrative hearing and the option to continue enrollment in
the CCO or DCO pending the outcome of the hearing, in accordance with 42 CFR 438.420.
If the member requests a hearing, the disenrollment shall proceed unless the member
requests continued enrollment pending a decision:
(c) The disenrollment effective
date will be ten calendar days after the disenrollment notice is sent to the member,
unless the member requests a hearing and ongoing enrollment pending a hearing decision.
The disenrollment shall become effective immediately upon the issuing of an Administrative
Law Judge’s decision to uphold disenrollment.
(d) If disenrollment is approved,
the CAR shall contact the member’s care team to arrange enrollment in a different
plan. The Division may require the member to obtain services from FFS providers
or a PCM until such time as they can be enrolled with another CCO or DCO;
(e) If no other CCO or DCO
is available to the member, the member shall be exempt from enrollment in that type
of managed care plan for 12 months. If a member who has been disenrolled for cause
is re-enrolled in the CCO or DCO, the CCO or DCO may request a disenrollment review
by the CAR. A member may not be involuntarily disenrolled from the same CCO or DCO
for a period of more than 12 months. If the member is re-enrolled after the 12-month
period and the CCO or DCO or the member again requests disenrollment for cause,
the request shall be referred to the Authority’s assessment team for review.
(7) Other reasons for the
CCO or DCO's requests for disenrollment may include the following:
(a) If the member is enrolled
in the CCO or DCO on the same day the member is admitted to the hospital, the CCO
or DCO shall be responsible for the hospitalization. If the member is enrolled after
the first day of the inpatient stay, the member shall be disenrolled and enrolled
on the next available enrollment date following discharge from inpatient hospital
services;
(b) The member has surgery
scheduled at the time their enrollment is effective with the CCO or DCO, the provider
is not on the CCO or DCO's provider panel, and the member wishes to have the services
performed by that provider;
(c) The Medicare member is
enrolled in a Medicare Advantage plan and was receiving hospice services at the
time of enrollment in the CCO or DCO;
(d) Excluding the DCOs, if
the CCO determines that the member or MHO member has Third Party Liability (TPL),
the CCO will contact the Health Insurance Group (HIG) to request disenrollment;
(e) If a CCO or DCO has knowledge
of a member's change of address, the CCO or DCO shall notify the member’s
care team. The care team shall verify the address information and disenroll the
member from the CCO or DCO, if the member no longer resides in the CCO or DCO's
service area. Members shall be disenrolled if out of the CCO or DCO's service area
for more than three months, unless previously arranged with the CCO or DCO. The
effective date of disenrollment shall be the date specified by the Division, and
if a partial month remains, the Division shall recoup the balance of that month's
capitation payment from the CCO or DCO;
(f) The member is an inmate
who is serving time for a criminal offense or confined involuntarily in a state
or federal prison, jail, detention facility, or other penal institution. This does
not include members on probation, house arrest, living voluntarily in a facility
after their case has been adjudicated, infants living with an inmate, or inmates
who become inpatients. The CCO or DCO shall identify the members and provide sufficient
proof of incarceration to the Division for review of the disenrollment request.
The Division shall approve requests for disenrollment from CCO or DCOs for members
who have been taken into custody;
(g) The member is in a state
psychiatric institution.
(8) The Division may initiate
and disenroll members as follows:
(a) If informed that a member
has TPL, the Division shall refer the case to the HIG for investigation and possible
exemption from CCO or DCO enrollment. The Division shall disenroll members who have
TPL effective the end of the month in which HIG makes such a determination. In some
situations, the Division may approve retroactive disenrollment;
(b) If the member moves out
of the CCO or DCO's service area, the effective date of disenrollment shall be the
date specified by the Division, and the Division shall recoup the balance of that
month's capitation payment from the CCO or DCO;
(c) If the member is no longer
eligible for OHP, the effective date of disenrollment shall be the date specified
by the Division;
(d) If the member dies, the
last date of enrollment shall be the date of death.
(9) Unless specified otherwise
in these rules or in the Division notification of disenrollment to the CCO or DCO,
all disenrollments are effective the end of the month the Authority approves the
disenrollment with the following exceptions;
(a) The Authority may retroactively
disenroll or suspend enrollment when the member is taken into custody. The effective
date shall be the date the member was incarcerated.
(b) The Authority may retroactively
disenroll enrollment if the member has TPL pursuant to this rule. The effective
date shall be the end of the month in which HIG makes the determination.
Stat. Auth.: ORS 413.032, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 47-2012(Temp), f. & cert. ef. 10-16-12 thru 4-13-13; DMAP 55-2012(Temp),
f. & cert. ef. 11-15-12 thru 4-13-13; Administrative correction 4-22-13; DMAP
19-2013, f. & cert. ef. 4-23-13; DMAP 25-2013, f. & cert. ef. 6-11-13; DMAP
38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 65-2013, f. & cert.
ef. 11-29-13; DMAP 8-2014(Temp), f. 1-31-14, cert. ef. 2-1-14 thru 7-31-14; DMAP
30-2014, f. 5-23-14, cert. ef. 6-1-14
410-141-3120
Operations
and Provision of Health Services
(1) CCOs shall establish, maintain,
and operate with a governance structure and community advisory council that is consistent
with the requirements of ORS 414.625 and applicable health system transformation
laws.
(2) At a minimum, CCOs shall
provide medically appropriate health services including flexible services within
the scope of the member’s benefit package of health services in accordance
with the Prioritized List of Health Services and the terms of the contract.
(3) CCOs shall select providers
using universal application and credentialing procedures and objective quality information.
CCOs shall take steps to remove providers from their provider network if they fail
to meet objective quality standards:
(a) CCOs shall ensure that
all participating providers providing coordinated care services to members are credentialed
upon initial contract with the CCO and recredentialed no less frequently than every
three years. The credentialing and recredentialing process shall include review
of any information in the National Practitioners Databank. CCOs shall accept both
the Oregon Practitioner Credentialing Application and the Oregon Practitioner Recredentialing
Application;
(b) CCOs shall screen their
providers to be in compliance with 42 CFR 455 Subpart E (42 CFR 455.410 through
42 CFR 455.470) and retain all resulting documentation for audit purposes;
(c) CCOs may elect to contract
for or to delegate responsibility for the credentialing and screening processes;
however, CCOs shall be responsible for the following activities including oversight
of the following processes regardless of whether the activities are provided directly,
contracted, or delegated:
(A) Ensuring that coordinated
care services are provided within the scope of license or certification of the participating
provider or facility and within the scope of the participating provider’s
contracted services. They shall ensure participating providers are appropriately
supervised according to their scope of practice;
(B) Providing training for
CCO staff and participating providers and their staff regarding the delivery of
coordinated care services, applicable administrative rules, and the CCOs administrative
policies.
(d) The CCO shall provide
accurate and timely information to the Authority about:
(A) License or certification
expiration and renewal dates;
(B) Whether a provider’s
license or certification is expired or not renewed or is subject to licensing termination,
suspension, or certification sanction;
(C) If a CCO knows or has
reason to know that a provider has been convicted of a felony or misdemeanor related
to a crime or violation of federal or state laws under Medicare, Medicaid, or Title
XIX (including a plea of “nolo contendre”).
(e) CCOs may not refer members
to or use providers that:
(A) Have been terminated
from the Division;
(B) Have been excluded as
a Medicaid provider by another state;
(C) Have been excluded as
Medicare/Medicaid providers by CMS; or
(D) Are subject to exclusion
for any lawful conviction by a court for which the provider could be excluded under
42 CFR 1001.101.
(f) CCOs may not accept billings
for services to members provided after the date of the provider’s exclusion,
conviction, or termination. CCOs shall recoup any monies paid for services to members
provided after the date of the provider’s exclusion, conviction, or termination;
(g) CCOs shall require each
atypical provider to be enrolled with the Authority and shall obtain and use registered
National Provider Identifiers (NPIs) and taxonomy codes reported to the Authority
in the Provider Capacity Report for purposes of encounter data submission prior
to submitting encounter data in connection with services by the provider. CCOs shall
require each qualified provider to have and use an NPI as enumerated by the National
Plan and Provider Enumeration System (NPPES);
(h) The provider enrollment
request (for encounter purposes) and credentialing documents require the disclosure
of taxpayer identification numbers. The Authority shall use taxpayer identification
numbers for the administration of this program including provider enrollment, internal
verification, and administrative purposes for the medical assistance program for
administration of tax laws. The Authority may use taxpayer identification numbers
to confirm whether the individual or entity is subject to exclusion from participation
in the medical assistance program. Taxpayer identification number includes Employer
Identification Number (EIN), Social Security Number (SSN), and Individual Tax Identification
Number (ITIN) used to identify the individual or entity on the enrollment request
form or disclosure statement. Disclosure of all tax identification numbers for these
purposes is mandatory. Failure to submit the requested taxpayer identification numbers
may result in denial of enrollment as a provider and denial of a provider number
for encounter purposes or denial of continued enrollment as a provider and deactivation
of all provider numbers used by the provider for encounters.
(4) A CCO may not discriminate
with respect to participation in the CCO against any health care provider who is
acting within the scope of the provider’s license or certification under applicable
state law on the basis of that license or certification. If a CCO declines to include
individual or groups of providers in its network, it shall give the affected providers
written notice of the reason for its decision. This rule may not be construed to:
(a) Require that a CCO contract
with any health care provider willing to abide by the terms and conditions for participation
established by the CCO; or
(b) Preclude the CCO from
establishing varying reimbursement rates based on quality or performance measures.
For purposes of this section, quality and performance measures include all factors
that advance the goals of health system transformation including:
(A) Factors designed to maintain
quality of services and control costs and are consistent with its responsibilities
to members; or
(B) Factors that add value
to the service provided including, but not limited to, expertise, experience, accessibility,
or cultural competence.
(c) The requirements in subsection
(b) do not apply to reimbursement rate variations between providers with the same
license or certification or between specialists and non-specialty providers.
(5) A CCO shall establish
an internal review process for a provider aggrieved by a decision under section
(4) of this rule including an alternative dispute resolution or peer review process.
An aggrieved provider may appeal the determination of the internal review to the
Authority.
(6) To resolve appeals made
to the Authority under sections (4) and (5) of this rule, the Authority shall provide
administrative review of the provider’s appeal using the administrative review
process established in OAR 410-120-1580. The Authority shall invite the aggrieved
provider and the CCO to participate in the administrative review. In making a determination
of whether there has been discrimination, the Authority shall consider the CCO’s:
(a) Network adequacy;
(b) Provider types and qualifications;
(c) Provider disciplines;
and
(d) Provider reimbursement
rates.
(7) A prevailing party in
an appeal under sections (4) through (6) of this rule shall be awarded the costs
of the appeal.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 20-2012(Temp),
f. & cert. ef. 3-30-12 thru 9-25-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 45-2014, f. 7-15-14, cert. ef. 8-1-14
410-141-3140
Emergency
and Urgent Care Services
(1)
CCOs shall have written policies, procedures, and monitoring systems that ensure
the provision of appropriate urgent, emergency, and triage services 24-hours a day,
7-days-a-week for all members. CCOs shall:
(a)
Communicate these policies and procedures to participating providers;
(b)
Regularly monitor participating providers' compliance with these policies and procedures;
and
(c)
Take any corrective action necessary to ensure compliance. CCOs shall document all
monitoring and corrective action activities.
(2)
CCOs shall have written policies, procedures, and monitoring processes to ensure
that a provider provides a medically or dentally appropriate response as indicated
to urgent or emergency calls including but limited to the following:
(a)
Telephone or face-to-face evaluation of the member;
(b)
Capacity to conduct the elements of an assessment to determine the necessary interventions
to begin stabilization;
(c)
Development of a course of action;
(d)
Provision of services and referral needed to begin post-stabilization care or provide
outreach services in the case of a member requiring behavioral health services,
or a member who cannot be transported or is homebound;
(e)
Provision for notifying a referral emergency room, when applicable, concerning the
arriving member’s presenting problem, and whether or not the provider will
meet the member at the emergency room; and
(f)
Provision for notifying other providers, when necessary, to request approval to
treat members.
(3)
CCOs shall ensure the availability of an after-hours call-in system adequate to
triage urgent care and emergency calls from members or a member’s long-term
care provider or facility. The CCO representative shall return urgent calls appropriate
to the member's condition but in no event more than 30 minutes after receipt. If
information is not adequate to determine if the call is urgent, the CCO representative
shall return the call within 60 minutes to fully assess the nature of the call.
If information is adequate to determine that the call may be emergent in nature,
the CCO shall return the call.
(4)
If emergency room screening examination leads to a clinical determination by the
examining provider that an actual emergency medical condition exists under the prudent
layperson standard, the CCO must pay for all services required to stabilize the
patient, except as otherwise provided in section (6) of this rule. The CCO may not
require prior authorization for emergency services:
(a)
The CCO may not retroactively deny a claim for an emergency screening examination
because the condition, which appeared to be an emergency medical condition under
the prudent layperson standard, turned out to be non-emergent;
(b)
The CCO may not limit what constitutes an emergency medical condition based on lists
of diagnoses or symptoms;
(c)
The CCO may not deny a claim for emergency services merely because the PCP was not
notified, or because the CCO was not billed within ten calendar days of the service.
(5)
When a member's PCP, designated provider, or other CCO representative instructs
the member to seek emergency care, in or out of the network, the CCO shall pay for
the screening examination and other medically appropriate services. Except as otherwise
provided in section (6) of this rule, the CCO shall pay for post-stabilization care
that was:
(a)
Pre-authorized by the CCO;
(b)
Not pre-authorized by the CCO if the CCO, or the on-call provider, failed to respond
to a request for pre-authorization within one hour of the request, or the member
could not contact the CCO or provider on call; or
(c)
If the CCO and the treating provider cannot reach an agreement concerning the member's
care and a CCO representative is not available for consultation, the CCO must give
the treating provider the opportunity to consult with a CCO provider. The treating
provider may continue with care of the member until a CCO provider is reached or
one of the criteria is met.
(6)
The CCO’s responsibility for post-stabilization care it has not authorized
ends when:
(a)
The participating provider with privileges at the treating hospital assumes responsibilities
for the member's care;
(b)
The participating provider assumes responsibility for the member's care through
transfer;
(c)
A CCO representative and the treating provider reach an agreement concerning the
member's care; or
(d)
The member is discharged.
(7)
CCOs shall have methods for tracking inappropriate use of urgent and emergency care
and shall take action, including individual member counseling, to improve appropriate
use of urgent and emergency care services. In partnership with CCOs, DCOs shall
take action to improve appropriate use of urgent and emergency care settings for
dental health care.
(a)
CCOs shall educate members about how to appropriately access care from emergency
rooms, urgent care and walk-in clinics, non-traditional health care workers, and
less intensive interventions other than their primary care home;
(b)
CCOs shall apply and employ innovative strategies to decrease unnecessary hospital
utilization.
(8)
CCOs must limit charges to members for post-stabilization care services to an amount
no greater than what the CCO would charge the member if he or she had obtained the
services through the CCO. For purposes of cost sharing, post stabilization care
services begin upon inpatient admission.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3145
Community
Health Assessment and Community Health Improvement Plans
(1) Pursuant to ORS 414.627 to the extent
practicable, CCOs shall partner with their local public health authority, local
mental health authority, and hospital systems to develop a shared Community Health
Assessment (CHA) process including conducting the assessment and development of
the resulting Community Health Improvement Plan (CHP).
(2) CCOs shall work with
the Authority to identify the components of the CHA. CCOs are encouraged to partner
with their local public health authority, hospital system, type B Area Agency on
Aging, APD field office and local mental health authority, the Early Learning Council,
the Youth Development Council, and school health providers in the region using existing
resources when available and avoiding duplication where practicable.
(3) In developing and maintaining
a health assessment, CCOs shall meaningfully and systematically engage representatives
of critical populations and community stakeholders to create a plan for addressing
community health needs that build on community resources and skills and emphasizes
innovation including, but not limited to, the following:
(a) Emphasis on disproportionate,
unmet, health-related need;
(b) Emphasis on primary prevention;
(c) Building a seamless continuum
of care;
(d) Building community capacity;
(e) Emphasis on collaborative
governance of community benefit.
(4) The CCO requirements
for conducting a CHA and CHP will be met for purposes of ORS 414.627 if they substantially
meet the community health needs assessment requirement of the federal Patient Protection
and Affordable Care Act, 2010 Section 9007, and the Public Health Accreditation
Board CHA and CHP requirements for local health departments and the AAA and local
mental health authority in the process.
(5) The CCO’s CAC shall
oversee the CHA and adopt a plan to serve as a strategic population health and health
care system service plan for the community served by the CCO. The Council shall
annually publish a report on the progress of the CHP.
(6) The CHP adopted by the
Council shall describe the scope of the activities, services, and responsibilities
that the CCO shall consider upon implementation. The activities, services, and responsibilities
defined in the CHP may include, but are not limited to:
(a) Analysis and development
of public and private resources, capacities, and metrics based on ongoing community
health assessment activities and population health priorities;
(b) Health policy;
(c) System design;
(d) Outcome and quality improvement;
(e) Integration of service
delivery;
(f) Workforce development;
and
(g) Public Health Accreditation
Board standards for CHPs.
(7) CCOs and their participating
providers shall work together to develop best practices of culturally and linguistically
appropriate care and service delivery to eliminate health disparities and improve
member health and well-being.
(8) CCOs and their CAC shall
collaborate with the Authority’s Office of Equity and Inclusion to develop
meaningful baseline data on health disparities. CCOs shall include in the CHA identification
and prioritization of health disparities among CCOs’ diverse communities,
including those defined by race, ethnicity, language, health literacy, age, disability,
gender, sexual orientation, behavioral health status, geography, or other factors
in their service areas such as type of living setting including, but not limited
to, home independent support living, adult foster home, or homeless. CCOs shall
collect and maintain data on race, ethnicity, and primary language for all members
on an ongoing basis in accordance with standards established by the Authority. CCOs
shall also include representatives of populations experiencing health disparities
in CHA and CHP prioritization. CCOs shall track and report on any quality measure
by these demographic factors and shall develop, implement, and evaluate strategies
to improve health equity among members. CCOs shall make this information available
by posting on the web.
(9) To the extent practicable,
CCOs shall:
(a) Base the CHP on research
including research into adverse childhood experiences;
(b) Evaluate the adequacy
of the existing school-based health center (SBHC) network to meet the specific pediatric
and adolescent health care needs in the community and make recommendations to improve
the SBHC system;
(c) Improve the integration
of all services provided to meet the needs of children, adolescents, and families;
(d) Address primary care,
behavioral and oral health, promotion of health and prevention, and early intervention
in the treatment of children and adolescents;
(e) With the development
of its CHP SBHCs, school nurses, school mental health providers, and individuals
representing child and adolescent health services shall be included.
(10) CCOs shall develop and
review and update its CHA and plan at least every five years to ensure the provision
of all medically appropriate covered coordinated care services including urgent
care and emergency services, preventive, community support, and ancillary services
in those categories of services included in CCO contracts or agreements with the
Authority.
(11) CCOs shall communicate
these policies and procedures to providers, regularly monitor providers’ compliance,
and take any corrective action necessary to ensure compliance. CCOs shall document
all monitoring and corrective action activities.
(12) If there is more than
one CCO in a community, the CCOs and their community partners may work together
to develop one shared CHA and one shared CHP.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 45-2014, f. 7-15-14, cert. ef. 8-1-14
410-141-3150
Other Non-Medical Services
(1) For purposes of this rule: “Other
Non-Medical Services” means non-state plan, health related services, also
referred to as “flexible services.” These services are provided in lieu
of traditional benefits and are intended to improve care delivery and member health
and lower costs. Services may effectively treat or prevent physical or behavioral
healthcare conditions. Services are consistent with the member’s treatment
plan as developed by the member’s primary care team and documented in the
member’s medical record.
(2) In the conventional manner
using CPT or HCPCS codes, Other Non-Medical Services cannot be reported for utilization
purposes. CCOs report qualified Other Non-Medical Services to the Authority in the
financial report category “health related services” referenced in the
CCO contract and accounted for in the CCO’s medical or member services’
expenses. These expenditures are not counted as administrative costs when determining
medical loss ratio. Other Non-Medical Services may include, but are not limited
to:
(a) Training and education
for health improvement or management, e.g., classes on healthy meal preparation,
diabetes self-management curriculum;
(b) Self-help or support
group activities, e.g., post-partum depression programs, Weight Watchers groups;
(c) Care coordination, navigation,
or case management activities not covered under state plan benefits, e.g., high
utilizer intervention program;
(d) Home and living environment
items or improvements such as non-DME items to improve mobility, access, hygiene,
or other improvements to address a particular health condition, e.g., air conditioner,
athletic shoes, or other special clothing;
(e) Transportation not covered
under state plan benefits, e.g., other than transportation to a medical appointment;
(f) Programs to improve the
general community health, e.g., farmers’ market in the “food desert;”
(g) Housing supports related
to social determinates of health, e.g., shelter, utilities, or critical repairs;
and
(h) Assistance with food
or social resources, e.g., supplemental food, referral to job training or social
services.
(3) The contractor shall
establish and maintain written policies and procedures for authorizing Other Non-Medical
Services. In compliance with the contractor’s policy, CCO-covered services
may be substituted with or expanded to include Other Non-Medical Services. These
services shall be coordinated by the contractor and may be in collaboration with
the PCPCH or other participating PCPs. The contractor, the member, and, as appropriate,
the family of the member are to agree that such services are an effective alternative
for the member. These policies and procedures shall be submitted to the Authority
for review and approval.
Stat. Auth.: ORS 413.042
Stats Implemented: ORS 413.042
Hist.: DMAP 43-2015(Temp),
f. & cert. ef. 8-13-15 thru 2-8-16
410-141-3160
Integration and Care Coordination
(1) In order to achieve the objectives
of providing CCO members’ integrated person centered care and services, CCOs
must assure that physical, behavioral and oral health services are consistently
provided to members in all age groups and all covered populations when medically
appropriate and consistent with the needs identified in the community health assessment
and community health improvement plan (Plan). CCOs must develop, implement and participate
in activities supporting a continuum of care that integrates physical, behavioral,
and oral health interventions in ways that are whole to the member and serve members
in the most integrated setting appropriate to their needs:
(a) CCOs shall ensure the
provision of care coordination, treatment engagement, preventive services, community
based services, and follow up services for all members health conditions;
(b) CCOs must enter into
contracts with providers of residential chemical dependency treatment services not
later than July 1, 2013 and must notify the Authority within 30 calendar days of
executing the contract;
(c) By July 1, 2014, each
CCO must have a contractual relationship with any dental care organization that
serves members in the area where they reside;
(d) CCOs must have adequate,
timely and appropriate access to hospital and specialty services. CCOs must establish
hospital and specialty service agreements that include the role of patient-centered
primary care homes and that specify processes for requesting hospital admission
or specialty services, performance expectations for communication and medical records
sharing for specialty treatments, at the time of hospital admission or discharge,
for after-hospital follow up appointments;
(e) CCOs must demonstrate
how hospitals and specialty services will be accountable to achieve successful transitions
of care. CCOs shall ensure members are transitioned out of hospital settings into
the most appropriate independent and integrated community settings. This includes
transitional services and supports for children, adolescents, and adults with serious
behavioral health conditions facing admission to or discharge from acute psychiatric
care, residential treatment settings and the state hospital.
(2) CCOs shall develop evidence-based
or innovative strategies for use within their delivery system networks to ensure
access to integrated and coordinated care, especially for members with intensive
care coordination needs. CCOs must:
(a) Demonstrate that each
member has a primary care provider or primary care team that is responsible for
coordination of care and transitions and that each member has the option to choose
a primary care provider of any eligible CCO participating provider type.
(b) Ensure that members with
high health needs, multiple chronic conditions, or behavioral health issues are
involved in accessing and managing appropriate preventive, health, behavioral health,
remedial and supportive care and services;
(c) Use and require its provider
network to use individualized care plans to the extent feasible to address the supportive
and therapeutic needs of each member, particularly those with intensive care coordination
needs, including members with severe and persistent mental illness receiving home
and community based services covered under the state’s 1915(1) State Plan
Amendment, and those receiving DHS Medicaid-funded long-term care services. Plans
should reflect member family, or caregiver preferences and goals to ensure engagement
and satisfaction;
(d) Implement systems to
assure and monitor improved transitions in care so that members receive comprehensive
transitional care, and improve members’ experience of care and outcomes, particularly
for transitions between hospitals and long-term care;
(e) Demonstrate that participating
providers have the tools and skills necessary to communicate in a linguistically
and culturally appropriate fashion with members and their families or caregivers
and to facilitate information exchange between other providers and facilities (e.g.,
addressing issues of health literacy, language interpretation, having electronic
health record capabilities);
(f) Work across provider
networks to develop partnerships necessary to allow for access to and coordination
with social and support services, including crisis management and community prevention
and self-managed programs;
(g) Communicate its integration
and coordination policies and procedures to participating providers, regularly monitor
providers' compliance and take any corrective action necessary to ensure compliance.
CCOs shall document all monitoring and corrective action activities.
(3) CCO’s must assess
the needs of its membership and make available supported employment and assertive
community treatment services available when medically appropriate and when an appropriate
provider is available. Appropriate providers are those that meet the requirements
in 309-016-0825. When no appropriate provider is available, the CCO must consult
with AMH and develop an approved plan to make supported employment and assertive
community treatment services available.
(4) CCOs must develop and
use Patient Centered Primary Care Home (PCPCH) capacity by implementing a network
of PCPCHs to the maximum extent feasible:
(a) PCPCHs should become
the focal point of coordinated and integrated care, so that members have a consistent
and stable relationship with a care team responsible for comprehensive care management;
(b) CCOs must develop mechanisms
that encourage providers to communicate and coordinate care with the PCPCH in a
timely manner, using electronic health information technology, where available;
(c) CCOs must engage other
primary care provider (PCP) models to be the primary point of care and care management
for members, where there is insufficient PCPCH capacity;
(d) CCOs must develop services
and supports for primary care that are geographically located as close as possible
to the member’s residence and are, if available, offered in nontraditional
settings that are accessible to families, diverse communities, and underserved populations.
CCOs shall ensure that all other services and supports are provided as close to
the member’s residence as possible.
(5) If a CCO implements other
models of patient-centered primary health care in addition to the use of PCPCH,
the CCO shall ensure member access to coordinated care services that provide effective
wellness and prevention, coordination of care, active management and support of
individuals with special health care needs, a patient and family-centered approach
to all aspects of care, and an emphasis on whole-person care in order to address
a patient’s physical and behavioral health care needs.
(6) If the member is living
in a DHS Medicaid funded long-term care (LTC) nursing facility or community based
care facility, or other residential facility, the CCO must communicate with the
member and the DHS Medicaid funded long-term care provider or facility about integrated
and coordinated care services:
(a) The CCO shall establish
procedures for coordinating member health services, and how it will work with long-term
care providers or facilities to develop partnerships necessary to allow for access
to and coordination of CCO services with long-term care services and crisis management
services;
(b) CCOs shall coordinate
transitions to DHS Medicaid-funded long-term care by communicating with local AAA/APD
offices when members are being discharged from an inpatient hospital stay, or transferred
between different LTC settings;
(c) CCOs shall develop a
Memorandum of Understanding (MOU) or contract with the local type B Area Agency
on Aging or the local office of the Department’s APD, detailing their system
coordination agreements regarding members’ receiving Medicaid-funded LTC services.
(7) For members who are discharged
to post hospital extended care, at the time of admission to a skilled nursing facility
(SNF) the CCO shall notify the appropriate AAA/APD office and begin appropriate
discharge planning. The CCO shall pay for the post hospital extended care benefit
if the member was a member of the CCO during the hospitalization preceding the nursing
facility placement. The CCO shall notify the SNF and the member no later than two
working days before discharge from post hospital extended care. For members who
are discharged to Medicare Skilled Care, the CCO shall notify the appropriate AAA/APD
office when the CCO learns of the admission.
(8) When a member's care
is being transferred from one CCO to another or for OHP clients transferring from
fee-for-service or PHP to a CCO, the CCO shall make every reasonable effort within
the laws governing confidentiality to coordinate, including but not limited to ORS
414.679 transfer of the OHP client into the care of a CCO participating provider.
(9) CCOs shall establish
agreements with the Local Mental Health Authorities (LMHAs) and Community Mental
Health Programs (CMHPs) operating in the service area, consistent with ORS 414.153,
to maintain a comprehensive and coordinated behavioral health delivery system and
to ensure member access to mental health services, some of which are not provided
under the global budget.
(10) CCOs shall coordinate
a member’s care even when services or placements are outside the CCO service
area. CCO assignment is based on the case member’s residence, and referred
to as county of origin or jurisdiction. Temporary placements by the Authority, Department
or health services placements for services including residential placements may
be located out of the service area, however, the CCO shall coordinate care while
in placement and discharge planning for return to county of origin or jurisdiction.
For out of area placements, an out of area exception must be made for the member
to retain the CCO enrollment in the county of origin or jurisdiction, while the
member’s placement is a temporary residential placement elsewhere. For program
placements in Child Welfare, BRS, OYA, and PTRS, refer to OAR 410-141-3050 for program
specific rules.
(11) CCOs shall ensure that
members receiving services from extended or long-term psychiatric care programs
such as secure residential facilities, PASSAGES projects, or state hospital, shall
receive follow-up services as medically appropriate to ensure discharge within five
working days of receipt of notice of discharge readiness.
(12) CCOs shall coordinate
with Community Emergency Service Agencies, including but not limited to police,
courts, juvenile justice, corrections, LMHAs and CMHPs, to promote an appropriate
response to members experiencing a behavioral health crisis and to prevent inappropriate
use of the emergency department or jails.
(13) CCOs shall accept FFS
authorized services, medical, and pharmacy prior authorizations, ongoing services
where a FFS prior authorization is not required, and services authorized by the
Division’s Medical Management Review Committee for 90 days, or until the CCO
can establish a relationship with the member and develop an evidence based, medically
appropriate coordinated care plan, whichever is later, except where customized equipment,
services, procedures, or treatment protocol require service continuation for no
less than six months.
(14) Except as provided in
OAR 410-141-3050, CCOs shall coordinate patient care, including care required by
temporary residential placement outside the CCO service area, or out-of-state care
in instances where medically necessary specialty care is not available in Oregon:
(a) CCO enrollment shall
be maintained in the county of origin with the expectation of the CCO to coordinate
care with the out of area placement and local providers;
(b) The CCO shall coordinate
the discharge planning when the member returns to the county of origin.
(15) CCOs shall coordinate
and authorize care, including instances where the member’s medically appropriate
care requires services and providers outside the CCO’s contracted network,
in another area, out-of-state, or a unique provider specialty not otherwise contracted.
The CCO shall pay the services and treatment plan as a non-participating provider
pursuant to OAR 410-120-1295.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610–414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 1-2013(Temp), f. & cert. ef. 1-4-13 thru 7-2-13; DMAP 34-2013, f. &
cert. ef. 6-27-13
410-141-3170
Intensive
Care Coordination Services (Exceptional Needs Care Coordination (ENCC))
(1)
CCOs are responsible for intensive care coordination services, otherwise known as
Exceptional Needs Care Coordination (ENCC). Even if the CCO uses another term, these
rules set forth the elements and requirements for intensive care coordination services.
Where the term ENCC appears in rule or contract, it shall be given the meaning in
this rule.
(2)
CCOs shall make intensive care coordination services available to members identified
as aged, blind, or disabled, who have complex medical needs, high health care needs,
multiple chronic conditions, behavioral health issues, and for members with severe
and persistent behavioral health issues receiving home and community-based services
under the state’s 1915(1) State Plan Amendment. The member, member’s
representative, provider, other medical personnel serving the member, or the member's
Authority case manager may request intensive care coordination services.
(3)
CCOs shall respond to requests for intensive care coordination services with an
initial response made by the next working day following the request.
(4)
CCOs shall periodically inform all participating providers of the availability of
intensive care coordination services, provide training for patient centered primary
care homes and other primary care providers’ staff on intensive care coordination
services and other support services available for members.
(5)
CCOs shall ensure that the case manager’s name and telephone number are available
to Authority staff and members or member representatives when intensive care coordination
services are provided to the member.
(6)
CCOs shall make intensive care coordination services available to coordinate the
provision of these services to members who exhibit inappropriate, disruptive, or
threatening behaviors in a provider's office or clinic or other health care setting.
(7)
CCOs shall implement procedures to share the results of its identification and assessment
of any member appropriate for intensive care coordination services, with participating
providers serving the member so that those activities are not duplicated. Information
sharing shall be consistent with ORS 414.679 and applicable privacy requirements.
(8)
CCOs must have policies and procedures, including a standing referral process for
direct access to specialists, for identifying, assessing and producing a treatment
plan for each member identified as having a special health care need. Each treatment
plan shall be:
(a)
Developed by the member’s designated provider with the member’s participation;
(b)
Include consultation with any specialist caring for the member;
(c)
Approved by the CCO in a timely manner if CCO approval is required; and
(d)
In accordance with any applicable quality assurance and utilization review standards.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3180
Record
Keeping and Use of Health Information Technology
(1)
CCOs shall have written policies and procedures that ensure maintenance of a record
keeping system that includes maintaining the security of records as required by
the Health Insurance Portability and Accountability Act (HIPAA), 42 USC §1320-d
et seq., and the federal regulations implementing the Act, and complete clinical
records that document the coordinated care services received by the members. CCOs
shall communicate these policies and procedures to participating providers, regularly
monitor participating providers' compliance and take any corrective action necessary
to ensure compliance. CCOs shall document all monitoring and corrective action activities.
These policies and procedures shall ensure that records are secured, safeguarded
and stored in accordance with applicable Oregon Revised Statutes and Oregon Administrative
Rules.
(2)
A member must have access to the member’s personal health information in the
manner provided in 45 C.F.R. 164.524 and ORS 179.505(9) so the member may share
the information with others involved in the member’s care and make better
health care and lifestyle choices. CCO's participating providers may charge the
member for reasonable duplication costs, as set forth in OAR 943-014-0030, when
the member seeks copies of their records.
(3)
Notwithstanding ORS 179.505, a CCO, its provider network and programs administered
by the Department ‘s Aging and People with Disabilities shall use and disclose
member information for purposes of service and care delivery, coordination, service
planning, transitional services and reimbursement, in order to improve the safety
and quality of care, lower the cost of care and improve the health and well-being
of the members.
(4)
A CCO and its provider network shall use and disclose sensitive diagnosis information
including HIV and other health and behavioral health diagnoses, within the CCO for
the purpose of providing whole-person care. Individually identifiable health information
must be treated as confidential and privileged information subject to ORS 192.553
to 192.581 and applicable federal privacy requirements. Redisclosure of individually
identifiable information outside of the CCO and the CCO’s providers for purposes
unrelated to this section or the requirements of ORS 414.625, 414.632, 414.635,
414.638, 414.653 or 414.655 remains subject to any applicable federal or state privacy
requirements including the Authority’s rules established in OAR 943-014-0000
through 0070 for matters that involve privacy and confidentiality and privacy of
members protected information.
(5)
The CCO must document its methods and findings to ensure across the organization
and the network of providers there is documentation of the following coordinated
care services and supports:
(a)
Each member has a consistent and stable relationship with a care team that is responsible
for comprehensive care management and service delivery;
(b)
The supportive and therapeutic needs of the member are addressed in a holistic fashion,
using patient centered primary care homes and individualized care plans to the extent
feasible;
(c)
Members receive comprehensive transitional care, including appropriate follow-up,
when entering and leaving an acute care facility, including acute psychiatric facility,
state hospital or residential care settings for members with mental illness or
a DHS Medicaid funded long-term care setting, including engagement of the member
and family in care management and treatment planning;
(d)
Members receive assistance in navigating the health care delivery system and in
accessing community and social support services and statewide resources, for example,
the use of certified or qualified health care interpreters, as defined in ORS 413.550,
community health workers and personal health navigators who meet competency standards
established in ORS 414.665 or who are certified by the Home Care Commission under
ORS 410.604;
(e)
Members have access to advocates, for example, qualified peer wellness specialists
where appropriate, personal health navigators, and qualified community health workers
who are part of the member’s care team to provide assistance that is culturally
and linguistically appropriate to the member’s need to access appropriate
services and participate in processes affecting the member’s care and services;
(f)
Members are encouraged within all aspects of the integrated and coordinated health
care delivery system to use wellness and prevention resources and to make healthy
lifestyle choices.
(6)
CCOs shall facilitate the adoption and use of electronic health records (EHRs) by
its provider network. To achieve advanced EHR adoption, CCOs shall:
(a)
Identify EHR adoption rates; rates may be divided by provider type and geographic
region;
(b)
Develop and implement strategies to increase adoption rates of certified EHRs;
(c)
Encourage EHR adoption.
(7)
CCOs shall facilitate the adoption and use of electronic health information exchange
(HIE) in a way that allows all participating providers to exchange a member’s
health, behavioral health, and dental health information with any other provider
in that CCO.
(8)
CCOs shall establish minimum requirements for HIE, including rates of e-prescribing
and electronic lab orders, over time.
(9)
CCOs shall initially identify their current HIT capacity and develop and implement
a plan for improvement in the following areas:
(a)
Analytics that are regularly and timely used in reporting to its provider network
(e.g. to assess provider performance, effectiveness and cost-efficiency of treatment);
(b)
Quality and utilization reporting (to facilitate quality improvement within the
CCO as well as to report the data on quality of care that will allow the Authority
to monitor the CCOs performance);
(c)
Patient engagement through HIT (using existing tools such as e-mail); and
(d)
Other appropriate uses for HIT (e.g. telehealth, mobile devices).
(10)
CCOs shall maintain health information systems that collect, analyze, integrate,
and report data and can provide information on areas including but not limited to
the following:
(a)
Names and phone numbers of the member's primary care provider or clinic, primary
dentist and behavioral health provider;
(b)
Copies of Client Process Monitoring System (CPMS) enrollment forms;
(c)
Copies of long-term psychiatric care determination request forms;
(d)
Evidence that the member has been informed of rights and responsibilities;
(e)
Complaint and appeal records;
(f)
Disenrollment requests for cause and the supporting documentation;
(g)
Coordinated care services provided to enrollees, through an encounter data system;
and
(h)
Based on written policies and procedures, the record keeping system developed and
maintained by CCOs and their participating providers shall include sufficient detail
and clarity to permit internal and external review to validate encounter submissions
and to assure medically appropriate services are provided consistent with the documented
needs of the member. The system shall conform to accepted professional practice
and facilitate an adequate system to allow the CCO to ensure that data received
from providers is accurate and complete by:
(A)
Verifying the accuracy and timeliness of reported data;
(B)
Screening the data for completeness, logic, and consistency; and
(C)
Collecting service information in standardized formats to the extent feasible and
appropriate.
(11)
CCOs and their provider network shall cooperate with the Division, AMH, the Department
of Justice Medicaid Fraud Unit, and CMS, or other authorized state or federal reviewers,
for purposes of audits, inspection and examination of members' clinical records,
whether those records are maintained electronically or in physical files. Documentation
must be sufficiently complete and accurate to permit evaluation and confirmation
that coordinated care services were authorized and provided, referrals made, and
outcomes of coordinated care and referrals sufficient to meet professional standards
applicable to the health care professional and meet the requirements for health
oversight and outcome reporting in these rules.
(12)
Across the CCO’s provider network, all clinical records shall be retained
for seven years after the date of services for which claims are made. If an audit,
litigation, research and evaluation, or other action involving the records is started
before the end of the seven-year period, the clinical records must be retained until
all issues arising out of the action are resolved.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3200
Outcome
and Quality Measures
(1) CCOs shall report to the Authority
its health promotion and disease prevention activities, national accreditation organization
results, and HEDIS measures as required by DCBS in OAR 836-053-1000. A copy of the
reports may be provided to the Authority’s Performance Improvement Coordinator
concurrent with any submission to DCBS
(2) As required by Health
System Transformation, CCOs shall be accountable for performance on outcomes, quality,
and efficiency measures incorporated into the CCO’s contract with the Authority.
The measures are adopted by the Metrics and Scoring Committee using a public process;
information can be requested from the Authority or viewed online at http://www.oregon.gov/oha/Pages/metrix.aspx.
(3) CCOs shall address objective
outcomes, quality measures, and benchmarks for ambulatory care, inpatient care,
behavioral health treatment, oral health care (to the extent that dental services
are the responsibility of a CCO under an agreement with a DCO), and all other health
services provided by or under the responsibility of the CCO as specified in the
CCO’s contract with the Authority.
(4) CCOs shall maintain an
effective process for monitoring, evaluating, and improving the access, quality,
and appropriateness of services provided to members consistent with the needs and
priorities identified in the CCO’s community health assessment, community
health improvement plan, and the standards in the CCO’s contract. CCOs shall
have in effect mechanisms to:
(a) Detect both underutilization
and overutilization of services;
(b) Evaluate performance
and customer satisfaction;
(c) Evaluate grievance, appeals,
and contested case hearings consistent with OAR 410-141-3260; and
(d) Assess the quality and
appropriateness of coordinated care services provided to members who are aged, blind,
or disabled who have high health care needs, multiple chronic conditions, mental
illness, or Substance Use Disorder (SUD) services; who received Medicaid funded
long-term care benefits; or who are children receiving CAF (Child Welfare) or OYA
services.
(5) CCOs shall implement
policies and procedures that assure it will collect timely data including health
disparities and other data required by rule or contract that will allow the CCO
to conduct and report on its outcome and quality measures and report its performance.
CCOs shall submit to the Authority the CCO’s annual written evaluation of
outcome and quality measures established for the CCO or other reports as the Authority
may require in response to the measures adopted by the Metrics and Scoring Committee.
(6) CCOs shall adopt practice
guidelines consistent with 42 CFR 438.236 that address physical health care, behavioral
health treatment, or dental care concerns identified by members or their representatives
and to implement changes that have a favorable impact on health outcomes and member
satisfaction in consultation with its community advisory council or clinical review
panel.
(7) CCOs shall be accountable
for both core and transformational measures of quality and outcomes:
(a) Core measures will be
triple-aim oriented measures that gauge CCO performance against key expectations
for care coordination, consumer satisfaction, quality, and outcomes. The measures
will be uniform across CCOs and shall encompass the range of services included in
CCO global budgets (e.g., behavioral health, hospital care, women’s health);
(b) Transformational metrics
shall assess CCO progress toward the broad goals of health systems transformation
and require systems transitions and experimentation in effective use. This subset
may include newer kinds of indicators (for which CCOs have less measurement experience)
or indicators that entail collaboration with other care partners.
(8) CCOs shall provide the
required data to the All Payer All Claims data system established in ORS 442.464
and 442.466.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 45-2014, f. 7-15-14, cert. ef. 8-1-14
410-141-3220
Accessibility
(1) Consistent with the community health
assessment and health improvement plan, CCOs must assure that members have access
to high quality care. The CCO shall accomplish this developing a provider network
that demonstrates communication, collaboration, and shared decision making with
the various providers and care settings. The CCO shall develop and implement the
assessment and plan over time that meets access-to-care standards, and allows for
appropriate choice for members. The goal shall be that services and supports should
be geographically as close as possible to where members reside and, to the extent
necessary, offered in nontraditional settings that are accessible to families, diverse
communities, and underserved populations.
(2) CCOs shall ensure access
to integrated and coordinated care as outlined in OAR 410-141-3160, which includes
access to a primary care provider or primary care team that is responsible for coordination
of care and transitions.
(3) In developing its access
standards, the CCO should anticipate access needs, so that the members receive the
right care at the right time and place, using a patient-centered approach. The CCO
provider network shall support members, especially those with behavioral health
issues, in the most appropriate and independent setting, including in their own
home or independent supported living.
(4) CCOs shall have policies
and procedures which ensure that for 90% of their members in each service area,
routine travel time or distance to the location of the PCPCH or PCP does not exceed
the community standard for accessing health care participating providers. The travel
time or distance to PCPCHs or PCPs shall not exceed the following, unless otherwise
approved by the Authority:
(a) In urban areas-30 miles,
30 minutes or the community standard, whichever is greater;
(b) In rural areas-60 miles,
60 minutes or the community standard, whichever is greater.
(5) CCOs shall have an access
plan that establishes standards for access, outlines how capacity is determined
and establishes procedures for monthly monitoring of capacity and access, and for
improving access and managing risk in times of reduced participating provider capacity.
The access plan shall also identify populations in need of interpreter services
and populations in need of accommodation under the Americans with Disabilities Act.
(6) CCOs shall make the services
it provides including: primary care, specialists, pharmacy, hospital, vision, ancillary,
and behavioral health services, as accessible to members for timeliness, amount,
duration, and scope as those services are to other members within the same service
area. If the CCO is unable to provide those services locally, it must so demonstrate
to the Authority and provide reasonable alternatives for members to access care
that must be approved by the Authority. CCOs shall have a monitoring system that
shall demonstrate to the Authority that the CCO has surveyed and monitored for equal
access of members to referral providers of pharmacy, hospital, vision, ancillary,
and behavioral health services:
(a) CCOs shall ensure that
PCPs screen all eligible members for behavioral health issues to promote prevention,
early detection, intervention and referral to treatment, especially at initial contact
or physical exam or at initial prenatal examination, when a member shows evidence
of behavioral health issues or when a member over utilizes services;
(b) CCOs must use a universal
screening process that assesses members for critical risk factors that trigger intensive
care coordination for high-needs members.
(7) CCOs shall have policies
and procedures and a monitoring system to ensure that members who are aged, blind,
or disabled, or who have complex or high health care needs, multiple chronic conditions,
behavioral health issues or who are children receiving Department or OYA services
have access to primary care, dental care (when the CCO or DCO is responsible for
dental care), mental health providers and referral, and involves those members in
accessing and managing appropriate preventive, health, remedial and supportive care
and services.
(8) CCOs shall have policies
and procedures that ensure scheduling and rescheduling of member appointments are
appropriate to the reasons for, and urgency of, the visit. The member shall be seen,
treated, or referred as within the following timeframes:
(a) Emergency care-Immediately
or referred to an emergency department depending on the member's condition;
(b) Urgent care-Within 72
hours or as indicated in initial screening, in accordance with OAR 410-141-0140;
(c) Well care-Within 4 weeks
or within the community standard;
(d) Emergency dental care
(when dental care is provided by the CCO or DCO)-Seen or treated within 24- hours;
(e) Urgent dental care (when
dental care is provided by the CCO or DCO)-Within one to two weeks or as indicated
in the initial screening in accordance with OAR 410-123-1060; and
(f) Routine dental care (when
dental care is provided by the CCO or DCO)-Seen for routine care within an average
of eight weeks and within 12 weeks or the community standard, whichever is less,
unless there is a documented special clinical reason which would make access longer
than 12 weeks appropriate;
(g) Non-Urgent behavioral
health treatment-Seen for an intake assessment within 2 weeks from date of request.
(9) CCOs shall develop policies
and procedures for communicating with, and providing care to members who have difficulty
communicating due to a medical condition or who are living in a household where
there is no adult available to communicate in English or here there is no telephone:
(a) The policies and procedures
shall provide certified or qualified interpreter services by phone, in person, in
CCO administrative offices, especially those of member services and complaint and
grievance representatives and in emergency rooms of contracted hospitals;
(b) CCOs shall ensure the
provision of certified or qualified interpreter services for covered coordinated
care services including medical, behavioral health or dental care (when the CCO
or DCO is responsible for dental care) visits, and home health visits, to interpret
for members with hearing impairment or in the primary language of non-English speaking
members. All interpreters shall be linguistically appropriate and be capable of
communicating in English and the members’ primary language and be able to
translate clinical information effectively. Interpreter services shall be sufficient
for the provider to understand the member's complaint; to make a diagnosis; respond
to member's questions and concerns; and to communicate instructions to the member;
(c) CCOs shall ensure the
provision of coordinated care services which are culturally appropriate, i.e., demonstrating
both awareness for and sensitivity to cultural differences and similarities and
the effect on the members’ care;
(d) CCOs shall have written
policies and procedures that ensure compliance with requirements of the Americans
with Disabilities Act of 1990 in providing access to covered coordinated care services
for all members and shall arrange for services to be provided by non- participating
referral providers when necessary;
(e) CCOs shall have a plan
for ensuring compliance with these requirements and shall monitor for compliance.
Stat. Auth.: ORS 413.032, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 65-2013, f. &
cert. ef. 11-29-13
410-141-3260
Grievance
System: Grievances, Appeals and Contested Case Hearings
(1) This rule applies to requirements
related to the grievance system, which includes appeals, contested case hearings,
and grievances. For purposes of this rule and OAR 410-141-3261 through 410-141-3264,
references to member means a member, member’s representative and the representative
of a deceased member’s estate.
(2) The CCO must establish
and have a Division approved process and written procedures for the following:
(a) Member rights to appeal
and request a CCO’s review of an action;
(b) Member rights to request
a contested case hearing on a CCO action under the Administrative Procedures Act;
and
(c) Member rights to file
a grievance for any matter other than an appeal or contested case hearing;
(d) An explanation of how
CCOs shall accept, process and respond to appeals, hearing requests and grievances;
(e) Compliance with grievance
system requirements as part of the state quality strategy and to monitor and enforce
consumer rights and protections within the Oregon Integrated and Coordinated Health
Care Delivery System and ensure consistent response to complaints of violations
of consumer right and protections.
(3) Upon receipt of a grievance
or appeal, the CCO must:
(a) Acknowledge receipt to
the member;
(b) Give the grievance or
appeal to staff with the authority to act upon the matter;
(c) Obtain documentation
of all relevant facts concerning the issues;
(d) Ensure staff making decisions
on the grievance or appeal are:
(A) Not involved in any previous
level of review or decision-making; and
(B) Health care professionals
as defined in OAR 410-120-0000 with appropriate clinical expertise in treating the
member’s condition or disease if the grievance or appeal involves clinical
issues or if the member requests an expedited review.
(4) The CCO must analyze
all grievances, appeals and hearings in the context of quality improvement activity
pursuant to OAR 410-141-3200 and 410-141-3260.
(5) CCOs must keep all healthcare
information concerning a member's request confidential, consistent with appropriate
use or disclosure as the terms treatment, payment or CCO health care operations
are defined in 45 CFR 164.501.
(6) The following pertains
to release of a member’s information:
(a) The CCO and any provider
whose authorizations, treatments, services, items, quality of care or requests for
payment are involved in the grievance, appeal or hearing may use this information
without the member’s signed release for purposes of:
(A) Resolving the matter;
or
(B) Maintaining the grievance
or appeals log.
(b) If the CCO needs to communicate
with other individuals or entities not listed in subsection (a) to respond to the
matter, the CCO must obtain the member’s signed release and retain the release
in the member’s record.
(7) The CCO must provide
members with any reasonable assistance in completing forms and taking other procedural
steps related to filing grievances, appeals or hearing requests. Reasonable assistance
includes, but is not limited to:
(a) Assistance from qualified
community health workers, qualified peer wellness specialists or personal health
navigators to participate in processes affecting the member’s care and services;
(b) Free interpreter services;
(c) Toll-free phone numbers
that have adequate TTY/TTD and interpreter capabilities; and
(d) Reasonable accommodation
or policy and procedure modifications as required by any disability of the member.
(8) The CCO and its participating
providers may not:
(a) Discourage a member from
using any aspect of the grievance, appeal or hearing process;
(b) Encourage the withdrawal
of a grievance, appeal or hearing request already filed; or
(c) Use the filing or resolution
of a grievance, appeal or hearing request as a reason to retaliate against a member
or to request member disenrollment.
(9) In all CCO administrative
offices and in those physical, behavioral and oral health offices where the CCO
has delegated response to the appeal, hearing request or grievance, the CCO must
have the following forms available:
(a) OHP Complaint Form (OHP
3001);
(b) Appeal forms;
(c) Hearing request form
(DHS 443) and Notice of Hearing Rights (DMAP 3030); or
(d) The Division of Medical
Assistance Programs Service Denial Appeal and Hearing Request form (DMAP 3302) or
approved facsimile.
(10) A member’s provider:
(a) Acting on behalf of and
with written consent of the member may file an appeal;
(b) May not act as the member’s
authorized representative for requesting a hearing or filing a grievance.
(11) The CCO and its participating
providers must cooperate with the Department of Human Services Governor’s
Advocacy Office, the Authority’s Ombudsman and hearing representatives in
all activities related to member appeals, hearing requests and grievances including
providing all requested written materials.
(12) If the CCO delegates
the grievance and appeal process to a subcontractor, the CCO must:
(a) Ensure the subcontractor
meets the requirements consistent with this rule and OAR 410-141-3261 through 410-141-3264;
(b) Monitor the subcontractor’s
performance on an ongoing basis;
(c) Perform a formal compliance
review at least once a year to assess performance, deficiencies or areas for improvement;
and
(d) Ensure the subcontractor
takes corrective action for any identified areas of deficiencies that need improvement.
(13) CCO’s must maintain
yearly logs of all appeals and grievances for seven calendar years with the following
requirements:
(a) The logs must contain
the following information pertaining to each member’s appeal or grievance:
(A) The member’s name,
ID number, and date the member filed the grievance or appeal;
(B) Documentation of the
CCO’s review, resolution or disposition of the matter, including the reason
for the decision and the date of the resolution or disposition;
(C) Notations of oral and
written communications with the member; and
(D) Notations about appeals
and grievances the member decides to resolve in another way if the CCO is aware
of this.
(b) For each calendar year,
the logs must contain the following aggregate information:
(A) The number of actions;
and
(B) A categorization of the
reasons for and resolutions or dispositions of appeals and grievances.
(14) The CCO must review
the log monthly for completeness and accuracy, which includes but is not limited
to timeliness of documentation and compliance with procedures.
(15) A member or a member’s
provider may request an expedited resolution of an appeal or a contested case hearing
if the member or provider believes taking the standard time of resolution could
seriously jeopardize the member’s:
(a) Life, health, mental
health or dental health; or
(b) Ability to attain, maintain
or regain maximum function.
(16) A member who may be
entitled to continuing benefits may request and receive continuing benefits in the
same manner and same amount while an appeal or contested case hearing is pending:
(a) To be entitled to continuing
benefits, the member must complete a hearing request or request for appeal requesting
continuing benefits no later than:
(A) The tenth day following
the date of the notice or the notice of appeal resolution; and
(B) The effective date of
the action proposed in the notice, if applicable.
(b) In determining timeliness
under section (3)(a) of this rule, delay for good cause, as defined in OAR 137-002-0528,
is not counted;
(c) The benefits must be
continued until:
(A) A final appeal resolution
resolves the appeal unless the member requests a hearing with continuing benefits
no later than ten days following the date of the notice of appeal resolution;
(B) A final order resolves
the contested case;
(C) The time period or service
limits of a previously authorized service have been met; or
(D) The member withdraws
the request for hearing.
(17) The CCO shall review
and report to the Authority complaints that raise issues related to racial or ethnic
background, gender, religion, sexual orientation, socioeconomic status, culturally
or linguistically appropriate service requests, disability status and other identity
factors for consideration in improving services for health equity.
(18) If a CCO receives a
complaint or grievance related to a member’s entitlement of continuing benefits
in the same manner and same amount during the transition of transferring from one
CCO to another CCO for reasons defined in OAR 410-141-3080 (15) the CCO shall log
the complaint/grievance and work with the receiving/sending CCO to ensure continuity
of care during the transition.
Stat. Auth.: ORS 413.032, 414.615, 414.625,
414.635, 414.651
Stats. Implemented: ORS 414.610
– 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 54-2012(Temp), f. & cert. ef. 11-1-2 thru 4-29-13; DMAP 22-2013, f. &
cert. ef. 4-26-13; DMAP 60-2013, f. & cert. ef. 10-31-13; DMAP 33-2014, f. 5-30-14,
cert. ef. 7-1-14
410-141-3261
CCO
Grievance Process Requirements
(1)
A member may file a grievance:
(a)
Orally or in writing; and
(b)
With the Authority or the CCO. The Authority shall promptly send the grievance to
the CCO.
(2)
The CCO must resolve each grievance and provide notice of the disposition as expeditiously
as the member’s health condition requires but no later than the following
timeframes:
(a)
Within 5 working days from the date of receipt of the grievance; or
(b)
If the CCO needs additional time to resolve the grievance, the CCO shall respond
within 30 calendar days from the date of receipt of the grievance. If additional
time is needed the CCO shall notify the member, within 5 working days, of the reasons
additional time is necessary.
(3)
When informing members of the CCO’s decision the CCO:
(a)
May provide its decision about oral grievances either orally or writing;
(b)
Must address each aspect of the grievance and explain the reason for the decision;
and
(c)
Must respond in writing to written grievances. In addition to written responses,
the CCO may also respond orally.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3262
Requirements for CCO Appeal
(1) A member, their representative or
a subcontractor/provider, with the member’s consent, who disagrees with a
notice of action (notice) has the authority to file an appeal with their CCO.
(2) For purposes of this
rule, an appeal includes a request from the Division to the CCO for review of action.
(3) The member may request
an appeal either orally or in writing directly to their CCO for any action by the
CCO unless the member requests an expedited resolution, the member must follow an
oral filing with a written, signed and dated appeal. If the member files an oral
appeal, the CCO must send the member an appeal request form.
(4) The member must file
the appeal no later than 45 calendar days from the date on the notice.
(5) The CCO must have written
policies and procedures for handling appeals that:
(a) Address how the CCO will
accept, process and respond to such appeals, including how the CCO will acknowledge
receipt of each appeal;
(b) Ensure that members who
receive a notice are informed of their right to file an appeal and how to do so;
(c) Ensure that each appeal
is transmitted timely to staff having authority to act on it;
(d) Consistent with confidentiality
requirements, ensure that the CCO's staff person who is designated to receive appeals
begins to obtain documentation of the facts concerning the appeal upon receipt of
the appeal;
(e) Ensure that each appeal
is investigated and resolved in accordance with these rules; and
(f) Ensure that the individuals
who make decisions on appeals are:
(A) Not involved in any previous
level of review or decision making; and
(B) Health care professionals
who have the appropriate clinical expertise in treating the member’s condition
or disease if an appeal of a denial is based on lack of medical appropriateness;
or if an appeal involves clinical issues.
(g) Include a provision that
the CCO must document appeals in an appeals log maintained by the CCO that complies
with OAR 410-141-3260 and consistent with contractual requirements.
(h) Ensure oral requests
for appeal an action are treated as appeals to establish the earliest possible filing
date for the appeal; and
(i) Ensure the member is
informed that the member must in writing unless the person filing the appeal requests
expedited resolution;
(j) Provide the member a
reasonable opportunity to present evidence and allegations of fact or law in person
as well as in writing;
(k) Provide the member an
opportunity before and during the appeals process to examine the member’s
file, including medical records and any other documents or records to be considered
during the appeals process.
(6) Parties to the appeal
Include:
(a) The CCO;
(b) The member and the member’s
representative, if applicable;
(c) The legal representative
of a deceased member’s estate.
(7) The CCO must resolve
each appeal and provide the member and their representative with a notice of appeal
resolution as expeditiously as the member’s health condition requires and
within the following periods for:
(a) Standard resolution of
appeal: no later than 16 calendar days from the day, the CCO receives the appeal;
(b) Expedited resolution
of appeal (when granted by the CCO): no later than three working days from the date
the CCO receives the appeal. In addition, the CCO must:
(A) Inform the member and
their representative of the limited time available;
(B) Make reasonable efforts
to call the member to tell them of the resolution within three calendar days after
receiving the request; and
(C) Mail written confirmation
of the resolution to the member within three calendar days.
(c) In accordance with 42
CFR 438.408, the CCO may extend these timeframes from subsections (a) or (b) of
this section up to 14 calendar days if:
(A) The member or their representative
requests the extension; or
(B) The CCO shows (to the
satisfaction of the Division’s Hearing Unit, upon its request) that there
is need for additional information and how the delay is in the member’s interest.
(C) If the CCO extends the
timeframes; it must for any extension not requested by the Member, give the Member
or their representative written notice of the reason for the delay.
(8) For all appeals, the
CCO must provide written notice of appeal resolution to the member and also to their
representative when the CCO knows there is a representative for the member.
(9) The written notice of
appeal resolution must include the following information:
(a) The results of the resolution
process and the date the CCO completed the resolution; and
(b) For appeals not resolved
wholly in favor of the member:
(A) Reasons for the resolution
and a reference to the particular sections of the statutes and rules involved for
each reason identified in the Notice of Appeal Resolution relied upon to deny the
appeal;
(B) Unless the appeal was
referred to the CCO from the Division as part of a contested case hearings process,
the right to request a hearing and how to do so;
(C) The right to request
to receive benefits while the hearing is pending and how to do so; and
(D) That the member may be
held liable for the cost of those benefits if the hearing decision upholds the CCO’s
Action.
(10) Unless the appeal was
referred to the CCO as part of a contested case hearing process, a member may request
a hearing not later than 45 calendar days from the date on the Notice of Appeal
Resolution.
(11) If the appeal was referred
to the CCO from the Division as part of a contested case hearing process, within
two business days from the date of the appeal resolution, the CCO must transmit
the:
(a) Notice of Appeal Resolution;
and
(b) Complete record of the
appeal to the Division’s Hearings Unit.
(12) If the appeal was made
directly by the member or their representative, and the Notice of Appeal Resolution
was not favorable to the member, the CCO must, if a contested case hearing is requested,
submit the record to the Division’s Hearings Unit within two business days
of the Division’s request.
(13) Documentation:
(a) The CCO’s records
must include, at a minimum, a log of all appeals received by the CCO and contain
the following information:
(A) Member’s name and
Medical Care ID number;
(B) Date of the Notice;
(C) Date and nature of the
appeal;
(D) Whether continuing benefits
were requested and provided; and
(E) Resolution and resolution
date of the appeal.
(b) The CCO must maintain
a complete record for each appeal included in the log for no less than 45 days to
include:
(A) Records of the review
or investigation; and
(B) Resolution, including
all written decisions and copies of correspondence with the member.
(c) The CCO must review the
written appeals log on a monthly basis for:
(A) Completeness;
(B) Accuracy;
(C) Timeliness of documentation;
(D) Compliance with written
procedures for receipt, disposition and documentation of appeals; and
(E) Compliance with OHP rules.
(d) The CCO must address
the analysis of appeals in the context of quality improvement activity consistent
with OAR 410-141-3200 OHP CCO Quality Improvement System and 410-141-3260 General
Requirements for CCO Grievance System;
(e) The CCO must have written
policies and procedures for the review and analysis of all appeals received by the
CCO. The analysis of the grievance system must be reviewed by the CCO’s Quality
Improvement Committee consistent with contractual requirements and comply with the
quality improvement standards.
Stat. Auth.: ORS 413.032
Stats. Implemented: ORS 414.065
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 10-2013(Temp), f. & cert. ef. 3-1-13 thru 8-27-13; DMAP 16-2013(Temp),
f. & cert. ef. 4-10-13 thru 8-27-13; DMAP 46-2013, f. & cert. ef. 8-26-13
410-141-3263
Notice
of Action
(1) A CCO must provide a member with
a notice of action when the CCO’s decision about a health service constitutes
an action. The notice of action must:
(a) Be written in language
sufficiently clear that a layperson could understand the notice and make an informed
decision about appealing the action and requesting a hearing;
(b) Comply with the Authority’s
formatting and readability standards;
(c) The notice must include
but is not limited to the following:
(A) Date of the notice;
(B) CCO’s name and
telephone number;
(C) Name of the member’s
PCP, PCD, or behavioral health professional, as applicable;
(D) Member’s name and
member ID number;
(E) Service requested and
whether the CCO is denying, terminating, suspending or reducing a service or payment;
(F) Date of the service or
date the member requested the service;
(G) Name of the provider
who performed or requested the service;
(H) Effective date of the
action if different from the date of the notice;
(I) Whether the CCO considered
other conditions as co-morbidity factors if the service was below the funding line
on the OHP Prioritized List of Health Services;
(J) Clearly and thoroughly
explain specific reasons for the action and a reference to the specific sections
of the statutes and rules pertaining to each reason;
(K) Member’s right
to file an appeal with the CCO or request a contested case hearing;
(L) An explanation of circumstances
under which the member may request expedited resolution of an appeal, and how to
request one; and
(M) A statement that the
member has the right to request to receive the services that are being denied pending
resolution of the appeal and that the member may be responsible for the cost of
those services if the outcome of the appeal upholds the CCO’s action;
(d) The Notice of Action
must be on a Division approved form.
(2) The CCO must include
the appropriate forms based on the Division approved Notice of Action, as outlined
in OAR 410-141-3260, to the notice.
(3) For actions affecting
previously authorized services, the CCO must mail the notice at least 10 calendar
days before the date of action with the exception of circumstances described in
section (4) of this rule.
(4) The CCO may mail the
notice no later than the date of action if:
(a) The CCO or provider has
information confirming the death of the member;
(b) The member sends the
CCO a signed statement stating the member no longer wants the service;
(c) The CCO can verify that
the member is in an institution where the member is no longer eligible for OHP services;
(d) The CCO is unaware of
the member’s whereabouts; the post office returns the mail indicating no forwarding
address; and the Authority or Department of Human Services has no other address;
(e) The CCO verifies another
state, territory, or commonwealth has accepted the member for Medicaid services;
(f) The member’s PCP,
PCD, or behavioral health professional has prescribed a change in the level of health
services; or
(g) The date of action shall
occur in less than 10 calendar days when the CCO:
(A) Has facts indicating
probable fraud by the member, and the CCO has certified those facts, if possible,
through a secondary resource; or
(B) Denies payment for a
claim.
(5) For actions affecting
services not previously authorized, the CCO must send the notice as expeditiously
as the member’s health condition requires but no later than 14 calendar days
following the date of receipt of the request for service.
(6) For actions affecting
services not previously authorized and for which the CCO grants expedited review,
the CCO must send the notice as expeditiously as the member’s health condition
requires but no later than three business days after receipt of the request for
service.
(7) In accordance with 42
CFR 438.408, the CCO may extend the timeframes from (5) above by up to 14 calendar
days, if:
(a) The Division member or
Division member’s representative requests the extension; or
(b) The CCO shows (to the
satisfaction of the Division’s Hearings Unit upon it request) that there is
need for additional information and how the delay is in the Division member’s
interest.
(8) If the CCO extends the
timeframes, it must, for any extension not requested by the Division member, give
the Division member and Division member’s representative, a written notice
of the reason for the delay.
Stat. Auth.: ORS 414.032, 414.615, 414.625,
414.635, 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 60-2013, f. & cert. ef. 10-31-13
410-141-3264
Contested
Case Hearings
(1)
A CCO must have a system in place to ensure its members and providers have access
to appeal a CCO’s action by requesting a contested case hearing. Contested
case hearings are conducted pursuant to ORS 183.411 to 183.497 and the Attorney
General’s Uniform and Model Rules of Procedure for the Office of Administrative
Hearings, OAR 137-003-0501 to 137-003-0700.
(2)
The member may request a hearing without first filing an appeal with their CCO.
The member must file a hearing request with the Authority no later than 45 days
from the date of the CCO’s notice of action or notice of appeal resolution.
If the member files the hearing request with the Department of Human Services or
the CCO no later 45 days from the date of the notice, the Authority shall consider
the request timely.
(3)
In the event a request for hearing is not timely, the Authority shall determine
whether the failure to timely file the hearing request was caused by circumstances
beyond the member’s control and enter an order accordingly. The member must
submit a written statement explaining why the hearing request was late. The Authority
may conduct further inquiry as the Authority deems appropriate. The Authority may
refer an untimely request to the Office of Administrative Hearings (OAH) for a hearing
on the question of timeliness;
(4)
The CCO must conduct an appeal if the member requests an appeal without filing a
request for hearing. If the member requests a hearing, without first requesting
an appeal, the Authority may require the CCO to conduct an appeal prior to referring
the matter to OAH.
(5)
Effective February 1, 2012, the method described in OAR 137-003-0520(8)–(10)
is used in computing any period of time prescribed in the division of rules in OAR
410 division 120 and 141 applicable to timely filing of requests for hearing. Due
to operational conflicts, the procedures needing revision and the expense of doing
so, OAR 137-003-0520(9) and 137-003-0528(1)(a), which allows hearing requests to
be treated as timely based on the date of postmark, does not apply to CCO hearing
requests.
(6)
If the member files a request for hearing with the Authority, the Authority shall
provide a copy of the hearing request to the member’s CCO. The CCO shall:
(a)
Review the request immediately as an appeal of the CCO’s action;
(b)
Approve or deny the appeal within 16 calendar days, and provide the member with
a notice of appeal resolution.
(7)
If a member sends the hearing request to their CCO, the CCO must:
(a)
Date-stamp the hearing request with the date of receipt; and
(b)
Submit the following to the Authority within two business days:
(A)
A copy of the hearing request, notice of action, and notice of appeal resolution,
if applicable;
(B)
All documents and records the CCO relied upon to take its action, including those
used as the basis for the initial action or the notice of appeal resolution, if
applicable, and all other relevant documents and records the Authority requests.
(8)
A member’s provider may request a hearing about an action affecting the provider.
However, the provider must resolve an appeal with the CCO before requesting a hearing.
(a)
The CCO must approve or deny the appeal within 16 calendar days, and provide the
provider with a notice of appeal resolution.
(b)
The provider must file a hearing request with the Authority no later than 45 days
from the date of the CCO’s notice of appeal resolution.
(9)
The parties to a contested case hearing include the:
(a)
CCO and the member requesting a hearing; or
(b)
CCO and the member’s provider if the provider requests a hearing.
(10)
The Authority shall refer the hearing request along with the notice of action or
notice of appeal resolution to OAH for hearing.
(11)
The Authority must issue a final order or the Authority must resolve the case ordinarily
within 90 calendar days from the earlier of the date:
(a)
The CCO receives the member’s request for appeal. This does not include the
number of days the member took to subsequently file a hearing request; or
(b)
The Authority receives the request for hearing.
(12)
If a member requests an expedited hearing, the Authority shall request documentation
from the CCO, and the CCO shall submit relevant documentation, including clinical
documentation, to the Authority within two working days.
(13)
The Authority must determine whether the member is entitled to an expedited hearing
within two working days from the date of receipt of the medical documentation. If
the Authority denies a request for an expedited hearing, the Authority must make
reasonable efforts to:
(a)
Call the member; and
(b)
Send written notice within two calendar days.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3267
Process for Resolving Disputes between
Coordinated Care Organizations (CCOs) and the Oregon Health Authority
For purposes of this rule:
(1) “Party” means
a CCO taking one side of a question or dispute.
(2) In the event of a dispute
with the Oregon Health Authority (Authority) initiated by a CCO, the CCO shall use
the Division’s Administrative Review process as specified in OAR 410-120-1580.
If the dispute is likely to impact another CCO, the Authority will notify all CCOs
potentially impacted by the dispute and provide an opportunity for the impacted
CCOs to participate in the dispute as a party. The Authority shall maintain the
confidentiality of proprietary information of a CCO to the extent such information
is protected under state or federal law if more than one CCO is involved in the
dispute and the dispute involves a subject necessitating the use of proprietary
information.
(3) An administrative review,
for purposes of this rule, allows the opportunity for the director of the Division
of Medical Assistance Programs (Division) or their designee to review a dispute
affecting the CCO under the procedures set forth in OAR 410-120-1580. Examples of
such disputes may include, but are not limited to, contract compliance disputes,
service area changes, and the Authority decisions made through the OHA Provider
Discrimination Review Process as a result of a provider discrimination appeal. These
disputes primarily address legal or policy issues that may arise in the context
of a Division decision that is perceived by the CCO to adversely affect the CCO
and is not otherwise reviewed as a claim redeterminaton, a contested case, or client
appeal.
(4) The Division shall send
written results of the administrative review to the CCO initiating the dispute and
any other impacted party within 30 calendar days of the conclusion of the administrative
review proceeding, or such other time as may be agreed to by the parties and the
Division.
(5) The Division’s
final decision on administrative review is the final decision of the Authority on
the dispute and is binding on the parties. The decision is an order in other than
a contested case. Judicial appeal of the decision is subject to ORS 183.484 and
the procedures set forth in OAR 137-004-0080 to 137-004-0092.
Stat. Auth: ORS 183.484, ORS 413.042
Stats. Implemented: ORS 183.484,
ORS 413.042
Hist.: DMAP 39-2015(Temp),
f. & cert. ef. 7-1-15 thru 12-27-15
410-141-3268
Process for Resolving Disputes on Formation,
Certification, and Recertification of CCOs
(1) The dispute resolution process described
in this rule applies only when, under ORS 414.635:
(a) An entity is applying
to the Authority for certification as a CCO (applicant);
(b) A Health Care Entity
(HCE) and the applicant (together, the “parties” for purposes of this
rule) have failed to agree upon terms for a contract; and
(c) One or more of the following
occurs:
(A) The applicant states
that the HCE is necessary for the applicant to qualify as a CCO;
(B) An HCE states that its
inclusion is necessary for the applicant to be certified as a CCO; or
(C) In reviewing the applicant’s
information, the Authority identifies the HCE as necessary for the applicant to
qualify as a CCO.
(2) If an applicant and HCE
disagree about whether the HCE is necessary for the applicant’s certification
as a CCO, the applicant or HCE may request the Authority to review the issue.
(3) If the Authority determines
the HCE is not necessary for the applicant’s certification, the process described
in this rule does not apply.
(4) If the Authority determines
or the parties agree the HCE is necessary for the applicant’s certification,
the following applies:
(a) The HCE and the applicant
shall participate in good faith contract negotiations. The parties shall take the
following actions in an attempt to reach a good faith resolution:
(A) The applicant shall provide
a written offer of terms and conditions to the HCE. The HCE shall explain the area
of disagreement to the applicant;
(B) The applicant’s
or HCE’s chief financial officer, chief executive officer, or an individual
authorized to make decisions on behalf of the HCE or applicant shall have at least
one face-to-face meeting in a good faith effort to resolve the disagreement.
(b) The applicant or HCE
may request the Authority to provide technical assistance. The Authority also may
offer technical assistance, with or without a request. The Authority’s technical
assistance is limited to clarifying the CCO certification process, criteria, and
other program requirements.
(5) Pursuant to 2013 Engrossed
SB 568 and 2013 Oregon Laws chapter 27, if the applicant and HCE cannot reach agreement
on contract terms within ten calendar days of the face-to-face meeting, either
party may request arbitration. The requesting party shall notify the other party
in writing to initiate a referral to an independent third party arbitrator for an
HCE’s refusal to contract with the CCO or the termination, extension, or renewal
of a HCE’s contract with a CCO. The party initiating the referral shall provide
a copy of the notification to the Authority.
(6) After notification that
one party initiated arbitration, the parties shall attempt to agree upon the selection
of the arbitrator and complete the paperwork required to secure the arbitrator’s
services. If the parties are unable to agree, each party shall appoint an arbitrator,
and these arbitrators shall select the final arbitrator.
(7) The parties shall pay
for all arbitration costs. In consideration of potentially varied financial resources
between the parties, which may pose a barrier to the use of this process, the parties
may ask the arbitrator to allocate costs between the parties based on ability to
pay.
(8) Within ten calendar days
of a referral to an arbitrator, the applicant and HCE shall submit to each other
and to the arbitrator the following:
(a) The most reasonable contract
offer; or
(b) The HCE’s statement
that a contract is not desirable and an explanation of why this is reasonable.
(9) Within ten calendar days
of receiving the other party’s offer or the HCE’s statement that a contract
is not desirable, each party shall submit to the arbitrator and the other party
the advocacy briefs regarding whether the HCE is reasonably or unreasonably refusing
to contract with the applicant.
(10) The arbitrator shall
apply the following standards when making a determination about whether an HCE reasonably
or unreasonably refused to contract with the applicant:
(a) An HCE may reasonably
refuse to contract when an applicant’s reimbursement to an HCE for a health
service is below the reasonable cost to provide the service. The arbitrator shall
apply federal or state statutes or regulations that establish specific reimbursements,
such as payments to federally qualified health centers, rural health centers, and
tribal health centers; and
(b) An HCE may reasonably
refuse to contract if that refusal is justified in fact or by circumstances, taking
into consideration the Health Services Transformation (HST) legislative policies.
Facts or circumstances outlining what is a reasonable or unreasonable refusal to
contract include, but are not limited to:
(A) Whether contracting with
the applicant would impose demands that the HCE cannot reasonably meet without significant
negative impact on HCE costs, obligations, or structure while considering the proposed
reimbursement arrangement or other CCO requirements. Some of the requirements include:
(i) Use of electronic health
records;
(ii) Service delivery requirements,
or
(iii) Quality or performance
requirements;
(B) Whether the HCE’s
refusal affects access to covered services in the applicant’s community. This
factor alone cannot result in a finding that the refusal to contract is unreasonable;
however, the HCE and applicant shall make a good faith effort to work out differences
in order to achieve beneficial community objectives and HST policy objectives;
(C) Whether the HCE has entered
into a binding obligation to participate in the network of a different CCO or applicant
and that participation significantly reduces the HCE’s capacity to contract
with the applicant.
(11) The following outlines
the arbitrator determination and the parties’ final opportunity to settle:
(a) The arbitrator shall
evaluate the final offers or statement of refusal to contract and the advocacy briefs
from each party and issue a determination within 15 calendar days of the receipt
of the parties’ information;
(b) The arbitrator shall
provide the determination to the parties. The arbitrator and the parties may not
disclose the determination to the Authority for ten calendar days to allow the parties
an opportunity to resolve the issue themselves. If the parties resolve the issue
no later than the end of the tenth day, the arbitrator may not release the determination
to the Authority;
(c) If the parties have not
reached an agreement after ten calendar days, the arbitrator shall provide its decision
to the Authority. After submission to the Authority, the arbitrator’s determination
becomes a public record, subject to protection of trade secret information if identified
by one of the parties prior to the arbitrator’s submission of the determination.
(12) If the parties cannot
agree, the Authority shall evaluate the arbitrator’s determination and may
take the following actions:
(a) The Authority may certify
an applicant if the arbitrator determined the applicant made a reasonable attempt
to contract with the HCE or the HCE’s refusal to contract was unreasonable;
(b) The Authority may refuse
to certify, recertify, or continue to certify an applicant when the arbitrator determined
the applicant did not reasonably attempt to contract with the HCE or the HCE’s
refusal to contract was reasonable, and the Authority determines that participation
from the HCE remains necessary for certification of applicant as a CCO;
(c) The Authority may not
pay fee-for-service reimbursements to an HCE if the arbitrator determined the HCE
unreasonably refused to contract with the applicant. This applies to health services
available through a CCO;
(d) In any circumstance within
the scope of this rule when the parties have failed to agree, the current statutes
regarding reimbursement to non-participating providers shall apply to certified
CCOs and the HCE, consistent with ORS 414.743 for hospitals and consistent with
Authority rules for other providers.
(13) To be qualified to resolve
disputes under this rule, the arbitrator shall:
(a) Be a knowledgeable and
experienced arbitrator;
(b) Be familiar with health
care provider contracting matters;
(c) Be familiar with HST;
and
(d) Follow the terms and
conditions specified in this rule for the arbitration process.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 70-2013(Temp), f. 12-24-13, cert. ef. 1-1-14 thru 6-30-14; DMAP 17-2015, f.
& cert. ef. 4-1-15
410-141-3269
Process for Resolving Contract Disputes
Between Health Care Entities and Coordinated Care Organizations
Process for Resolving Contract Disputes
Between Health Care Entities and Coordinated Care Organizations
(1) Pursuant to ORS 414.635, Coordinated
Care Organizations (CCOs) and Health Care Entities (HCE) shall participate in good
faith contract negotiations. This rule covers the termination, extension, and renewal
of an HCE’s contract with a CCO.
(2) In the event of a dispute
involving the termination, extension, or renewal of an HCE’s contract with
a CCO, the parties may take the following actions in an attempt to reach a good
faith resolution:
(a) Both parties shall provide
a written offer of terms and conditions to the other party. The parties shall explain
the basis for their disagreement with the terms and conditions offered by the other
party;
(b) The CCO’s and HCE’s
chief financial officer, chief executive officer, or an individual authorized to
make decisions on behalf of the HCE or CCO shall have at least one face-to-face
meeting in a good faith effort to resolve the disagreement;
(c) The CCO or HCE may request
the Authority to provide technical assistance. The Authority’s technical assistance
is limited to clarifying the CCO contractual provisions, subcontracting criteria,
current reimbursement requirements, access standards, and other legal requirements.
(3) If the CCO and HCE cannot
reach agreement on contract terms, the parties may engage in mediation. Either the
CCO or the HCE may request mediation:
(a) After the parties have
agreed to enter into mediation, the parties shall attempt to agree on the selection
of the mediator and complete paperwork required to secure the mediator’s services.
If the parties are unable to agree, each party shall appoint a mediator, and those
mediators shall select the final mediator;
(b) To be qualified to propose
resolutions for disputes under this rule, the mediator shall:
(A) Be a knowledgeable and
experienced mediator;
(B) Be familiar with health
care and contracting matters; and
(C) Follow the terms and
conditions specified in this rule for the mediation process.
(c) The parties shall pay
for all mediation costs, whether a conclusion is reached or not. In consideration
of potentially varied financial resources between the parties, which may pose a
barrier to the use of this process, the parties may ask the mediator to allocate
costs between the parties based on the ability to pay;
(d) Within ten business days
of a selection of a mediator, the CCO and HCE shall submit to each other and to
the mediator the following:
(A) Contract offer; and
(B) Explanation of their
position (i.e., advocacy brief).
(e) Unless an extension is
agreed on by all parties, the mediator shall issue a report to the involved parties
that will include mediation findings and recommendations no longer than 15 business
days from the conclusion of the mediation.
(4) Pursuant to ORS 414.635,
if the CCO and HCE cannot reach an agreement on contract terms within ten business
days of receipt of the mediator’s report, either party may request non-binding
arbitration. The requesting party shall notify the other party in writing of the
party’s intent to refer the matter to arbitration:
(a) After notification that
one party initiated arbitration, the parties shall agree on the selection of the
arbitrator and complete the paperwork required to secure the arbitrator’s
services. If the parties are unable to agree, each party shall appoint an arbitrator,
and these arbitrators shall select the final arbitrator;
(b) To be qualified to propose
resolutions for disputes under this rule, the arbitrator shall:
(A) Be a knowledgeable and
experienced arbitrator;
(B) Be familiar with health
care provider contracting matters; and
(C) Follow the terms and
conditions specified in this rule for the arbitration process.
(c) The parties shall pay
for all arbitration costs. In consideration of potentially varied financial resources
between the parties, which may pose a barrier to the use of this process, the parties
may ask the arbitrator to allocate costs between the parties based on ability to
pay;
(d) Within ten business days
of a selection of an arbitrator, the CCO and HCE shall submit to each other and
to the arbitrator the following:
(A) Final contract offer;
and
(B) Explanation of their
position (i.e., advocacy brief).
(e) The arbitrator shall
evaluate the final offers and the advocacy briefs from each party and issue a non-binding
determination within 15 business days of the receipt of the parties’ submissions.
Stat. Auth.: ORS 414.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 86-2014(Temp),
f. 12-31-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 23-2015, f. 4-15-15, cert. ef.
5-1-15
410-141-3270
Coordinated Care Organization Marketing
Requirements
(1) For the purposes of this rule, the
following definitions apply:
(a) “Cold-call Marketing”
means any unsolicited personal contact with a potential member for the purpose of
marketing by the CCO.
(b) “Marketing”
means any communication from a CCO to a potential member who is not enrolled in
the CCO that can reasonably be interpreted as intended to compel or entice the potential
member to enroll in that particular CCO.
(c) “Marketing Materials”
means materials that are produced in any medium by or on behalf of a CCO and that
can reasonably be interpreted as intended to market to potential members.
(d) “Outreach”
means any communication from a CCO to any audience that cannot reasonably be interpreted
as intended to compel or entice a potential member to enroll in a particular CCO.
Outreach activities include, but are not limited to, the act of raising the awareness
of the CCO, the CCO’s subcontractors and partners, and the CCO contractually
required programs and services; and the promotion of healthful behaviors, health
education and health related events.
(e) “Outreach Materials”
means materials that are produced in any medium, by or on behalf of a CCO that cannot
reasonably be interpreted as intended to compel or entice a potential member to
enroll in a particular CCO.
(f) “Potential Member”
means a person who meets the eligibility requirements to enroll in the Oregon Health
Plan but has not yet enrolled with a specific CCO.
(2) CCOs shall comply with
42 CFR 438.10, 438.100 and 438.104 to ensure that before enrolling OHP clients,
the CCO provides accurate oral and written information that potential members need
to make an informed decision on whether to enroll in that CCO. CCOs shall distribute
the materials to its entire service area as indicated in its CCO contract. The CCOs
may not:
(a) Distribute any marketing
materials without first obtaining state approval;
(b) Seek to compel or entice
enrollment in conjunction with the sale of or offering of any private insurance;
and
(c) Directly or indirectly
engage in door to door, telephone, or cold-call marketing activities.
(3) The following communications
are expressly permitted:
(a) The creation of name
recognition and communication methodologies may include, but are not limited to,
brochures, pamphlets, newsletters, posters, fliers, websites, bus wraps, bill boards,
web banners, health fairs, or health related events.
(b) A CCO or its subcontractor’s
communications that express participation in or support for a CCO by its founding
organizations or its subcontractors may not constitute an attempt to compel or entice
a client’s enrollment.
(4) CCOs shall update plan
access information with the Authority on a monthly basis for use in updating the
availability charts. The Authority shall confirm information before posting.
(5) CCOs have sole accountability
for producing or distributing materials following Authority approval.
(6) CCOs shall comply with
the Authority marketing materials submission guidelines. CCOs shall participate
in development of guidelines with the Authority through a transparent public process,
including stakeholder input. The guidelines include, but are not limited to:
(a) A list of communication
or outreach materials subject to review by the Authority;
(b) A clear explanation of
the Authority’s process for review and approval of marketing materials;
(c) A process for appeals
of the Authority’s edits or denials;
(d) A marketing materials
submission form to ensure compliance with CCO marketing rules; and
(e) An update of plan availability
information submitted to the Authority on a monthly basis for review and posting.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 45-2014, f. 7-15-14, cert. ef. 8-1-14
410-141-3280
Coordinated Care Organization (CCO) Potential
Member Information Requirements
(1) For the purpose of this rule, the
following definitions apply:
(a) “Alternate Format”
means any alternate approach to presenting print information to an individual with
a disability. The Americans with Disabilities Act (ADA) groups the standard alternate
formats: braille, large (18 point) print, audio narration, oral presentation, and
electronic file along with other aids and services for other disabilities, including
sign language interpretation and sighted guide;
(b) “Potential Member”
means an individual who meets the eligibility requirements to enroll in the Oregon
Health Plan but has not yet enrolled with a specific CCO;
(c) “Prevalent Non-English
Language” means all non-English languages that are identified as the preferred
written language by the lesser of either:
(A) 5 percent of the CCO’s
total OHP enrollment; or
(B) 1,000 of the CCO’s
members;
(d) “Health Literacy”
means the degree to which individuals have the capacity to obtain, process, and
understand basic health information needed to make appropriate health decisions
regarding services needed to prevent or treat illness.
(2) Information for potential
members shall comply with marketing prohibitions in 42 CFR 438.104 and OAR 410-141-3270;
Oregon Health Plan Marketing Requirements.
(3) The creation of name
recognition because of the CCO’s health promotion or education activities
shall not constitute an attempt by the CCO to influence a client’s enrollment.
(4) A CCO or its subcontractor’s
communications that express participation in or support for a CCO by its founding
organizations or its subcontractors shall not constitute an attempt to compel or
entice a client’s enrollment.
(5) The following shall not
constitute marketing or an attempt by the MCO to influence client enrollment:
(a) Communications to notify
dual-eligible members of opportunities to align CCO provided benefits with Medicare
Advantage or Special Needs Plans;
(b) Improving coordination
of care;
(c) Communicating with providers’
service dual-eligible members about unique care coordination needs; or
(d) Streamlining communications
to the dually-enrolled member to improve coordination of benefits.
(6) CCOs shall update plan
access information with OHA on a monthly basis for use in updating the availability
charts. OHA shall confirm before posting.
(7) CCOs shall develop informational
materials for potential members.
(8) CCOs shall provide the
Authority with informational materials sufficient for the potential member to make
an informed decision about provider selection. The CCO shall make available to potential
members, upon request, information on participating providers.
(9) CCO provider directories
shall include notation of the following: names, locations, telephone numbers including
TTY, office hours, accessibility for members with disabilities, non-English languages
spoken by current contracted providers in the enrollee’s service area, and
direction on how members can access information on providers that are not accepting
new patients. A CCO or the Division may include informational materials in the application
packet for potential members.
(10) CCOs shall develop informational
materials for potential members in their service area that meet the language requirements
as identified in this rule. Materials shall be culturally and linguistically appropriate
and be sensitive to people with disabilities or reading limitations, including those
whose primary language is not English.
(11) CCO’s shall honor
requests made by other sources such as potential members, potential family members,
or caregivers for language accommodation, translating to the potential member’s
language needs as requested. Alternate formats shall be provided and may include
but are not limited to braille, large (18 point) print, audio narration, oral presentation,
and electronic file along with other aids and services for other disabilities, including
sign language interpretation and sighted guide:
(a) CCOs shall address health
literacy issues by preparing these documents at a 6th grade reading level, incorporating
graphics and utilizing alternate format materials for potential members and using
a12-point font or larger (18 point);
(b) CCOs shall ensure that
all CCO staff who have contact with potential members are fully informed of CCO
and Authority rules applicable to enrollment, disenrollment, complaint and grievance
policies and procedures, and the availability of free certified health care interpreters,
and which participating providers’ offices have bilingual capacity and which
are accepting new members.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 16-2015, f. 3-31-15, cert. ef. 4-1-15; DMAP 21-2015, f. 4-14-15, cert. ef.
4-15-15; DMAP 24-2015, f. & cert. ef. 4-15-15
410-141-3300
Coordinated Care Organization (CCO) Member
Education and Information Requirements
(1) For the purpose of this rule, the
following definitions apply:
(a) “Alternate Format”
means any alternate approach to presenting print information to an individual with
a disability. The Americans with Disabilities Act (ADA) groups the standard alternate
formats: braille, large (18 point) print, audio narration, oral presentation, and
electronic file along with other aids and services for other disabilities, including
sign language interpretation and sighted guide;
(b) “Alternate Format
Statement Insert” means an insert developed by the Oregon Health Authority
that includes instructions on how to receive an alternate format or oral interpretation
of materials translated into the state’s top sixteen preferred written languages
as identified by OHP enrollees. CCOs shall insert their contact information into
the template.
(c) “Health Literacy”
means the degree to which individuals have the capacity to obtain, process, and
understand basic health information needed to make appropriate health decisions
regarding services needed to prevent or treat illness.
(d) “Prevalent Non-English
Language” means: All non-English languages that are identified as the preferred
written language by the lesser of either:
(A) 5 percent of the CCO’s
total OHP enrollment; or
(B) 1, 000 of the CCO’s
members.
(2) CCOs may engage in activities
for existing members related to outreach, health promotion, and health education.
The Division shall approve, prior to distribution, any written communication by
the CCO or its subcontractors and providers that:
(a) Is intended solely for
members; and
(b) Pertains to requirements
for obtaining coordinated care services at service area sites or benefits.
(3) CCOs may communicate
with providers, caseworkers, community agencies, and other interested parties for
informational purposes. The intent of these communications should be informational
only and not to entice or solicit membership. Communication methodologies may include
but are not limited to brochures, pamphlets, newsletters, posters, fliers, websites,
health fairs, or sponsorship of health-related events. CCOs shall address health
literacy issues by preparing these documents at a low-literacy reading level, incorporating
graphics and utilizing alternate formats.
(4) The creation of name
recognition because of the CCO’s health promotion or education activities
shall not constitute an attempt by the CCO to influence a client’s enrollment.
(5) A CCO or its subcontractor’s
communications that express participation in or support for a CCO by its founding
organizations or its subcontractors shall not constitute an attempt to compel or
entice a client’s enrollment.
(6) The following shall not
constitute marketing or an attempt by the CCO to influence client enrollment:
(a) Communication to notify
dual-eligible members of opportunities to align CCO provided benefits with a Medicare
Advantage or Special Needs Plan;
(b) Improving coordination
of care;
(c) Communicating with providers’
service dual-eligible members about unique care coordination needs; or
(d) Streamlining communications
to the dually-enrolled member to improve coordination of benefits.
(7) CCOs shall have a mechanism
to help members understand the requirements and benefits of the CCO’s integrated
and coordinated care plan. The mechanisms developed shall be culturally and linguistically
appropriate.
(8) CCOs shall have written
procedures, criteria, and an ongoing process of member education and information
sharing that includes member orientation, member handbook, and health education.
As a CCO transitions to fully coordinating a member’s care, the CCO is responsible
only for including information about the care they are coordinating. CCOs shall
update their educational material as they add coordinated services. Member education
shall:
(a) Include information about
the coordinated care approach and how to navigate the coordinated health care system,
including where applicable for dual-eligible individuals, the process for coordinating
Medicaid and Medicare benefits;
(b) Clearly explain how members
may receive assistance from advocates, including certified health care interpreters,
community health workers, peer wellness specialists, and personal health navigators
and include information to members that interpreter services at provider offices
are free to CCO members as stated in 42 CFR 438.10 (4).
(9) Within 14 calendar days
or a reasonable timeframe of a CCO’s receiving notice of a member’s
enrollment, CCOs shall mail a welcome packet to new members and to members returning
to the CCO twelve months or more after previous enrollment. The packet shall include,
at a minimum, a welcome letter, a member handbook, and information on how to access
a provider directory
(10) Provider directories
shall include notation of the following: names, locations, telephone numbers including
TTY, office hours, accessibility for members with disabilities, non-English languages
spoken by current contracted providers in the enrollee’s service area, and
direction on how members can access information on providers that are not accepting
new patients.
(11) For those who are existing
members, a CCO shall notify members annually of the availability of a member handbook
and provider directory and how to access those materials. CCOs shall send hard copies
upon request.
(12) CCOs shall facilitate
materials as follows:
(a) Translate the following
written materials into the prevalent non-English languages served by the CCO:
(A) Welcome Packets that
include welcome letters and member handbooks; and
(B) Notices of medical benefit
changes;
(b) Alternate format statement
inserts with:
(A) Communications regarding
member enrollment; and
(B) Notice of Action to deny,
reduce, or stop a benefit;
(c) Accommodate requests
of the member to translate written materials into prevalent non-English languages
served by the CCO;
(d) Make oral interpretation
services available free of charge to each potential member and member. This applies
to all non-English languages, not just prevalent non-English languages;
(e) Notify enrollees:
(A) That oral interpretation
is available free of charge for any language, and written information is available
in prevalent non-English languages and alternate formats; and
(B) How to access those services;
(f) Make available materials
in alternate formats by request. Alternate formats include but are not limited to
audio recording, close-captioned videos, large type, and braille.
(13) A CCO shall electronically
provide to the Division for approval each version of the printed welcome packet
that includes a welcome letter, member handbook, and information on how to access
a provider directory. At a minimum, the member handbook shall contain the following:
(a) Revision date;
(b) Tag lines in English
and other prevalent non-English languages, as defined in this rule, spoken by populations
of members. The tag lines shall be located at the beginning of the document for
the ease of the member and describe how members may access free sign and oral interpreters,
as well as translations and materials in other formats. Alternate formats may include
but are not limited to audio recordings, close-captioned videos, large (18 point)
type, and braille.
(c) CCO’s office location,
mailing address, web address if applicable, office hours, and telephone numbers
including TTY;
(d) Availability and access
to coordinated care services through a patient-centered primary care home or other
primary care team with the member as a partner in care management. Explain how to
choose a PCP, how to make an appointment, and how to change PCPs and the CCO’s
policy on changing PCPs;
(e) How to access information
on contracted providers currently accepting new members and any restrictions on
the member’s freedom of choice among participating providers;
(f) What participating or
non-participating provider services the member may self-refer;
(g) Policies on referrals
for specialty care, including prior authorization requirements and how to request
a referral;
(h) Explanation of intensive
care coordination services and how members with the following special health care
needs can access intensive care coordination services: Those who are aged, blind,
or disabled or who have complex medical needs, high health needs, multiple chronic
conditions, mental illness, or chemical dependency.
(i) Information about the
coordinated care approach, how to navigate the coordinated care health care system
as applicable to dual-eligible individuals, and the process for coordinating Medicaid
and Medicare benefits;
(j) How and where members
are to access urgent care services and advice, including how to access these services
and advice when away from home;
(k) How and when members
are to use emergency services, both locally and when away from home, including examples
of emergencies;
(L) Information on contracted
hospitals in the member’s service area;
(m) Information on post-stabilization
care after a member is stabilized in order to maintain, improve, or resolve the
member’s condition;
(n) Information on the CCO’s
grievance and appeals processes and the Division’s contested case hearing
procedures, including:
(A) Information about assistance
in filling out forms and completing the grievance process available from the CCO
to the member as outlined in OAR 410-141-3260;
(B) Information about the
member’s right to continued benefits during the grievance process as provided
in OAR 410-141-3263;
(o) Information on the member’s
rights and responsibilities, including the availability of the OHP Ombudsman;
(p) Information on copayments,
charges for non-covered services, and the member’s possible responsibility
for charges if they go outside of the CCO for non-emergent care; including information
specific to copayments, deductibles, and coinsurance for dually-enrolled qualified
Medicare beneficiaries;
(q) Information about when
providers may bill clients for services and what to do if they receive a bill, including
information specific to payment responsibilities for dually-enrolled qualified Medicare
beneficiaries;
(r) The transitional procedures
for new members to obtain prescriptions, supplies, and other necessary items and
services in the first month of enrollment if they are unable to meet with a PCP
or PCD, other prescribing provider, or obtain new orders during that period; including
specific communications for members who are becoming new Medicare enrollees;
(s) Information on advance
directive policies including:
(A) Member rights under federal
and Oregon law to make decisions concerning their medical care, including the right
to accept or refuse medical or surgical treatment and the right to formulate advance
directives;
(B) The CCO’s policies
for implementation of those rights, including a statement of any limitation regarding
the implementation of advanced directives as a matter of conscience;
(t) Whether or not the CCO
uses provider incentives to reduce cost by limiting services;
(u) The member’s right
to request and obtain copies of their clinical records, whether they may be charged
a reasonable copying fee and that they may request the record be amended or corrected;
(v) How and when members
are to obtain ambulance services;
(w) Resources for help with
transportation to appointments with providers;
(x) Explanation of the covered
and non-covered coordinated care services in sufficient detail to ensure that members
understand the benefits to which they are entitled;
(y) How members are to obtain
prescriptions including information on the process for obtaining non-formulary and
over-the-counter drugs;
(z) The CCO’s confidentiality
policy;
(aa) How and where members
are to access any benefits that are available under OHP but are not covered under
the CCO’s contract, including any cost sharing;
(bb) When and how members
can voluntarily and involuntarily disenroll from CCOs and change CCOs;
(cc) CCOs shall, at a minimum,
annually review their member handbook for accuracy and update it with new and corrected
information to reflect OHP program changes and the CCO’s internal changes.
If changes affect the member’s ability to use services or benefits, the CCO
shall offer the updated member handbook to all members;
(dd) The “Oregon Health
Plan Client Handbook” is in addition to the CCO’s member handbook, and
a CCO may not use it to substitute for any component of the CCO’s member handbook.
(14) Member health education
shall include:
(a) Information on specific
health care procedures, instruction in self-management of health care, promotion
and maintenance of optimal health care status, patient self-care, and disease and
accident prevention. CCO providers or other individuals or programs approved by
the CCO may provide health education. CCOs shall endeavor to provide health education
in a culturally sensitive and linguistically appropriate manner in order to communicate
most effectively with individuals from non-dominant cultures;
(b) CCOs shall ensure development
and maintenance of an individualized health educational plan for members whom their
provider has identified as requiring specific educational intervention. The Division
may assist in developing materials that address specifically identified health education
problems to the population in need;
(c) Explanation of intensive
care coordination services and how to access intensive care coordination through
outreach to members with special health care needs who are aged, blind, or disabled,
or who have complex medical needs or high health care needs, multiple chronic conditions,
mental illness, or chemical dependency;(d) The appropriate use of the delivery system,
including proactive and effective education of members on how to access emergency
services and urgent care services appropriately;
(e) CCOs shall provide written
notice to affected members of any significant changes in program or service sites
that affect the member’s ability to access care or services from CCO’s
participating providers. The CCO shall provide, translated as appropriate, the notice
at least 30 calendar days before the effective date of that change, or as soon as
possible if the participating provider has not given the CCO sufficient notification
to meet the 30-day notice requirement. The Division shall review and approve the
materials within two working days.
(15) Informational materials
that CCOs develop for members shall meet the language requirements identified in
this rule and be culturally and linguistically sensitive to members with disabilities
or reading limitations, including members whose primary language is not English:
(a) CCOs shall provide free
interpreters for all of their members with hearing impairments and limited English
proficiency who request them. This also applies to family members and caregivers
with hearing impairments or limited English proficiency who need to understand the
member’s condition and care:
(A) CCOs shall translate
materials into all languages as identified in this rule. Written and spoken language
preferences are indicated on the OHP application form and reported to plans in 834
enrollment updates. CCOs shall honor requests made by other sources such as members,
family members, or caregivers for language accommodation, translating to the member’s
language needs as requested;
(B) CCOs shall provide written
translations of informational materials including their welcome packet, consisting
of at least a welcome letter and a member handbook in all languages as specified
in this rule and as identified by members either through the OHP application or
other means as their preferred written language;
(b) Form correspondence may
be sent to members, including, but not limited to, enrollment information and notices
of action to deny or stop a benefit, accompanied by alternate format statement inserts
as specified in section (12) of this rule. If sent in English to members who prefer
a different language, the tag lines, placed in the alternate format statement insert
shall have instructions on how to receive an oral or written translation of the
material.
(16) CCOs shall provide an
identification card to members, unless waived by the Division, that contains simple,
readable, and usable information on how to access care in an urgent or emergency
situation. The cards are solely for the convenience of the CCO, members, and providers.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 16-2015, f. 3-31-15, cert. ef. 4-1-15; DMAP 21-2015, f. 4-14-15, cert. ef.
4-15-15; DMAP 24-2015, f. & cert. ef. 4-15-15
410-141-3320
Coordinated
Care Organization Member Rights and Responsibilities
(1)
CCO members shall have the following rights and are entitled to:
(a)
Be treated with dignity and respect;
(b)
Be treated by participating providers the same as other people seeking health care
benefits to which they are entitled, and to be encouraged to work with the member’s
care team, including providers and community resources appropriate to the member’s
needs;
(c)
Choose a Primary Care Provider (PCP) or service site, and to change those choices
as permitted in the CCO’s administrative policies;
(d)
Refer oneself directly to behavioral health or family planning services without
getting a referral from a PCP or other participating provider;
(e)
Have a friend, family member, or advocate present during appointments and other
times as needed within clinical guidelines;
(f)
Be actively involved in the development of their treatment plan;
(g)
Be given information about their condition and covered and non-covered services
to allow an informed decision about proposed treatments;
(h)
Consent to treatment or refuse services, and be told the consequences of that decision,
except for court ordered services;
(i)
Receive written materials describing rights, responsibilities, benefits available,
how to access services, and what to do in an emergency;
(j)
Have written materials explained in a manner that is understandable to the member
and be educated about the coordinated care approach being used in the community
and how to navigate the coordinated health care system;
(k)
Receive culturally and linguistically appropriate services and supports, in locations
as geographically close to where members reside or seek services as possible, and
choice of providers within the delivery system network that are, if available, offered
in non-traditional settings that are accessible to families, diverse communities,
and underserved populations.
(l)
Receive oversight, care coordination and transition and planning management from
their CCO within the targeted population of AMH to ensure culturally and linguistically
appropriate community-based care is provided in a way that serves them in as natural
and integrated an environment as possible and that minimizes the use of institutional
care.
(m)
Receive necessary and reasonable services to diagnose the presenting condition;
(n)
Receive integrated person centered care and services designed to provide choice,
independence and dignity and that meet generally accepted standards of practice
and are medically appropriate;
(o)
Have a consistent and stable relationship with a care team that is responsible for
comprehensive care management;
(p)
Receive assistance in navigating the health care delivery system and in accessing
community and social support services and statewide resources including but not
limited to the use of certified or qualified health care interpreters, and advocates,
community health workers, peer wellness specialists and personal health navigators
who are part of the member’s care team to provide cultural and linguistic
assistance appropriate to the member’s need to access appropriate services
and participate in processes affecting the member’s care and services;
(q)
Obtain covered preventive services;
(r)
Have access to urgent and emergency services 24 hours a day, 7 days a week without
prior authorization;
(s)
Receive a referral to specialty providers for medically appropriate covered coordinated
care services, in the manner provided in the CCO’s referral policy;
(t)
Have a clinical record maintained which documents conditions, services received,
and referrals made;
(u)
Have access to one's own clinical record, unless restricted by statute;
(v)
Transfer of a copy of the clinical record to another provider;
(w)
Execute a statement of wishes for treatment, including the right to accept or refuse
medical, surgical, or behavioral health treatment and the right to execute directives
and powers of attorney for health care established under ORS 127;
(x)
Receive written notices before a denial of, or change in, a benefit or service level
is made, unless a notice is not required by federal or state regulations;
(y)
Be able to make a complaint or appeal with the CCO and receive a response;
(z)
Request a contested case hearing;
(aa)
Receive certified or qualified health care interpreter services; and
(bb)
Receive a notice of an appointment cancellation in a timely manner.
(2)
CCO members shall have the following responsibilities:
(a)
Choose, or help with assignment to, a PCP or service site;
(b)
Treat the CCO, provider, and clinic staff members with respect;
(c)
Be on time for appointments made with providers and to call in advance to cancel
if unable to keep the appointment or if he/she expects to be late;
(d)
Seek periodic health exams and preventive services from his/her PCP or clinic;
(e)
Use his/her PCP or clinic for diagnostic and other care except in an emergency;
(f)
Obtain a referral to a specialist from the PCP or clinic before seeking care from
a specialist unless self-referral to the specialist is allowed;
(g)
Use urgent and emergency services appropriately, and notify the member’s PCP
or clinic within 72 hours of using emergency services, in the manner provided in
the CCO’s referral policy;
(h)
Give accurate information for inclusion in the clinical record;
(i)
Help the provider or clinic obtain clinical records from other providers which may
include signing an authorization for release of information;
(j)
Ask questions about conditions, treatments, and other issues related to his/her
care that is not understood;
(k)
Use information provided by CCO providers or care teams to make informed decisions
about treatment before it is given;
(l)
Help in the creation of a treatment plan with the provider;
(m)
Follow prescribed agreed upon treatment plans and actively engage in their health
care;
(n)
Tell the provider that his/her health care is covered under the OHP before services
are received and, if requested, to show the provider the Division Medical Care Identification
form;
(o)
Tell the Department or Authority worker of a change of address or phone number;
(p)
Tell the Department or Authority worker if the member becomes pregnant and to notify
the worker of the birth of the member's child;
(q)
Tell the Department or Authority worker if any family members move in or out of
the household;
(r)
Tell the Department or Authority worker if there is any other insurance available;
(s)
Pay for non-covered services under the provisions described in OAR 410-120-1200
and 410-120-1280;
(t)
Pay the monthly OHP premium on time if so required;
(u)
Assist the CCO in pursuing any third party resources available and reimburse the
CCO the amount of benefits it paid for an injury from any recovery received from
that injury; and
(v)
Bring issues, or complaints or grievances to the attention of the CCO.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3340
Procedure
for General Financial Reporting and for Determining Financial Solvency Matters
(1)
The Authority shall determine financial solvency of a CCO in accordance with OAR
410-141-3345 through 410-141-3395, the request for applications and the CCO contract.
In implementing OAR 410-141-3345 to 410-141-3395, the Authority may enter into a
cooperative agreement with another state agency to carry out these provisions. For
purposes of obtaining necessary information to determine financial solvency, any
reference to OHA in these rules shall include DCBS when DCBS is working cooperatively
with OHA to implement these provisions. However, only OHA may take enforcement action
or other regulatory sanctions related to the implementation of OAR 410-141-3345
to 410-141-3395 and the CCO contract.
(2)
OAR 410-141-3345 to 410-141-3395 are developed in consultation with DCBS in accordance
with Section 13, chapter 602, Oregon Laws 2011 (Enrolled House Bill 3650) and Section
1, chapter 8, Oregon Laws 2012 (Enrolled Senate Bill 1580).
(3)
Where these rules specify that the OHA may request or receive information or provide
a response or take any action, DCBS may act on behalf of OHA. A response to DCBS
under these rules shall be considered a response to the OHA on the matter, consistent
with the objective of providing a single point of reporting by CCOs.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3345
General
Financial Reporting and Financial Solvency Matters; CCO Reporting Method
(1)
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.
(2)
The Authority shall collaborate with DCBS to review CCO financial reports and evaluate
financial solvency. Except as provided in this section, CCOs are not required to
file financial reports with both OHA and DCBS:
(a)
Initial applicants for certification as a CCO will submit all required information
to OHA as part of the application process, and OHA will transmit that information
to DCBS for its review. In making its determination about the qualifications of
the applicant OHA will consult with DCBS about the financial materials and reports
submitted with the application;
(b)
For purposes of these financial reporting and solvency rules, DCBS is authorized
to make recommendations to OHA and to act in conjunction with OHA in accordance
with these rules. If quarterly reports or other evidence suggest that a CCO’s
financial solvency is in jeopardy, OHA will act as necessary to protect the public
interest.
(3)
OHA may address any proper inquiries to any CCO or its officers in relation to the
activities or condition of the CCO or any other matter connected with its transactions.
The person shall promptly and truthfully reply to the inquiries using the form of
communication requested by OHA. The reply shall be timely, accurate and complete
and, if OHA requires, verified by an officer of the CCO. A reply is subject to the
provisions of ORS 731.260.
(4)
OAR 410-141-3345 through 410-141-3395 provide for three alternative methods for
a CCO’s solvency plan and financial reporting requirements, depending on the
status of the CCO as described in this rule:
(a)
OHA reporting CCO: The CCO complies with restricted reserve and net worth requirements
OHA used to regulate financial solvency of MCOs on July 1, 2012, submitting financial
information and reports to OHA as detailed in the CCO contract. Under this approach,
OHA will monitor the CCO’s financial solvency utilizing the same reporting
format and financial standards that OHA used for MCOs on July 1, 2012;
(b)
DCBS reporting CCO: The CCO complies with financial requirements as detailed in
the CCO contract and in OAR 410-141-3345 through 410-141-3395, including risk based
capital and NAIC reporting requirements. These requirements will be monitored by
DCBS;
(c)
Certificate of Authority: The CCO has a certificate of authority and complies with
financial reporting and solvency requirements applicable to licensed health entities
pursuant to applicable DCBS requirements under the Oregon insurance code and DCBS
rules. In addition, the CCO shall report to OHA the schedules outlined in the CCO
contract.
(5)
CCO Status. The method described in this rule that applies to a CCO is determined
as follows:
(a)
If the CCO is a licensed health entity, CCO shall use the method described in this
rule for certificate of authority. The CCO shall submit a copy of its certificate
of authority to OHA, not later than the readiness review document submission date
under the initial CCO contract, and annually thereafter not later than August 31st.
CCO shall report to OHA immediately at any time that this certificate of authority
is suspended or terminated;
(b)
If the CCO is neither a converting MCO nor a licensed health entity, the CCO shall
use the method described in this rule for DCBS reporting CCO;
(c)
If the CCO is a converting MCO and is not a licensed health entity, the CCO shall
elect either the method described in this rule for OHA reporting CCO or the method
described in this rule for DCBS reporting CCO. The CCO shall notify OHA of its election
no later than the readiness review document submission date under the initial CCO
contract. The CCO shall comply with the requirements applicable to its elected method
until it notifies OHA of its intent to change its election. If the CCO expects to
change its election, any elements of the solvency plan or solvency protection arrangements,
the CCO shall provide written advance notice to OHA, at least 90 calendar days before
the proposed effective date of change. Such changes are subject to written approval
from OHA.
(6)
CCOs may be required to use specific required reporting forms or items in order
to supply information related to financial responsibility, financial solvency and
financial management. The OHA or DCBS, as applicable, will provide supplemental
instructions about the use of these forms.
(7)
The standards established in OAR 410-141-3350 through 410-141-3395 are intended
to be consistent with, and may utilize procedures and standards common to insurers
and to DCBS in its administration of financial reporting and solvency requirements.
Any reference in these rules to the insurance code or to rules adopted by DCBS under
the insurance code shall not be deemed to require a CCO to be an insurer, but is
adopted and incorporated by reference as an OHA standard.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3350
Assets,
Liabilities, Reserves — DCBS REPORTING CCOs ONLY
(1)
The provisions of this rule apply only to DCBS reporting CCOs, and do not apply
to Authority reporting CCOs.
(2)
In any determination of the financial condition of a CCO, there shall be allowed
as assets only such assets as are owned by the CCO and which consist of:
(a)
Cash in the possession or control of the CCO, including the true balance of any
deposit in a solvent bank or trust company;
(b)
Investments held in accordance with these rules, and due or accrued income items
in connection therewith to the extent considered by the Authority to be collectible;
(c)
Due premiums, deferred premiums, installment premiums, and written obligations taken
for premiums, to the extent allowed by the Authority;
(d)
The amount recoverable from a reinsurer if credit for reinsurance may be allowed
to the CCO pursuant to OAR 410-141-3380;
(e)
Deposits or equities recoverable from any suspended banking institution, to the
extent deemed by the Authority to be available for the payment of losses and claims;
(f)
Other assets considered by the Authority to be available for the payment of losses
and claims, at values determined by the Authority.
(3)
In addition to assets impliedly excluded by this rule, the following expressly shall
not be allowed as assets in any determination of the financial condition of a CCO:
(a)
Advances to officers, employees, agents and other persons on personal security only;
(b)
Stock of such CCO owned by it, or any material equity therein or loans secured thereby,
or any material proportionate interest in such stock acquired or held through the
ownership by such CCO of an interest in another firm, corporation or business unit;
(c)
Tangible personal property, except such property as the CCO is otherwise permitted
to acquire and retain as an investment under these rules and which is deemed by
the Authority to be available for the payment of losses and claims or which is otherwise
expressly allowable, in whole or in part, as an asset;
(d)
The amount, if any, by which the book value of any investment as carried in the
ledger assets of the CCO exceeds the value thereof as determined under these rules.
(4)
In any determination of the financial condition of a CCO, liabilities to be charged
against its assets shall be calculated in accordance with these rules and shall
include:
(a)
The amount necessary to pay all of its unpaid losses and claims incurred on or prior
to the date of the statement, whether reported or unreported to the CCO, together
with the expenses of adjustment or settlement thereof;
(b)
For insurance other than specified in Subsection (c) of this section, the amount
of reserves equal to the unearned portions of the gross premiums charged on policies
in force, calculated in accordance with these rules;
(c)
Reserves which place a sound value on its liabilities and which are not less than
the reserves according to accepted actuarial standards consistently applied and
based on actuarial assumptions relevant to contract provisions;
(d)
Taxes, expenses and other obligations due or accrued at the date of the statement;
(e)
Any additional reserves for asset valuation contingencies or loss contingencies
required by these rules or considered to be necessary by the Authority for the protection
of the Authority and the members of the CCO.
(5)
If the Authority determines that a CCO’s reserves, however calculated or estimated,
are inadequate, the Authority shall require the CCO to maintain reserves in such
additional amount as is needed to make them adequate.
(6)
Funds of a CCO may be invested in a bond, debenture, note, warrant, certificate
or other evidence of indebtedness that are not investment grade as established by
these rules, but the funds that a CCO may invest under this section shall not exceed
20 percent of the CCO’s assets. For purposes of this rule CCOs shall be subject
to the requirements of OAR 836-033-0105 through 836-033-0130.
(7)
A CCO shall not have any combination of investments in or secured by the stocks,
obligations, and property of one person, corporation or political subdivision in
excess of 10 percent of the CCO’s assets, nor shall it invest more than 10
percent of its assets in a single parcel of real property or in any other single
investment. This subsection does not apply to:
(a)
Investments in, or loans upon, the security of the general obligations of a sovereign;
or
(b)
Investments by a CCO in all real or personal property used exclusively by such CCO
to provide health services or in real property used primarily for its home office.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3355
Restricted
Reserves, Capital and Surplus– DCBS Reporting CCOs Only
(1)
The provisions of OAR 410-141-3355 apply only to DCBS reporting CCOs, and do not
apply to Authority reporting CCOs.
(2)
A CCO shall:
(a)
Establish a restricted reserve account; and
(b)
Maintain adequate funds in this account to meet the Authority’s primary and
secondary restricted reserve requirements. Reserve funds are held for the purpose
of making payments to providers in the event of the CCO’s insolvency.
(3)
A CCO shall establish a restricted reserve account with a third party financial
institution for the purpose of holding the CCO’s primary and secondary restricted
reserve funds. CCOs shall use the model depository agreement to establish a restricted
reserve account;
(a)
A model depository agreement shall be used by the CCO to establish a restricted
reserve account. CCOs shall request the model depository agreement form from the
Authority. CCOs shall submit the model depository agreement to the Authority at
the time of application and the model depository agreement shall remain in effect
throughout the period of time that the CCO contract is in effect. The model depository
agreement cannot be changed without the Authority’s written authorization;
(b)
The CCO shall not withdraw funds, change third party financial institutions, or
change account numbers within the restricted reserve account without the written
consent of the Authority;
(c)
A CCO shall submit a copy of the model depository agreement at the time of application
for certification. If a CCO requests and receives written authorization from the
Authority to make a change to their existing restricted reserve account, the CCO
shall submit a model depository agreement reflecting the changes to the Authority
within 15 days of the date of the change;
(d)
The following instruments are considered eligible deposits for the purposes of the
Authority’s primary and secondary restricted reserves:
(A)
Cash;
(B)
Certificates of Deposit; or
(C)
Amply secured obligations of the United States, a state or a political subdivision
thereof as determined by the Authority.
(e)
In addition to the instruments allowed in this rule, a CCO may satisfy the primary
restricted reserve amount by a surety bond that meets the requirements listed below:
(A)
The bond is prepaid at the beginning of the contract year for 18 months;
(B)
Evidence of prepayment is provided to the Authority;
(C)
The surety bond is purchased by a surety bond company approved by the Oregon Insurance
Division;
(D)
The surety bond agreement contains a clause stating the payment of the bond will
be made to the third party entity holding the restricted reserve account on behalf
of the contracting company for deposit into the restricted reserve account;
(E)
The surety bond agreement contains a clause that no changes to the surety bond agreement
will occur until approved by the Authority; and
(F)
The Authority approves the terms of the surety bond agreement.
(4)
A CCO’s primary and secondary reserve balances are determined by calculating
the average monthly medical expense incurred. A CCO that has submitted quarterly
financial statements for the current quarter and the prior three quarters, the average
monthly medical expense incurred is derived by adding together the “total
hospital and medical” expense (NAIC statement of revenue and expenses) for
the prior four quarters and dividing by 12. A newly formed CCO will use an average
of hospital and medical expense projected for the first four quarters of operation.
Each quarter the average expense liability will be recalculated using historical
quarter data available. The amount a CCO must deposit into the restricted reserve
account shall be:
(a)
If a CCO’s average monthly medical expense incurred is less than or equal
to $250,000, an amount equal to the average monthly medical expense incurred. This
amount will be referred to as the CCO’s primary reserve and the CCO shall
have no secondary reserve, until such time as the average monthly medical expense
exceeds $250,000;
(b)
If a CCO’s average monthly medical expense is greater than $250,000, funds
equaling 50 percent of the difference between the average monthly medical expense
and the primary reserve balance of $250,000. This amount will be referred to as
the CCO’s secondary reserve;
(c)
Adjusted each quarter after the CCO calculates its average monthly medical expense
each quarter.
(5)
Working capital or surplus requirements:
(a)
As used in this section, “net healthcare revenue” means direct healthcare
premium less the following: amounts paid for reinsurance ceded, HRA and GME payments
(if any received by a CCO), and MCO taxes. “Net healthcare revenue”
includes all healthcare related revenue and fee-for-service revenue adjusted for
the change in unearned premium reserves;
(b)
Except as provided in Section (8) CCOs shall possess and thereafter maintain capital
or surplus, or any combination thereof, equal to the greater of $2.5 million or
the amount required from the application of the risk-based capital standards in
OAR 410-141-3360;
(c)
A CCO that possesses the amount required in this rule as of the effective date of
this rule must thereafter maintain that capital and surplus;
(d)
Except as provided in Section (8), if a CCO does not possess the minimum capital
and surplus as of the effective date of these rules, the CCO shall possess and thereafter
maintain capital or surplus, or any combination thereof as follows:
(A)
Five percent of annualized total net healthcare revenue as of August 1, 2012. The
CCO shall calculate its authorized control level and file the RBC report in accordance
with these rules;
(B)
The greater of five percent annualized total net healthcare revenue or its authorized
control level risk-based capital as of January 1, 2014;
(C)
The greater of six percent of annualized total net healthcare revenue or 125 percent
of its authorized control level risk-based capital as of January 1, 2015;
(D)
The greater of seven percent of annualized total net healthcare revenue or 150 percent
of its authorized control level risk-based capital as of January 1, 2016;
(E)
The greater of eight percent of annualized total net healthcare revenue or 175 percent
of its authorized control level risk-based capital as of January 1, 2017;
(F)
The greater of nine percent of annualized total net healthcare revenue or 200 percent
of its authorized control level risk-based capital as of January 1, 2018;
(G)
The greater of 10 percent of annualized total net healthcare revenue or 200 percent
of its authorized control level risk-based capital as of January 1, 2019.
(e)
A CCO may use a subordinated surplus note to meet its minimum capital and surplus
requirement provided it meets the standards in Statements of Statutory Accounting
Principles #41 and the Authority has given prior approval of the form and content
of the surplus note;
(f)
A converting CCO will initially be subject to financial responsibility and solvency
standards applicable to an the Authority reporting CCO. Effective January 1, 2014,
the converting CCO shall comply with the minimum capital and surplus set forth in
this rule;
(g)
The converting CCO shall calculate its authorized control level and file the RBC
report in accordance with this rule.
(6)
Funds of a CCO at least equal to its required capital and surplus shall be invested
and kept invested as follows:
(a)
In amply secured obligations of the United States, a state or a political subdivision
of this state;
(b)
In loans secured by first liens upon improved, unencumbered real property (other
than leaseholds) in this state where:
(A)
The lien does not exceed 50 percent of the appraised value of the property and the
loan is for a term of five years or less;
(B)
The lien does not exceed 66-2/3 percent of the appraised value of the property provided
there is an amortization plan mortgage, deed of trust or other instrument under
the terms of which the installment payments are sufficient to repay the loan within
a period of not more than 25 years; or
(C)
The investment is insured or guaranteed by the Federal Housing Administration, the
United States Department of Veterans Affairs, or under Title I of the Housing Act
of 1949 (providing for slum clearance and redevelopment projects) enacted by Congress
on July 15, 1949.
(c)
In deposits, certificates of deposit, accounts or savings or certificate shares
or accounts of or in banks, trust companies, savings and loan associations or building
and loan associations to the extent such investments are insured by the Federal
Deposit Insurance Corporation.
(7)
Investments made pursuant to Section (6) of this rule shall be kept free of any
lien or pledge.
(8)
A CCO that is not a converting CCO shall possess $500,000 working capital above
the minimum capital and surplus requirement upon the CCO contract date sufficient
to pay initial expenses without causing the CCO to fall below the minimum capital
and surplus required by these rules.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3360
Risk-based
capital — DCBS Reporting CCOs Only
(1)
The provisions of OAR 410-141-3360 shall apply only to DCBS reporting CCOs, and
do not apply to OHA reporting CCOs.
(2)
As used in this rule:
(a)
"Authorized Control Level RBC" means the number determined under the risk-based
capital formula in accordance with the RBC Instructions;
(b)
"Company Action Level RBC" means, with respect to any CCO, the product of 2.0 and
the CCO’s Authorized Control Level RBC;
(c)
"Mandatory Control Level RBC" means the product of .70 and the CCO’s authorized
control level RBC;
(d)
"RBC Instructions" means the RBC report including risk-based capital instructions
adopted by the NAIC, as the RBC instructions may be amended by the NAIC from time
to time in accordance with the procedures adopted by the NAIC;
(e)
"RBC Level" means a CCO’s company action level RBC, regulatory action level
RBC, authorized control level RBC or mandatory control level RBC;
(f)
"RBC Plan" means a comprehensive financial plan containing the elements specified
in this rule. If OHA rejects the RBC plan and it is revised by the CCO with or without
OHA's recommendation, the plan shall be called the "revised RBC plan;"
(g)
"RBC Report" means the report required in OAR 410-141-3360;
(h)
"Regulatory Action Level RBC" means the product of 1.5 and the CCO’s authorized
control level RBC;
(i)
"Total Adjusted Capital" means the sum of:
(A)
A CCO’s capital and surplus (i.e. net worth) as determined in accordance with
the statutory accounting applicable to the annual financial statements required
to be filed under these rules; and
(B)
Such other items, if any, as the RBC instructions may provide.
(3)
For the purpose of determining the reasonableness and adequacy of a CCO’s
capital and surplus, the Oregon Health Authority must consider at least the following
factors, as applicable:
(a)
The size of the CCO, as measured by its assets, capital and surplus, reserves, premium
writings, insurance in force and other appropriate criteria;
(b)
The number of lives insured;
(c)
The extent of the geographical dispersion of the lives insured by the CCO;
(d)
The nature and extent of the reinsurance program of the CCO;
(e)
The quality, diversification and liquidity of the investment portfolio of the CCO;
(f)
The recent past and projected future trend in the size of the investment portfolio
of the CCO;
(g)
The combined capital and surplus maintained by comparable CCOs;
(h)
The adequacy of the reserves of the CCO;
(i)
The quality and liquidity of investments in affiliates. OHA may treat any such investment
as a disallowed asset for purposes of determining the adequacy of combined capital
and surplus whenever in the judgment of OHA the investment so warrants; and
(j)
The quality of the earnings of the CCO and the extent to which the reported earnings
include extraordinary items.
(4)
The following pertain to a CCO’s RBC levels:
(a)
On or before March 1 of each year, a CCO shall prepare and submit to OHA a report
of its RBC levels as of the end of the calendar year just ended, in a form and containing
such information as is required by the RBC instructions. In addition, a CCO shall
file its RBC report with the NAIC in accordance with the RBC instructions. The CCO
shall report in its annual financial statement the authorized control level calculated
using its RBC report. A CCO’s RBC report will be considered confidential under
OAR 410-141-3390;
(b)
A CCO’s RBC shall be determined in accordance with the formula set forth in
the RBC instructions. The formula shall take the following into account (and may
adjust for the covariance between) determined in each case by applying the factors
in the manner set forth in the RBC instructions:
(A)
Asset risk;
(B)
Credit risk;
(C)
Underwriting risk; and
(D)
All other business risks and such other relevant risks as are set forth in the RBC
instructions.
(c)
An excess of capital (i.e. net worth) over the amount produced by the risk-based
capital requirements contained in this rule and the formulas, schedules and instructions
referenced in this rule is desirable in the business of a CCO. Accordingly, CCOs
should seek to maintain capital above the RBC levels required by this rule. Additional
capital is used and useful in the business of a risk-bearing entity and helps to
secure a CCO against various risks inherent in, or affecting, the business of a
CCO and not accounted for or only partially measured by the risk-based capital requirements
contained in this rule;
(d)
If a CCO files an RBC report that in the judgment of OHA is inaccurate, then OHA
shall adjust the RBC report to correct the inaccuracy and shall notify the CCO of
the adjustment. The notice shall contain a statement of the reason for the adjustment.
An RBC report as so adjusted is referred to as an "adjusted RBC report."
(5)
"Company Action Level Event" means any of the following events:
(a)
The filing of an RBC report by a CCO that indicates that the CCO’s total adjusted
capital is greater than or equal to its regulatory action level RBC but less than
its company action level RBC;
(b)
If a CCO has total adjusted capital that is greater than or equal to its company
action level RBC but less than the product of its authorized control level RBC and
3.0 and triggers the trend test determined in accordance with the trend test calculation
included in the health RBC instructions;
(c)
Notification by OHA to the CCO of an adjusted RBC report that indicates an event
in Section 15 of this section, if the CCO does not challenge the adjusted RBC report
in this rule; or
(d)
If a CCO challenges an adjusted RBC report that indicates the event in Section (5)(a),
the notification by OHA to the CCO that OHA has, after a hearing, rejected the CCO’s
challenge.
(6)
In the event of a company action level event, the CCO shall prepare and submit to
OHA an RBC plan that shall:
(a)
Identify the conditions that contribute to the company action level event;
(b)
Contain proposals of corrective actions that the CCO intends to take and that would
be expected to result in the elimination of the company action level event;
(c)
Provide projections of the CCO’s financial results in the current year and
at least the two succeeding years, both in the absence of proposed corrective actions
and giving effect to the proposed corrective actions, including projections of statutory
balance sheets, operating income, net income, capital and surplus, and RBC levels.
The projections for both new and renewal business might include separate projections
for each major line of business and separately identify each significant income,
expense and benefit component;
(d)
Identify the key assumptions impacting the CCO’s projections and the sensitivity
of the projections to the assumptions; and
(e)
Identify the quality of, and problems associated with, the CCO’s business,
including but not limited to its assets, anticipated business growth and associated
surplus strain, extraordinary exposure to risk, mix of business and use of reinsurance,
if any, in each case.
(7)
The RBC plan shall be submitted:
(a)
Within 45 days of the Company Action Level Event; or
(b)
Within 45 days after notification to the CCO that OHA has, after a hearing, rejected
the CCO’s challenge, if the CCO challenges an adjusted RBC report;
(c)
Within 60 days after the submission by a CCO of an RBC plan to OHA, OHA shall notify
the CCO whether the RBC plan shall be implemented or is, in the judgment of OHA,
unsatisfactory. If OHA determines the RBC plan is unsatisfactory, the notification
to the CCO shall set forth the reasons for the determination and may set forth proposed
revisions that will render the RBC plan satisfactory, in the judgment of OHA. Upon
notification from OHA, the CCO shall prepare a revised RBC plan, which may incorporate
by reference any revisions proposed by OHA, and shall submit the revised RBC plan
to OHA:
(A)
Within 45 days after the notification from OHA; or
(B)
Within 45 days after a notification to the CCO that OHA has, after a hearing, rejected
the CCO’s challenge, if the CCO challenges the notification from OHA under
this rule.
(8)
In the event of a notification by OHA to a CCO that the CCO’s RBC plan or
revised RBC plan is unsatisfactory, OHA may at OHA's discretion, subject to the
CCO’s right to a hearing under this rule, specify in the notification that
the notification constitutes a regulatory action level event.
(9)"Regulatory
Action Level Event" means, with respect to a CCO, any of the following events:
(a)
The filing of an RBC report by the CCO that indicates that the CCO's total adjusted
capital is greater than or equal to its authorized control level RBC but less than
its regulatory action level RBC;
(b)
Notification by OHA to a CCO of an adjusted RBC report that indicates the event
in Section (9)(a), if the CCO does not challenge the adjusted RBC report in this
rule;
(c)
If the CCO challenges an adjusted RBC report that indicates the event in this rule,
the notification by OHA to the CCO that OHA has, after a hearing, rejected the CCO's
challenge;
(d)
The failure of the CCO to file an RBC report by the filing date, unless the CCO
has provided an explanation for the failure that is satisfactory to OHA and has
cured the failure within ten days after the filing date;
(e)
The failure of the CCO to submit an RBC plan to OHA within the time period set forth
in this rule;
(f)
Notification by OHA to the CCO that:
(A)
The RBC plan or revised RBC plan submitted by the CCO is, in the judgment of OHA,
unsatisfactory; and
(B)
Notification constitutes a regulatory action level event with respect to the CCO,
if the CCO has not challenged the determination in this rule.
(g)
If the CCO challenges a determination by OHA, the notification by OHA to the CCO
that OHA has, after a hearing, rejected the challenge;
(h)
Notification by OHA to the CCO that the CCO has failed to adhere to its RBC plan
or revised RBC plan, but only if the failure has a substantial adverse effect on
the ability of the CCO to eliminate the company action level event in accordance
with its RBC plan or revised RBC plan and OHA has so stated in the notification,
if the CCO has not challenged the determination; or
(i)
If the CCO challenges a determination by OHA, the notification by OHA to the CCO
that OHA has, after a hearing, rejected the challenge.
(10)
In the event of a regulatory action level event OHA shall:
(a)
Require the CCO to prepare and submit an RBC plan or, if applicable, a revised RBC
plan;
(b)
Perform such examination or analysis as OHA deems necessary of the assets, liabilities
and operations of the CCO including a review of its RBC plan or revised RBC plan;
and
(c)
Subsequent to the examination or analysis, issue an order specifying such corrective
actions as OHA shall determine are required (a "corrective order").
(11)
In determining corrective actions, OHA may take into account factors OHA deems relevant
with respect to the CCO based upon OHA's examination or analysis of the assets,
liabilities and operations of the CCO, including, but not limited to, the results
of any sensitivity tests undertaken pursuant to the RBC instructions. The RBC plan
or revised RBC plan shall be submitted:
(a)
Within 45 days after the occurrence of the regulatory action level event;
(b)
Within 45 days after the notification to the CCO that OHA has, after a hearing,
rejected the CCO's challenge; if the CCO challenges an adjusted RBC report, and
the challenge is not frivolous in the judgment of OHA; or
(c)
Within 45 days after the notification to the CCO that the care service CCO has,
after a hearing, rejected the CCO's challenge, if the CCO challenges a revised RBC
plan, and the challenge is not frivolous in the judgment of OHA.
(12)
OHA may retain actuaries and investment experts and other consultants as may be
necessary in the judgment of OHA to review the CCO's RBC plan or revised RBC plan,
examine or analyze the assets, liabilities and operations (including contractual
relationships) of the CCO and formulate the corrective order with respect to the
CCO. The fees, costs and expenses relating to consultants shall be borne by the
affected CCO or such other party as directed by OHA.
(13)
"Authorized Control Level Event" means any of the following events:
(a)
The filing of an RBC report by the CCO that indicates that the CCO's total adjusted
capital is greater than or equal to its mandatory control level RBC but less than
its authorized control level RBC;
(b)
The notification by OHA to the CCO of an adjusted RBC report that indicates the
event in this section, if the CCO does not challenge the adjusted RBC report;
(c)
If the CCO challenges an adjusted RBC report that indicates the event in this section,
notification by OHA to the CCO that OHA has, after a hearing, rejected the CCO's
challenge;
(d)
The failure of the CCO to respond, in a manner satisfactory to OHA, to a corrective
order if the CCO has not challenged the corrective order; or
(e)
If the CCO has challenged a corrective order in this rule and OHA has, after a hearing,
rejected the challenge or modified the corrective order, the failure of the CCO
to respond, in a manner satisfactory to OHA, to the corrective order subsequent
to rejection or modification by OHA.
(14)
In the event of an authorized control level event with respect to a CCO, OHA shall:
(a)
Take such actions as are required by this rule regarding a CCO with respect to which
an regulatory action level event has occurred; or
(b)
If OHA deems it to be in the best interests of the members and creditors of the
CCO and of the public, take such actions as are necessary to work with the Authority,
which may terminate the CCO contract and revoke or suspend its certification as
a CCO.
(15)"Mandatory
Control Level Event" means any of the following events:
(a)
The filing of an RBC report that indicates that the CCO's total adjusted capital
is less than its mandatory control level RBC;
(b)
Notification by OHA to the CCO of an adjusted RBC report that indicates the event
in this section, if the CCO does not challenge the adjusted RBC report; or
(c)
If the CCO challenges an adjusted RBC report that indicates the event in this section,
notification by OHA to the CCO that OHA has, after a hearing, rejected the CCO's
challenge.
(16)
In the event of a mandatory control level event, OHA shall take such actions as
are necessary to work with the Authority, which may to terminate the CCO contract
and revoke or suspend its certification as a CCO. Notwithstanding the provisions
of this rule, OHA may forego action for up to 90 days after the mandatory control
level event if OHA finds there is a reasonable expectation that the mandatory control
level event may be eliminated within the 90 day period.
(17)
Upon the occurrence of any of the following events, a CCO may request a hearing
for the purpose of challenging any determination or action by OHA in connection
with any event described in this rule. The CCO shall notify OHA of its request for
a hearing not later than the fifth day after notification by OHA under any of the
events described in this rule. Upon receipt of the CCO's request for a hearing,
OHA shall set a date for the hearing. The date shall be not less than 10 or more
than 30 days after the date of the CCO's request. The events to which the opportunity
for a hearing under this rule relates are as follows:
(a)
Notification to a CCO by OHA of an adjusted RBC report;
(b)
Notification to a CCO by OHA that:
(A)
The CCO's RBC plan or revised RBC plan is unsatisfactory; and
(B)
Notification constitutes a Regulatory Action Level Event with respect to the CCO.
(c)
Notification to a CCO by OHA that the CCO has failed to adhere to its RBC plan or
revised RBC plan and that the failure has a substantial adverse effect on the ability
of the CCO to eliminate the company action level event with respect to the CCO in
accordance with its RBC plan or revised RBC plan; or
(d)
Notification to a CCO by OHA of a corrective order with respect to the CCO.
(18)
OHA may keep confidential a CCO’s RBC plan or the results or report of any
examination or analysis conducted in this rule if OHA determines that disclosure
of such information would jeopardize the CCO’s corrective action plan.
(19)
This rule shall not preclude or limit any other powers or duties of OHA or OHA under
other laws and rules.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3365
Financial Reporting -- DCBS
Reporting CCOs Only
(1) The provisions of OAR 410-141-3365
shall apply only to DCBS reporting CCOs and do not apply to OHA reporting CCOs.
(2) Every CCO shall file
with DCBS, on or before March 1 of each year, a financial statement for the year
ending December 31 immediately preceding. The CCO shall also file with DCBS, on
or before May 15, August 15, and November 15 of each year, quarterly financial statements
for the quarter ending March 31, June 30 and September 30, respectively. All financial
statements shall be completed in accordance with NAIC annual statement instructions.
OHA may also require additional filings as OHA determines necessary.
(3) The financial statement
filed by a CCO under this rule shall be verified by the oaths of the president and
secretary of the CCO or, in their absence, by two other principal officers.
(4) Each CCO shall have an
annual audit conducted by an independent certified public accountant and shall file
an audited financial report annually with DCBS. The annual audited financial report
shall be in the form required of insurers by the insurance code, specifically ORS
731.488 and OAR 836-011-0100 through 836-011-0220.
Stat. Auth.: ORS 414.032, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
– 685 2011 OL Ch. 602 Sec. 13, 14, 16, 17, 62, 64(2), 65 & HB 3650
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12
410-141-3370
Solvency Monitoring and Corrective
Actions
(1) For purposes of this rule, the CCO
shall be monitored in the context of the financial standards applicable to the reporting
method described in OAR 410-141-3345. An OHA reporting CCO is accountable under
the standards in the CCO contract and this rule. A DCBS reporting CCO or a CCO with
a certificate of authority is accountable under DCBS standards.
(2) OHA shall examine every
CCO, including an audit of the financial affairs of such CCO, as often as OHA determines
an examination to be necessary but generally at least once during the CCO’s
certification period. An examination shall be conducted for the purpose of determining
the financial condition of the CCO, its ability to fulfill its obligations and its
manner of fulfillment, the nature of its operations and its compliance with these
rules and applicable CCO contract requirements.
(3) The following apply to
CCO examinations:
(a) When OHA determines that
an examination should be conducted, OHA shall appoint one or more examiners to perform
the examination and instruct them as to the scope of the examination. In conducting
the examination, each examiner shall consider the guidelines and procedures in the
examiner handbook, or its successor publication, adopted by the NAIC. OHA may prescribe
the examiner handbook or its successor publication and employ other guidelines and
procedures that OHA determines to be appropriate, taking into account whether the
CCO is an OHA reporting CCO, is a DCBS reporting CCO, or has a certificate of authority;
(b) When making an examination,
OHA may retain appraisers, independent actuaries, independent certified public accountants
or other professionals and specialists as needed. The cost of retaining such professionals
and specialists shall be borne by the CCO that is the subject of the examination;
(c) At any time during the
course of an examination, OHA may take other action pursuant to these rules;
(d) Facts determined and
conclusions made pursuant to an examination shall be presumptive evidence of the
relevant facts and conclusions in any judicial or administrative action;
(e) Upon an examination or
investigation OHA may examine under oath all persons who may have material information
regarding the property or business of the person being examined or investigated;
(f) Every person being examined
or investigated shall produce all books, records, accounts, papers, documents and
computer and other recordings in its possession or control relating to the matter
under examination or investigation, including, in the case of an examination, the
property, assets, business and affairs of the person; and
(g) The officers, directors
and agents of the person being examined shall provide timely, convenient and free
access at all reasonable hours at the offices of the person being examined to all
books, records, accounts, papers, documents and computer and other recordings. The
officers, directors, employees and agents of the person must facilitate the examination.
(4) The following apply to
the Authority’s report following the examination:
(a) Not later than the 60th
day after completion of an examination, the examiner in charge of the examination
shall submit to OHA a full and true report of the examination, verified by the oath
of the examiner. The report shall comprise only facts appearing upon the books,
papers, records, accounts, documents or computer and other recordings of the person,
its agents or other persons being examined or facts ascertained from testimony of
individuals concerning the affairs of such person, together with such conclusions
and recommendations as reasonably may be warranted from such facts;
(b) OHA shall make a copy
of the report submitted under this section available to the person who is the subject
of the examination and shall give the person an opportunity to review and comment
on the report. OHA may request additional information or meet with the person for
the purpose of resolving questions or obtaining additional information, and may
direct the examiner to consider the additional information for inclusion in the
report;
(c) Before OHA files the
examination report as a final examination report or makes the report or any matters
relating thereto public, the person being examined shall have an opportunity for
a hearing. A copy of the report must be mailed by certified mail to the person being
examined. The person may request a hearing not later than the 30th day after the
date on which the report was mailed. This subsection does not limit the authority
of OHA to disclose a preliminary or final examination report as otherwise provided
in this section, or to CMS or other federal or state authorities authorized to obtain
access to CCO financial records in accordance with the CCO contract;
(d) OHA shall consider comments
presented at a hearing requested under paragraph (c) of this section and may direct
the examiner to consider the comments or direct that the comments be included in
documentation relating to the report, although not as part of the report itself.
OHA may file the report as a final examination report at any time after consideration
of the comments or at any time after the period for requesting a hearing has passed
if a hearing is not requested;
(e) A report filed as a final
examination report is subject to public inspection. OHA, after filing any report,
if OHA considers it for the interest of the public to do so, may publish any report
or the result of any examination as contained therein in one or more newspapers
of the state without expense to the person examined; and
(f) OHA may disclose the
content of an examination report that has not yet otherwise been disclosed or may
disclose any of the materials described in this section as provided in OAR 410-141-3390.
(5) No cause of action may
arise and no liability may be imposed against OHA or DCBS, an authorized representative
of OHA or DCBS or any examiner appointed by OHA or DCBS for any statements made
or conduct performed in good faith pursuant to an examination or investigation.
No cause of action may arise and no liability may be imposed against any person
for communicating or delivering information or data to OHA or an authorized representative
of OHA or examiner pursuant to an examination or investigation if the communication
or delivery was performed in good faith and without fraudulent intent or intent
to deceive.
(6) Section (5) does not
abrogate or modify in any way any common law or statutory privilege or immunity
otherwise enjoyed by any person to which this subsection applies.
(7) Any CCO or applicant
for CCO certification examined under this rule shall pay to OHA the just and legitimate
costs of the examination as determined by OHA, including actual necessary transportation
and traveling expenses.
(8) In addition to other
powers of OHA under these rules relating to the examination and investigation of
CCOs, OHA may also order any CCO to produce such books, records, accounts, papers,
documents and computer and other recordings in the possession of the CCO or its
affiliates as are necessary to ascertain the financial condition of the CCO or to
determine compliance with these rules. If the CCO fails to comply with such an order,
OHA may examine the affiliates to obtain such information, in addition to imposing
sanctions or other remedies under these OHA rules or the CCO contract. A CCO shall
pay the costs of an examination of the CCO.
Stat. Auth.: ORS 414.032, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
– 414.685, 2011 OL Ch. 602 Sec. 13, 14, 16, 17, 62, 64(2) & 65 & HB
3650
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12
410-141-3375
Hazardous
Operations
(1)
For purposes of this rule, the CCO will be held financially responsible in the context
of the financial standards applicable to the reporting method described in OAR 410-141-3345.
An OHA reporting CCO is accountable under the standards in the CCO contract and
this rule. A DCBS reporting CCO or a CCO with a certificate of authority is accountable
under the DCBS standards:
(a)
Based upon standards established by these rules, if OHA determines that the continued
operation of a CCO is hazardous to its members or to the public in general, OHA
may order the CCO to take one or more of the following actions:
(A)
Reduce the total amount of present and potential liability for policy benefits by
reinsurance;
(B)
Reduce, suspend or limit the volume of business being accepted or renewed;
(C)
Reduce general insurance and commission expenses by methods specified by OHA;
(D)
Increase the capital and surplus of the CCO;
(E)
Suspend or limit the declaration and payment of dividends by the CCO to its stockholders
or members;
(F)
Limit or withdraw from certain investments or discontinue certain investment practices
to the extent OHA determines such action to be necessary.
(b)
OHA may exercise authority under Subsection (a) of this section in addition to or
instead of any other authority that OHA may exercise under these rules;
(c)
OHA may issue an order with or without a hearing. A CCO subject to an order issued
without a hearing may file a written request for a hearing to review the order.
Such a request shall not stay the effect of the order. The hearing shall be held
within 30 days after the filing of the request. OHA shall complete the review within
30 days after the record for the hearing is closed, and shall discontinue the action
taken if OHA determines that none of the conditions giving rise to the action exists.
(2)
OHA may consider the following standards, either singly or in combination of two
or more, to determine whether the continued operation of any CCO might be determined
to be hazardous to the CCO’s members, its creditors or the general public:
(a)
Adverse findings reported in financial condition examination reports, audit reports,
and actuarial opinions, reports or summaries;
(b)
Whether the CCO has made adequate provision, according to presently accepted actuarial
standards of practice, for the anticipated cash flows required by the contractual
obligations and related expenses of the CCO, when considered in light of the assets
held by the CCO with respect to such reserves and related actuarial items including
but not limited the investment earnings on such assets, and the considerations anticipated
to be received and retained under such contracts;
(c)
The ability of an assuming reinsurer to perform and whether the CCO's reinsurance
program provides sufficient protection for the CCO's remaining capital and surplus
after taking into account the CCO's cash flow and the classes of business written
as well as the financial condition of the assuming reinsurer;
(d)
Whether the CCO's operating loss in the last 12-month period or any shorter period
of time is greater than 50 percent of the CCO's remaining capital and surplus in
excess of the minimum required;
(e)
Whether the CCO’s operating loss in the last 12-month period or any shorter
period of time, excluding net capital gains, is greater than 20 percent of the CCO’s
remaining surplus in excess of the minimum required;
(f)
Whether a reinsurer or obligor, or any entity within the CCO’s system is insolvent,
threatened with insolvency or delinquent in payment of its monetary or other obligations
and which, in the opinion of OHA may affect the solvency of the CCO;
(g)
Contingent liabilities, pledges or guaranties that either individually or collectively
involves a total amount that in the opinion of OHA may affect the solvency of the
CCO;
(h)
Whether any "controlling person" of a CCO is delinquent in the transmitting to,
or payment of, net premiums to the CCO;
(i)
The age and collectability of receivables;
(j)
Whether the management of a CCO, including officers, directors or any other person
who directly or indirectly controls the operation of the CCO, fails to possess and
demonstrate the competence, fitness and reputation determined by OHA to be necessary
to serve the CCO in such position;
(k)
Whether management of a CCO has failed to respond to inquiries relating to the condition
of the CCO or has furnished false and misleading information concerning an inquiry;
(l)
Whether the CCO has failed to meet financial responsibility, accountability or filing
requirements in the absence of a reason satisfactory to OHA;
(m)
Whether management of a CCO either has filed a false or misleading sworn financial
statement or has released a false or misleading financial statement to lending institutions
or to the general public, or has made a false or misleading entry, or has omitted
an entry of material amount in the books of the CCO;
(n)
Whether the CCO has grown so rapidly and to such an extent that it lacks adequate
financial and administrative capacity to meet its obligations in a timely manner;
(o)
Whether the CCO has experienced or will experience in the foreseeable future cash
flow or liquidity problems, or both;
(p)
Whether management has established reserves that do not comply with minimum standards
established by the CCO contract or regulations, accounting standards, sound actuarial
principles and standards of practice;
(q)
Whether management persistently engages in material under reserving that results
in adverse development;
(r)
Whether transactions among affiliates, subsidiaries or controlling persons for which
the CCO receives assets or capital gains, or both, do not provide sufficient value,
liquidity or diversity to assure the CCO’s ability to meet its outstanding
obligations as they mature; and
(s)
Any other finding determined by OHA to be hazardous to the CCO’s members,
creditors or general public.
(3)
For the purposes of making a determination of the financial condition of a CCO under
these rules or the CCO contract, OHA may do one or more of the following:
(a)
Disregard any credit or amount receivable resulting from transactions with a reinsurer
that is insolvent, impaired or otherwise subject to a delinquency proceeding;
(b)
Make appropriate adjustments to asset values attributable to investments in or transactions
with parents, subsidiaries or affiliates;
(c)
Refuse to recognize the stated value of accounts receivable if the ability to collect
receivables is highly speculative in view of the age of the account or the financial
condition of the debtor; or
(d)
Increase the CCO's liability in an amount equal to any contingent liability, pledge,
or guarantee not otherwise included if there is a substantial risk that the CCO
will be called upon to meet the obligation undertaken within the next 12-month period.
(4)
In addition to the requirements OHA may impose, if OHA determines that the continued
operation of the CCO may be hazardous to OHA, the members or the general public,
OHA may require the CCO to:
(a)
File reports in a form acceptable to OHA concerning the market value of the CCO’s
assets;
(b)
In addition to regular annual statements, file interim financial reports on the
form specified by OHA;
(c)
Correct corporate governance practice deficiencies, and adopt and utilize the governance
practices acceptable to OHA; or
(d)
Provide a business plan to OHA demonstrating corrective action the CCO will take
to improve its financial condition.
(5)
No CCO shall reduce its combined capital and surplus by partial distribution of
its assets, by payment in the form of a dividend to stockholders or otherwise, below:
(a)
Its required capitalization; or
(b)
A greater amount which OHA, by rule or by order after hearing upon the motion of
OHA or the petition of any interested person, finds necessary to avoid injury or
prejudice to the interest of OHA, members or creditors.
(6)
Whenever OHA determines from any showing or statement made to OHA or from any examination
made by OHA that the assets of a CCO are less than its liabilities plus required
capitalization, OHA may proceed immediately to terminate the CCO contract and revoke
or suspend its certification as a CCO, or OHA may allow the CCO a period of time,
not to exceed 90 days, in which to make correct the amount of the impairment with
cash or authorized investments. If the amount of any such impairment is not corrected
within the time prescribed by OHA, OHA shall proceed immediately to terminate the
CCO contract and revoke or suspend its certification as a CCO.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3380
Disallowance
of Transactions — DCBS Reporting CCOs Only
(1)The
provisions of OAR 410-141-3380 apply only to DCBS reporting CCOs, and do not apply
to OHA reporting CCOs.
(2)
OHA shall disallow as an asset or as a credit against liabilities any reinsurance
found by OHA after a hearing thereon to have been arranged for the purpose principally
of deception as to the ceding CCO’s financial condition as of the date of
any financial statement of the CCO. Without limiting the general purport of the
foregoing provision, reinsurance of any substantial part of the CCO’s outstanding
risks contracted for in fact within four months prior to the date of any such financial
statement and canceled in fact within four months after the date of such statement,
or reinsurance under which the reinsurer bears no substantial insurance risk or
substantial risk of net loss to itself, shall prima facie be deemed to have been
arranged for the purpose principally of deception.
(3)
OHA shall disallow as an asset any deposit, funds or other assets of the CCO found
by OHA after a hearing thereon:
(a)
Not to be in good faith the property of the CCO;
(b)
Not freely subject to withdrawal or liquidation by the CCO at any time for the payment
or discharge of claims or other obligations arising under its policies; and
(c)
To be resulting from arrangements made principally for the purpose of deception
as to the CCO’s financial condition as of the date of any financial statement
of the CCO.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3385
Holding
Company
(1)
As used in this rule, “Holding Company System” as it applies to a CCO
means two or more affiliated persons, one or more of which is a CCO, and includes
a financial holding company as referred to in section 103 of the federal Gramm-Leach-Bliley
Act (P.L. 106-102). Such CCO shall also be subject to OAR 836-027-0001 through 836-027-0050
to the extent those rules relate to the filing of a registration statement (Form
B filing).
(2)
Every CCO that is a member of a holding company system shall be subject to ORS 732.551
to 732.572, except ORS 732.554.
(3)
A transaction within a holding company system to which a CCO subject to registration
is a party is subject to the following standards:
(a)
The terms must be fair and reasonable;
(b)
Charges or fees for services performed must be reasonable;
(c)
Expenses incurred and payment received must be allocated to the CCO in conformity
with customary insurance accounting practices consistently applied;
(d)
The books, accounts and records of each party to the transaction must be so maintained
as to disclose clearly and accurately the nature and details of the transaction,
including accounting information necessary to support the reasonableness of the
charges or fees to the respective parties; and
(e)
The combined capital and surplus of the CCO following any transaction with an affiliate
or any shareholder dividend must be reasonable in relation to the CCO’s outstanding
liabilities and adequate to its financial needs.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3390
Transparency
(1)
Pursuant to ORS 414.018, interactions between OHA or DCBS and CCOs shall be done
in a transparent and public manner. Without limitation of the preceding sentence,
OHA or DCBS shall publicly disclose all information pertaining to CCOs of a character
that DCBS publicly discloses pertaining to CCOs that are licensed health entities.
(2)
Certain documents pertaining to a CCO’s financial condition may be considered
confidential, when so described in these rules. financial analysis solvency tools
and analytical reports developed by the NAIC, and comparable reports developed or
used by DCBS or OHA, are confidential. In addition, any work papers, recorded information,
documents and copies thereof that are produced or obtained by or disclosed to OHA
or DCBS, or any other person in the course of an examination or in the course of
analysis by OHA or DCBS of the financial condition or market conduct of a CCO may
be considered confidential, if the CCO specifically designates the confidential
portions and cites an exemption from public disclosure under the Oregon Public Records
Law, ORS 192.410 to 192.505. If OHA, in its sole discretion, determines that the
cited exemption does not apply or disclosure is necessary to protect the public
interest, OHA may make available work papers, recorded information, documents and
copies thereof produced by, obtained by or disclosed to OHA or any other person
in the course of the examination.
(3)
The OHA or DCBS may use a confidential document, material or other information in
administering these rules and in furthering a regulatory or legal action brought
as a part of the OHA’s duties. In order to assist in the performance of OHA’s
duties, OHA may:
(a)
Authorize sharing a confidential document, material or other information as appropriate
among the administrative divisions and staff offices of the OHA or DCBS for the
purpose of administering and enforcing the statutes within the authority of OHA,
in order to enable the administrative divisions and staff offices to carry out their
functions and responsibilities;
(b)
Share a document, material or other information, including a confidential document,
material or other information that is subject to this rule or that is otherwise
exempt from disclosure under ORS 192.501 or ORS 192.502, with other state, federal,
foreign and international regulatory and law enforcement agencies and with the NAIC
and affiliates or subsidiaries of the NAIC, if the recipient agrees to maintain
the confidentiality of the document, material or other information; and
(c)
Receive a document, material or other information, including an otherwise confidential
document, material or other information, from state, federal, foreign and international
regulatory and law enforcement agencies and from the NAIC and affiliates or subsidiaries
of the NAIC. As provided in this section, the OHA shall maintain the confidentiality
of documents, materials or other information received upon notice or with an understanding
that the document, material or other information is confidential or privileged under
the laws of the jurisdiction that is the source of the document, material or other
information.
(4)
Disclosing a document, material or other information to the OHA, sharing a document,
material or other information does not waive an applicable privilege or claim of
confidentiality in the document, material or other information.
(5)
OHA may release a final, adjudicated action, including a suspension or revocation
of a CCO’s certification, if the action is otherwise open to public inspection,
to a database or other clearinghouse service maintained by the NAIC or affiliates
or subsidiaries of the NAIC.
(6)
All information, documents and copies thereof obtained by or disclosed to OHA, DCBS
or any other person in the course of an examination or investigation made pursuant
to OAR 410-141-3365 are subject to the provisions of ORS 731.312.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685
Hist.:
DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. &
cert. ef. 8-1-12
410-141-3395
Member
Protection Provisions
(1) In the event of a finding of impairment
by OHA or of a termination of certification as a CCO or of the CCO contract, members
of the CCO shall be offered disenrollment from the CCO and enrollment in accordance
with OHA rule.
(2) For the purpose of this
section only, and only in the event of a finding of impairment by OHA or of a termination
of certification or of the CCO contract, any covered health care service furnished
within the state by a provider to a member of a CCO shall be considered to have
been furnished pursuant to a contract between the provider and the CCO with whom
the member was enrolled when the services were furnished.
(3) Each contract between
a CCO and a provider of health services shall provide that if the CCO fails to pay
for covered health services as set forth in the contract, the member is not liable
to the provider for any amounts owed by the CCO.
(4) If the contract between
the contracting provider and the CCO has not been reduced to writing or fails to
contain the provisions required by this rule, the member is not liable to the contracting
provider for any amounts owed by the CCO.
(5) No contracting provider
or agent, trustee or assignee of the contracting provider shall bill a member, send
a member’s bill to a Collection Agency, or maintain a civil action against
a member to collect any amounts owed by the CCO for which the member is not liable
to the contracting provider in this rule and under 410-120-1280.
(6) Nothing in this section
impairs the right of a provider to charge, collect from, and attempt to collect
from or maintain a civil action against a member for any of the following:
(a) Deductible, copayment
or coinsurance amounts;
(b) Health services not covered
by the CCO, if a valid DMAP 3165, or facsimile, signed by the client, has been completed
as described in OAR 410-120-1280; or
(c) Health services rendered
after the termination of the contract between the CCO and the provider, unless the
health services were rendered during the confinement in an inpatient facility and
the confinement began prior to the date of termination or unless the provider has
assumed post-termination treatment obligations under the contract. Before providing
a non-covered service, the provider must complete a DMAP 3165, or facsimile, as
described in OAR 410-120-1280.
Stat. Auth.: ORS 413.042, 414.615, 414.625,
414.635 & 414.651
Stats. Implemented: ORS 414.610
- 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 60-2013, f. & cert. ef. 10-31-13
410-141-3420
Billing
and Payment
(1) Providers shall submit all billings
for CCO members in the following timeframes:
(a) Submit billings within
12 months of the date of service in the following cases:
(A) Pregnancy;
(B) Eligibility issues such
as retroactive deletions or retroactive enrollments;
(C) Medicare is the primary
payer, except where the CCO is responsible for the Medicare reimbursement;
(D) Other cases that could
have delayed the initial billing to the CCO, which does not include failure of the
provider to certify the member's eligibility; or
(E) Third Party Liability
(TPL). Pursuant to 42 CFR 136.61, subpart G: Indian Health Services and the amended
Public Law 93-638 under the Memorandum of Agreement that Indian Health Service and
638 Tribal Facilities are the payers of last resort and are not considered an alternative
liability or TPL.
(b) Submit bills within four
months of the date of service for all other cases.
(2) Providers shall be enrolled
with the Division to be eligible for fee-for-service (FFS) payments. Mental health
providers, except Federally Qualified Health Centers (FQHC), shall be approved by
the Local Mental Health Authority (LMHA) and the Authority’s Addictions and
Mental Health (AMH) division before enrollment with the Authority or to be eligible
for CCO payment for services. Providers may be retroactively enrolled in accordance
with OAR 410-120-1260 (Provider Enrollment).
(3) Providers, including
mental health providers, shall be enrolled with the Authority as a Medicaid provider
or an encounter-only provider prior to submission of encounter data to ensure the
encounter is accepted.
(4) Providers shall verify,
before providing services, that the member is eligible for coordinated care services
on the date of service. Providers shall use the Authority’s tools and the
CCO’s tools, as applicable, to determine if the service to be provided is
covered under the member’s OHP benefit package. Providers shall also identify
the party responsible for covering the intended service and seek preauthorizations
from the appropriate payer before providing services. Before providing a non-covered
service, the provider shall complete a DMAP 3165, or facsimile, signed by the client,
as described in OAR 141-120-1280.
(5) CCOs shall pay for all
covered coordinated care services. These services shall be billed directly to the
CCO, unless the CCO or the Authority specifies otherwise. CCOs may require providers
to obtain preauthorization to deliver certain coordinated care services.
(6) Payment by the CCO to
participating providers for coordinated care services is a matter between the CCO
and the participating provider except as follows:
(a) CCOs shall have written
procedures for processing preauthorization requests received from any provider and
written procedures for processing claims submitted from any source. The procedures
shall specify time frames for:
(A) Date stamping preauthorization
requests and claims when received;
(B) Determining within a
specific number of days from receipt whether a preauthorization request or a claim
is valid or non-valid;
(C) The specific number of
days allowed for follow-up on pended preauthorization requests or pended claims
to obtain additional information;
(D)The specific number of
days following receipt of the additional information that a redetermination shall
be made;
(E) Providing services after
office hours and on weekends that require preauthorization;
(F) Sending notice of the
decision with appeal rights to the member when the determination is a denial of
the requested service as specified in OAR 410-141-3263.
(b) CCOs shall make a determination
on at least 95 percent of valid preauthorization requests within two working days
of receipt of a preauthorization or reauthorization request related to urgent services,
alcohol and drug services, or care required while in a skilled nursing facility.
Preauthorization for prescription drugs shall be completed and the pharmacy notified
within 24 hours. If a preauthorization for a prescription cannot be completed within
the 24 hours, the CCO shall provide for the dispensing of at least a 72-hour supply
if there is an immediate medical need for the drug. CCOs shall notify providers
of the determination within two working days of receipt of the request;
(c) For expedited prior authorization
requests in which the provider indicates or the CCO determines that following the
standard timeframe could seriously jeopardize the member’s life or health
or ability to attain, maintain, or regain maximum function:
(A) The CCO shall make an
expedited authorization decision and provide notice as expeditiously as the member’s
health or mental health condition requires and no later than three working days
after receipt of the request for service;
(B) The CCO may extend the
three working day time period no more than 14 calendar days if the member requests
an extension or if the CCO justifies to the Authority a need for additional information
and how the extension is in the member’s best interest.
(d) For all other preauthorization
requests, CCOs shall notify providers of an approval, a denial, or the need for
further information within 14 calendar days of receipt of the request as outlined
in OAR 410-141-3263. CCOs shall make reasonable efforts to obtain the necessary
information during the 14-day period. However, the CCO may use an additional 14
days to obtain follow-up information if the CCO justifies to the Authority, upon
request, the need for additional information and how the delay is in the member’s
best interest. If the CCO extends the timeframe, it shall give the member written
notice of the reason for the extension as outlined in 410-141-3263. The CCO shall
make a determination as the member’s health or mental health condition requires,
but no later than the expiration of the extension;
(e) CCOs shall pay or deny
at least 90 percent of valid claims within 45 calendar days of receipt and at least
99 percent of valid claims within 60 calendars days of receipt. CCOs shall make
an initial determination on 99 percent of all claims submitted within 60 calendar
days of receipt;
(f) CCOs shall provide written
notification of CCO determinations when the determinations result in a denial of
payment for services as outlined in OAR 410-141-3263;
(g) CCOs may not require
providers to delay billing to the CCO;
(h) CCOs may not require
Medicare be billed as the primary insurer for services or items not covered by Medicare
or require non-Medicare approved providers to bill Medicare;
(i) CCOs may not deny payment
of valid claims when the potential TPR is based only on a diagnosis, and no potential
TPR has been documented in the member's clinical record;
(j) CCOs may not delay or
deny payments because a co-payment was not collected at the time of service.
(7) CCOs shall pay for Medicare
coinsurances and deductibles up to the Medicare or CCOs allowable for covered services
the member receives within the CCO for authorized referral care and urgent care
services or emergency services the member receives from non-participating providers.
CCOs may not pay for Medicare coinsurances and deductibles for non-urgent or non-emergent
care members receive from non-participating providers.
(8) CCOs shall pay transportation,
meals, and lodging costs for the member and any required attendant for services
that the CCO has arranged and authorized when those services are not available within
the state, unless otherwise approved by the Authority.
(9) CCOs shall pay for covered
services provided by a non-participating provider that was not preauthorized if
the following conditions exist:
(a) It can be verified that
the participating provider ordered or directed the covered services to be delivered
by a non-participating provider; and
(b) The covered service was
delivered in good faith without the preauthorization; and
(c) It was a covered service
that would have been preauthorized with a participating provider if the CCO's referral
procedures had been followed;
(d) The CCO shall pay non-participating
providers (providers enrolled with the Authority that do not have a contract with
the CCO) for covered services that are subject to reimbursement from the CCO in
the amount specified in OAR 410-120-1295. This rule does not apply to providers
that are Type A or Type B hospitals;
(e) CCOs shall reimburse
hospitals for services provided on or after January 1, 2012, using Medicare Severity
DRG for inpatient services and Ambulatory Payment Classification (APC) for outpatient
services or other alternative payment methods that incorporate the most recent Medicare
payment methodologies for both inpatient and outpatient services established by
CMS for hospital services and alternative payment methodologies, including but not
limited to pay-for-performance, bundled payments, and capitation. An alternative
payment methodology does not include reimbursement payment based on percentage of
billed charges. This requirement does not apply to Type A or Type B hospitals as
referenced in ORS 442.470. CCOs shall attest annually to the Authority in a manner
to be prescribed to CCO’s compliance with these requirements.
(10) For Type A or Type B
hospitals transitioning from Cost-Based Reimbursement (CBR) to an Alternative Payment
Methodology (APM):
(a) Sections (10)–(12)
only apply to services provided by Type A or Type B hospitals to clients or members
that are enrolled in a CCO;
(b) In accordance with ORS
414.653, the Authority may upon evaluation by an actuary retained by the Authority,
on a case-by-case basis, require CCOs to continue to reimburse fully a rural Type
A or Type B hospital determined to be at financial risk for the cost of covered
services based on a cost-to-charge ratio;
(c) For those Type A or Type
B hospitals transitioning from CBR to an APM, the Authority shall require hospitals
and CCO’s to enter into good faith negotiations for contracts to be effective
by January 1, 2015. Dispute resolution during the contracting process shall be subject
to OAR 410-141-3268 and 410-141-3269, as applicable;
(d) For monitoring purposes,
CCOs shall submit to the Authority no later than November 30 of each year a list
of those hospitals with which they have contracted for these purposes.
(11) Redetermination of which
Type A or Type B hospitals shall transition off of CBR:
(a) No later than April 30,
2015, the Authority shall update the algorithm for calculation of the CBR methodology
with the most recent data available;
(b) After recalculation for
each Type A and Type B hospital, any changes in a hospital’s status from CBR
to APM or from APM to CBR shall be effective January 1, 2016;
(c) The Authority shall recalculate
the reimbursement methodology for each hospital every two years thereafter;
(d) Type A and Type B hospitals
located in a county that is designated as “Frontier” will not be subject
to redetermination via the algorithm and shall remain on CBR.
(12) Non-contracted Type
A or Type B hospital rates for those transitioning off of CBR:
(a) Charges shall be discounted
for both inpatient and outpatient services. The initial reimbursement rate effective
January 1, 2015 shall be based on the individual hospital’s most recently
filed Medicare cost report adjusted to reflect the hospital’s Medicaid/OHP
mix of services;
(b) Reimbursement rates effective
for the calendar year beginning January 1, 2016 shall be based on the hospital’s
most recently filed Medicare cost report adjusted to reflect the hospital’s
Medicaid/OHP mix of services and further adjusted by the Actuarial Services Unit
(ASU) based on the individual hospital’s annual price increases during FY
2014 – FY 2015 and the Authority’s global budget rate increase as defined
by the CMS 1115 waiver, using the following formula: Current Reimbursement Rate
x (1+Global Budget Increase) / (1+Hospital Price Increase);
(c) Subsequent year reimbursement
rates shall be adjusted and calculated by the Actuarial Services Unit (ASU) based
on the individual hospital’s annual price increase and the Authority’s
global budget rate increase as defined by the CMS 1115 waiver, using the following
formula: Current Reimbursement Rate x (1+Global Budget Increase) / (1+Hospital Price
Increase);
(d) ASU shall contact hospitals
regarding price increases during March of each year;
(e) Inpatient and outpatient
reimbursement rates shall be calculated separately;
(f) A volume adjustment shall
be applied. ASU shall develop a risk corridor on the volume adjustment on a hospital
specific basis. The Authority shall determine when the volume adjustment might sunset
on a hospital specific basis;
(g) Non-contracted Type A
or Type B hospital reimbursement rates for those transitioning off of CBR can be
found in the Rate Table section at the following: http://www.oregon.gov/oha/healthplan/Pages/hospital.aspx.
(13) Members may receive
certain services on a Fee-for-Service (FFS) basis:
(a) Certain services shall
be authorized by the CCO or the Community Mental Health Program (CMHP) for some
mental health services, even though the services are then paid by the Authority
on a FFS basis. Before providing services, providers shall verify a member’s
eligibility using the web portal or AVR;
(b) Services authorized by
the CCO or CMHP are subject to the Authority’s administrative rules and supplemental
information including rates and billing instructions;
(c) Providers shall bill
the Authority directly for FFS services in accordance with billing instructions
contained in the Authority administrative rules and supplemental information;
(d) The Authority shall pay
at the Medicaid FFS rate in effect on the date the service is provided subject to
the Authority’s administrative rules , contracts, and billing instructions;
(e) The Authority may not
pay a provider for providing services for which a CCO has received a CCO payment
unless otherwise provided for in rule;
(f) When an item or service
is included in the rate paid to a medical institution, a residential facility, or
foster home, provision of that item or service is not the responsibility of the
Authority or a CCO except as provided in Authority administrative rules and supplemental
information (e.g., coordinated care services that are not included in the nursing
facility all-inclusive rate);
(g) CCOs that contract with
FQHCs and RHCs shall negotiate a rate of reimbursement that is not less than the
level and amount of payment that the CCO would pay for the same service furnished
by a provider who is not an FQHC nor RHC, consistent with the requirements of BBA
4712(b)(2).
(14) Coverage of services
through the OHP benefit package of covered services is limited by OAR 410-141-0500
(Excluded Services and Limitations for OHP Clients).
Stat. Auth.: ORS 413.042, 414.065, 414.615,
414.625, 414.635 & 414.651
Stats. Implemented: ORS 414.065
& 414.610 - 414.685
Hist.: DMAP 16-2012(Temp),
f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12;
DMAP 38-2013(Temp), f. 7-8-13, cert. ef. 7-9-13 thru 1-5-14; DMAP 60-2013, f. &
cert. ef. 10-31-13; DMAP 65-2013, f. & cert. ef. 11-29-13; DMAP 34-2014(Temp),
f. 6-25-14, cert. ef. 7-1-14 thru 12-27-14; DMAP 66-2014(Temp), f. 11-13-14, cert.
ef. 12-28-14 thru 6-25-15; DMAP 71-2014, f. 12-8-14, cert. ef. 1-1-15
410-141-3430
Coordinated
Care Organization Encounter Claims Data Reporting
(1) CCOs must meet
the data content and submission standards as required by HIPAA 45 CFR Part 162,
the Authority’s electronic data transaction rules (OAR 943-120-0100 through
943-120-0200), the Division’s 837 technical specifications for encounter data
and the Division’s encounter data submission guidelines which are subject
to periodic revisions and available on the Authority’s web site.
(2) CCOs
must collect service information in standardized formats to the extent feasible
and appropriate, if HIPAA standard, the CCO must utilize the HIPAA standards.
(a) CCOs
shall submit encounter claims for all services, whether they are flexible services
or covered services, provided to members as defined in OAR 410-120-0000 and 410-141-0000.
(b) CCOs
shall submit encounter claims data including encounters for services where the CCO
determined that:
(A) Liability
exists;
(B) No liability
exists even if the CCO did not make any payment for a claim;
(C) Including
claims for services to members provided by a provider under a subcontract, capitation
or special arrangement with another facility or program; and
(D) Including
paid amounts regardless of whether the servicing provider is paid on a fee for service
basis, on a capitated basis by the CCO, or the CCO’s subcontractor.
(c) CCOs
shall submit encounter claims data for all services to members who also have Medicare
coverage, if a claim has been submitted to the CCO.
(d) CCOs
shall report encounter claims data whether the provider is an in network participating
or out of network, non-participating, provider;
(3) CCOs
must follow the DCBS standards for electronic data exchange as described in the
Oregon Companion Guides available on the DCBS website.
(4) CCOs
must submit encounter claims in the time frames as described below for the following
claim types:
(a) Non-pharmacy
encounter claims; professional, dental, and institutional;
(A) CCOs
must submit encounter claims at least once per month for no less than 50% of all
claim types received and adjudicated that month;
(B) CCOs
must submit all remaining unreported encounter claims for services received and
adjudicated within 180 days of the date of service except as may be applicable in
paragraph (C) below;
(C) CCOs
may only delay submission of encounter claims within 180 days from the date of service
with prior notification to the Authority and only for any of the following reasons:
(i) Member's
failure to give the provider necessary claim information;
(ii) Resolving
local or out-of-area provider claims;
(iii) Third-Party
Resource liability or Medicare coordination;
(iv) Member’’s
pregnancy;
(v) Hardware
or software modifications to CCO’s health information system, or;
(vi) Authority
recognized system issues preventing timely submission or correction of encounter
claims data.
(b) Pharmacy
claims:
(A) CCOs
must ensure all pharmacy encounter claims data meet the data content standards as
required by the National Council for Prescription Drug Programs (NCPDP), as available
on their web site http://www.ncpdp.org/ or by contacting the National Council for
Prescription Drug Programs organization;
(B) All pharmacy
encounter claims data must be submitted by the CCO, whether by the CCO’s pharmacy
benefit manager or the CCO’s subcontractor at least once a month for all services
received and adjudicated that month and must submit all remaining unreported CCO
pharmacy encounter claims within 60 days from the date of service.
(c) Submission
Standards and Data Availability:
(A) CCOs
must only use the two types of provider identifiers, as allowed by HIPAA NPI standards
45 CFR 160.103 and as provided to the CCO by the Authority in encounter claims;
(i) The National
Provider Identifiers (NPI) for a provider covered entity enrolled with the Authority;
or
(ii) The
Oregon Medicaid proprietary provider numbers for the Authority enrolled non-covered
atypical provider entities.
(B) CCOs
must make an adjustment to any encounter claim when the CCO discovers the data is
incorrect, no longer valid or some element of the claim not identified as part of
the original claim needs to be changed;
(C) If the
Authority discovers errors or a conflict with a previously adjudicated encounter
claim except as specified in paragraph (E) below, the CCO must adjust or void the
encounter claim within 14 calendar days of notification by the Authority of the
required action or as identified in paragraph (E) below;
(D) If the
Authority discovers errors with a previously adjudicated encounter claim resulting
from a federal or State mandate or request that requires the completeness and accuracy
of the encounter data, the CCO must correct the errors within a time frame specified
by the Authority ;
(E) If circumstances
prevent the CCO from meeting requested time frames for correction the CCO may contact
the Authority to determine an agreed upon specified date except as required in subsection
(d) below;
(F) CCOs
must ensure claims data received from providers, either directly or through a third
party submitter, is accurate, truthful and complete by:
(i) Verifying
accuracy and timeliness of reported data;
(ii) Screening
data for completeness, logic, and consistency;
(iii) Submitting
a complete and accurate Encounter Data Certification and Validation Report available
on the Authority’s website; and
(H) CCOs
must make all collected and reported data available upon request to the Authority
and CMS as described in 42 CFR 438.242.
(d) Encounter
Claims Data Corrections for “must correct” Encounter Claims:
(A) The Authority
shall notify the CCO of the status of all encounter claims processed;
(B) Notification
of all encounter claims processed that are in a “must correct” status
shall be provided by the Authority to the CCO each week and for each subsequent
week the encounter claim remains in a “must correct” status;
(C) The Authority
may not necessarily notify the CCO of other errors however this information is available
in the CCO’s electronic remittance advice supplied by the Authority;
(D) CCOs
shall submit corrections to all encounter claims within 63 days from the date the
Authority sends the CCO notice that the encounter claim remains in a “must
correct” status.
(E) CCOs
may not delete encounter claims with a “must correct” status as specified
in section (3)(d) except when the Authority has determined the encounter claim cannot
be corrected or for other reasons;
(5) Enrollment
of providers included on an encounter claim.
(a) CCOs
shall ensure that all providers are enrolled with the Authority prior to submission
of the encounter claim as either;
(A) An Oregon
Medicaid fee for service provider or
(B) A provider
that is not a fee for service provider but does provide services to the CCO’s
enrolled members, and
(C) CCOs
must ensure the provider is not excluded per federal and state standards as set
forth in OAR 943-120-0100 through 943-120-0200 and as specified in 42 CFR 455.400
through 455.400.
(6) Electronic
Health Records (EHR) Systems OAR 410-165-0000 to 410-165-0140. In support of an
eligible provider’s ability to demonstrate meaningful use as an EHR user,
as described by 42 CFR 495.4 and 42 CFR 495.8, the CCO must:
(a) Submit
encounter data in support of a qualified EHR user’s meaningful use data report
to the Authority for validation as set forth in OAR 410-165-0080;
(b) CCOs
must respond within the time frame determined by the Authority to any request for:
(A) Any suspected
missing CCO encounter claims, or;
(B) CCO submitted
encounter claims found to be unmatched to an EHR user’s meaningful use report.
(7) CCOs
must comply with the following hysterectomy and sterilization standards as described
in 42 CFR 441.250 to 441.259 and the requirements of OAR 410-130-0580:
(a) CCOs
shall submit a signed informed consent form to the Authority for each member that
received either a hysterectomy or sterilization service within 30 days of the date
of service or
(b) Immediately
upon notification by the Authority that a qualifying encounter claim has been identified;
(c) The Authority,
in collaboration and cooperation, with the CCO shall reconcile all hysterectomy
or sterilization services with informed consents with the associated encounter claims
by either:
(A) Confirming
the validity of the consent and notifying the CCO that no further action is needed;
(B) Requesting
a corrected informed consent form, or;
(C) Informing
the CCO the informed consent is missing or invalid and the payment must be recouped
and the associated encounter claim must be changed to reflect no payment made for
services within the time frame set by the Authority.
(8) Upon
request by the Authority, CCOs must furnish information regarding rebates for any
covered outpatient drug provided by the CCO, as follows:
(a) The Authority
is eligible for the rebates authorized under Section 1927 of the Social Security
Act (42 USC 1396r-8), as amended by section 2501 of the Patient Protection and Affordable
Care Act (P.L. 111-148) and section 1206 of the Health Care and Education Reconciliation
Act of 2010 (P.L. 111-152), for any covered outpatient drug provided by the CCO,
unless the drug is subject to discounts under Section 340B of the Public Health
Service Act;
(b) CCOs
shall report prescription drug data as specified in section (3)(b).
(9) Encounter
Pharmacy Data Rebate Dispute Resolution as governed by SSA Section 1927 42 U.S.C.
1396r-8 and as required by OAR 410-121-0000 through 410-121-0625. When the Authority
receives an Invoiced Rebate Dispute from a drug manufacturer, the Authority shall
send the Invoiced Rebate Dispute to the CCO for review and resolution within 15
calendar days of receipt.
(a) The CCO
shall assist in the dispute process as follows:
(A) By notifying
the Authority that the CCO agrees an error has been made, and
(B) By correcting
and re-submitting the pharmacy encounter data to the Authority within 45 calendar
days of receipt of the Invoiced Rebate Dispute; or
(b) If the
CCO disagrees with the Invoiced Rebate Dispute that an error has been made, the
CCO shall send the details of the disagreement to the Authority’s encounter
data liaison within 45 calendar days of receipt of the Invoiced Rebate Dispute.
Stat.
Auth.: ORS 413.042, 414.615, 414.625, 414.635, 414.651
Stats.
Implemented: ORS 414.610 – 414.685

Hist.: DMAP
39-2012(Temp), f. & cert. ef. 8-9-12 thru 2-5-13; DMAP 52-2012, f. & cert.
ef. 11-1-12
410-141-3435
NEMT General Requirements
(1) A Coordinated Care Organization
shall provide all NEMT services for its members. The Authority shall provide NEMT
services in CCO’s service area only to members not enrolled in a CCO.
(2) A CCO shall provide a
toll-free call center for members to request rides.
(3) A CCO and its contracted
transportation provider may not bill a member for any transport to and from medical
services that are covered and where the CCO or its contracted transportation provider
denied reimbursement.
(4) CCOs shall require NEMT
providers to obtain and maintain insurance at limits no less than is required under
OAR 410-136-3060.
(5) Transportation providers
shall be considered “participating providers” for the purposes of OAR
410-141-3180 (Record Keeping and Use of Health Information Technology).
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3440
Vehicle Equipment and Driver Standards
(1) This rule does not apply to ambulance
providers, ambulance vehicles, or ambulance personnel that are licensed and regulated
by ORS Chapter 682 and OAR chapter 333, divisions 250, 255, 260 and 265, whether
providing ambulance or stretcher transports.
(2) The CCO shall require
all vehicles used for NEMT services to meet the following requirements for the comfort
and safety of the members:
(a) The interior of the vehicle
shall be clean and free from any debris impeding a member’s ability to ride
comfortably;
(b) Smoking is prohibited
in the vehicle at all times in accordance with ORS 433.835 to 433.990 and OAR 333-015-0025
to 333-015-0090; and
(c) The transportation provider
shall comply with appropriate local, state, and federal transportation safety standards
regarding passenger safety and comfort. The vehicle shall include, but is not limited
to, the following safety equipment:
(A) Safety belts for all
passengers if the vehicle is legally required to provide safety belts;
(B) First aid kit;
(C) Fire extinguisher;
(D) Roadside reflective or
warning devices;
(E) Flashlight;
(F) Tire traction devices
when appropriate;
(G) Disposable gloves; and
(H) All equipment necessary
to transport members using wheelchairs or stretchers, if the member is using a wheelchair
or stretcher.
(3) A preventative maintenance
schedule shall be followed for each vehicle that incorporates at least all of the
maintenance recommended by the vehicle manufacturer. The vehicle must be in good
operating condition and shall include, but is not limited to, the following equipment:
(a) Side and rear view mirrors;
(b) Horn; and
(c) Working turn signals,
headlights, taillights, and windshield wipers.
(4) Prior to hiring an NEMT
driver, the CCO shall require the following:
(a) The driver must have
a valid driver license. The license must be the class of license with any required
endorsements that permits the driver to legally operate the vehicle for which they
are hired to drive pursuant to ORS chapter 807 and OAR chapter 735, division 062,
or the applicable statutes of other states; and
(b) The driver must pass
a criminal background check in accordance with ORS 181.534, 181.537, and OAR chapter
257, division 10. If the driver is employed by a mass transit district formed under
ORS Chapter 267, the driver must pass a criminal background check in accordance
with ORS 267.237 as well as the mass transit district’s background check policies.
A CCO shall have an exception process to the criminal background check requirement
that may allow approval of a driver with a criminal background under certain circumstances.
The exception process must include review and consideration of when the crime occurred,
the nature of the offense, and any other circumstances to ensure that the member
is not at risk of harm from the driver. Any approvals made through the exception
process must be documented and maintained for three calendar years, even if the
CCO is no longer a Medicaid enrolled provider before the end of the three years.
The Authority may request this information at any time during the three year retention
period.
(5) Drivers authorized to
provide NEMT services must receive training on their job duties and responsibilities
including:
(a) Understanding NEMT services
in general, reporting forms, vehicle operation, requirements for fraud and abuse
reporting, and the geographic area in which drivers will provide service;
(b) Completing the National
Safety Council Defensive Driving course or equivalent within six months of the date
of hire and at least every three years thereafter;
(c) Completing Red Cross-approved
First Aid, Cardiopulmonary Resuscitation and blood spill procedures courses or equivalent
within six months of the date of hire and maintain the certification;
(d) Completing the Passenger
Service and Safety course or equivalent course within six months of the date of
hire and at least every three years thereafter; and
(e) Understanding the CCO’s
established procedures for responding to a member’s needs for emergency care
should they arise during the ride.
(6) For authorized out-of-state
NEMT services in which the transportation provider solely performs work in the other
state and for which the CCO has no oversight authority, the CCO is not responsible
for requiring that the subcontractor’s vehicle and standards meet the requirements
set forth in this rule.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3445
Out-of-Service-Area and Out-of-State Transportation
(1) A CCO shall provide NEMT services
outside the CCO’s service area under the following circumstances:
(a) The member is receiving
an OHP-covered health care service that is not available in the service area but
is available in another area of the state;
(b) The member is receiving
an OHP-covered service where the service location is no more than 75 miles from
the Oregon border and contiguous to the CCO’s service area;
(c) The CCO determines that
no local medical provider or facility as outlined in OAR 410-141-3220 will provide
OHP-covered medical services for the member; or,
(d) The member is receiving
an OHP-covered service outside of Oregon that is not available in Oregon.
(2) Nothing in this rule
prohibits a CCO from providing and paying for NEMT services to allow a client to
access other services the CCO authorizes.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3450
Attendants for Child and Special Needs
Transports
(1) This rule applies to NEMT for children
under 12 years of age who are eligible for NEMT services to and from OHP-covered
medical services. The rule also applies to children and young adults with special
physical or developmental needs regardless of age.
(2) Parents or guardians
must provide an attendant to accompany these members while traveling to and from
medical appointments except when:
(a) The driver is a Department
of Human Services (Department) volunteer or employee or an Authority employee;
(b) The member requires secured
transport pursuant to OAR 410-141-3437 (Secured Transports); or
(c) An ambulance provider
transports the member for non-emergent services, and the CCO reimburses the ambulance
provider at the ambulance transport rate, per CCO contract or non-contracted rate
policy.
(3) NEMT ambulance transports
shall have an attendant when the CCO uses an ambulance to provide wheelchair or
stretcher car or van rides.
(4) The Department shall
establish and administer written guidelines for members in the Department’s
custody including written guidelines for volunteer drivers. If the Department’s
requirements or administrative rules differ from this rule, the Department’s
requirements or administrative rules take precedence.
(5) An attendant may be the
member’s mother, father, stepmother, stepfather, grandparent, or guardian.
The attendant may also be any adult the parent or guardian authorizes. An attendant
may also be the member’s brother, sister, stepbrother, or stepsister if the
attendant is at least 18 years of age, and the parent or guardian authorizes it.
(6) CCOs may require the
member’s parent or guardian to provide written authorization for an attendant
other than the parent or guardian to accompany the member.
(7) The CCO may not bill
additional charges for a member’s attendant.
(8) The attendant must accompany
the member from the pick-up location to the destination and the return trip. The
attendant must also remain with the member during their appointment.
(9) The member’s parent,
guardian, or adult caregiver shall provide and install safety seats as required
by ORS 811.210–811.225. An NEMT driver may not transport a member if a parent
or guardian fails to provide a safety seat that complies with state law.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3455
Secured Transports
(1) “Secured transport”
means NEMT services for the involuntary transport of members who are in danger of
harming themselves or others. Secured transports may be used when:
(a) The CCO verified that
the secured transporter has met the requirements of the secured transport protocol
pursuant to OAR 309-033-0200 through 309-033-0970, and the secured transporter is
able to transport the member who is in crisis or at immediate risk of harming themselves
or others due to mental or emotional problems or substance abuse; and
(b) The transport is to a
Medicaid enrolled facility that the Authority recognizes as being able to treat
the immediate medical or behavioral health care needs of the member in crisis.
(2) One additional attendant
may accompany the member at no additional charge when medically appropriate, such
as to administer medications in-route or to satisfy legal requirements including,
but not limited to, when a parent, legal guardian, or escort is required during
transport.
(3) The CCO shall authorize
transports to and from OHP covered medical services for an eligible member for court
ordered medical services with the following exceptions:
(a) The member is in the
custody of or under the legal jurisdiction of any law enforcement agency;
(b) The member is an inmate
of a public institution as defined in OAR 461-135-0950 (Eligibility for Inmates);
or
(c) The Authority has suspended
the member’s OHP eligibility pursuant to ORS 411.443 or 411.439.
(4) The CCO shall assume
that a member returning to their place of residence is no longer in crisis or at
immediate risk of harming themselves or others, and is, therefore, able to use non-secured
transportation. In the event that a secured transport is medically appropriate to
return a member to their place of residence, the CCO shall obtain written documentation
signed by the treating medical professional stating the circumstances that required
secured transport. The CCO shall retain the documentation and a copy of the order
in their record for the Authority to review.
(5) The CCO may approve and
pay for secured medical transport provided to a person going to or from a court
hearing or to or from a commitment hearing if there is no other source of funding
for this transport.
(6) This rule does not apply
to ambulance providers, ambulance vehicles, or ambulance personnel that are licensed
and regulated by ORS chapter 682 and OAR chapter 333, divisions 250, 255, 260 and
265, whether providing ambulance or stretcher transports.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3460
Ground and Air Ambulance Transports
(1) Transporting a member via ambulance
is required when a medical facility or provider states the member’s medical
condition requires the presence of a health care professional during the emergency
or non-emergency transport. This includes neonatal transports.
(2) For NEMT services, the
CCOs shall authorize the transport.
(3) CCOs shall provide ambulance
transports with a medical technician when:
(a) A member’s medical
condition requires a stretcher;
(b) The length of transport
would require a personal care attendant; and
(c) The member does not have
an attendant who can assist with personal care during the ride.
(4) When a member’s
medical condition is an emergency as defined in OAR 410-120-0000, emergency ambulance
transportation must be used. The ambulance must transport the member to the nearest
appropriate facility able to meet the member's medical needs.
(5) CCOs shall verify that
the Authority has licensed providers of ground or air ambulance services to operate
ground or air ambulances. If the ambulance service provider is located in a contiguous
state and regularly provides rides to OHP members, the CCO must ensure that both
the Authority and the contiguous state have licensed the ambulance service provider.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3465
Modifications for Individuals with Disabilities
(1) For the purposes of this rule, “direct
threat” means a significant risk to the health or safety of others. A direct
threat is one that:
(a) Cannot be eliminated
or reduced to an acceptable level through the provision of auxiliary aids and services
or through reasonably modifying policies, practices, or processes.
(b) Is identified through
an individual assessment that relies on current medical evidence or the best available
objective evidence that shows:
(A) The nature, duration,
and severity of the risk;
(B) The probability that
a potential injury will actually occur; and
(C) Whether reasonable modification
of policies, practices, or processes will lower or eliminate the risk.
(2) CCO’s may not apply
criteria, standards, or practices that screen out or tend to screen out individuals
in a protected class from fully and equally enjoying any goods, services, programs,
or activities unless:
(a) The criteria can be shown
to be necessary for providing those goods and services; or
(b) The CCO determines the
screening or exclusion identifies a direct threat to the health and safety of others.
(3) CCOs and their subcontractors
shall comply with the Authority’s non-discrimination and modification rules
found at OAR 943-005-0000 to 943-005-0070.
(4) CCO members may use the
processes and rights specified in OAR 410-141-3260 through 3264 (Grievance System
and Contested Case Hearings Rules).
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3470
Service Modifications
(1) CCOs shall draft policies and procedures
describing passenger rights and responsibilities including the right to file a complaint
and request reconsideration and provide this information in all general information
materials such as handbooks.
(2) CCOs shall draft policies
and procedures that ensure the safety of all passengers in NEMT vehicles and provide
the information to contractors, subcontractors, and members receiving NEMT services.
(3) A CCO may modify or a
member may request modification of NEMT services when the member:
(a) Threatens harm to the
driver or others in the vehicle.
(b) Has a health condition
that creates a health or safety concern to the driver, others in the vehicle, or
the member as described in OAR 410-141-3439.
(c) Engages in behaviors
or circumstances that place the driver or others in the vehicle at risk of harm.
(d) Engages in behavior that,
in the CCO’s judgment, causes local medical providers or facilities to refuse
to provide further services without modifying NEMT services.
(e) Frequently does not show
up for scheduled rides.
(f) Frequently cancels the
ride on the day of the scheduled ride time.
(4) Reasonable modifications
include, but are not limited to, requiring members to:
(a) Use a specific transportation
provider;
(b) Travel with an attendant;
(c) Use public transportation
where available;
(d) Drive or locate someone
to drive the member and receive mileage reimbursement;
(e) Confirm the ride with
the NEMT provider on the day of or the day before the scheduled ride.
(5) Before modifying services,
the NEMT provider, a CCO representative, and the member shall:
(a) Communicate about the
reason for imposing a modification;
(b) Explore options that
are appropriate to the member’s needs;
(c) Address health and safety
concerns;
(d) The CCO or member may
include the member’s care team in the discussion;
(e) The member may include
another individual of their choosing in the discussion.
(6) Responses to requests
for modification or auxiliary aids based on disability or other protected class
status under state or federal rule or law must comply with the Americans with Disabilities
Act and all other applicable state and federal laws and rules.
(7) A CCO may not modify
NEMT services under this rule due solely to a request for modification or auxiliary
aid based on disability or other protected class status.
(8) A CCO may not modify
NEMT services to result in a denial of NEMT services to a member.
(9) A CCO shall make all
reasonable efforts to offer an appropriate alternative to meet a member’s
needs under the circumstances.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3475
Contested Case Hearings
As required by 42 CFR 431, the CCO shall
comply with OAR 410-141-3264 pertaining to contested case hearings when it denies
a ride with the following exceptions:
(1) Prior to mailing a notice
of action to a member, the CCO must provide a secondary review by another employee
when the initial screener denies a ride.
(2) The CCO shall mail a
notice of action to a member denied a ride within 72 hours of denial.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3480
Member Reimbursed Mileage, Meals, and Lodging
(1) A CCO may prior authorize a member’s
mileage, meals, and lodging to covered medical service in order for the member to
qualify for reimbursement.
(2) A CCO may disallow a
client reimbursement request received more than 45 days after the travel.
(3) A CCO shall reimburse
a member for mileage, meals, and lodging at rates not less than the Authority’s
allowable rates. See the Division’s fee schedule, available at: http://www.oregon.gov/oha/healthplan/pages/feeschedule.aspx.
(4) The member must return
any documentation a CCO requires before receiving reimbursement.
(5) A CCO may hold reimbursements
under the amount of $10 until the member’s reimbursement reaches $10.
(6) A CCO shall reimburse
members for meals when a member travels:
(a) Out of their local area
as outlined in OAR 410-141-3220(4)(a) and (b); and
(b) For a minimum of four
hours round-trip.
(7) A CCO’s brokerage
or other transportation subcontractor shall reimburse members for lodging when:
(a) A member would otherwise
be required to begin travel before 5 a.m. in order to reach a scheduled appointment;
(b) Travel from a scheduled
appointment would end after 9 p.m.; or
(c) The member’s health
care provider documents a medical need.
(8) A CCO may reimburse members
for lodging under additional circumstances at the CCO’s discretion.
(9) A CCO shall reimburse
for meals or lodging for one attendant, which may be a parent, to accompany the
member if medically necessary, if:
(a) The member is a minor
child and unable to travel without an attendant;
(b) The member's attending
physician provides a signed statement indicating the reason an attendant must travel
with the member;
(c) The member is mentally
or physically unable to reach his or her medical appointment without assistance;
or
(d) The member is or would
be unable to return home without assistance after the treatment or service.
(10) A CCO may reimburse
members for meals or lodging for additional attendants or under additional circumstances
at the CCOs discretion.
(11) A CCO may recover overpayments
made to a member. Overpayments occur when a CCO’s brokerage or other transportation
subcontractor paid the member:
(a) For mileage, meals, and
lodging, and another resource also paid:
(A) The member; or
(B) The ride, meal, or lodging
provider directly;
(b) Directly to travel to
medical appointments, and the member did not use the money for that purpose, did
not attend the appointment, or shared the ride with another member whom the brokerage
also paid directly;
(c) For common carrier or
public transportation tickets or passes, and the member sold or otherwise transferred
the tickets or passes to another individual.
(12) If an individual or
entity other than the member or the minor member’s parent or guardian provides
the ride, a CCO’s brokerage or other transportation subcontractor may reimburse
the individual or entity that provided the ride.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
410-141-3485
Reports and Documentation
(1) CCOs shall maintain documentation
of rides denied and rides provided to members.
(2) For NEMT services provided
to members, this documentation shall include:
(a) All encounter data required
in the current CCO contract;
(b) Names of the company
and driver transporting the member.
(3) For NEMT services denied
to members, this documentation shall include:
(a) The name of the member
and the individual requesting the ride on behalf of the member, if applicable;
(b) The member's OHP medical
care identification number;
(c) The date and time of
the request for transportation;
(d) The name of the employee
who denied a ride;
(e) The name of the employee
who performed the secondary review before denying the ride;
(f) The reason for the denial
and the applicable OAR supporting the denial;
(g) The date on the notice
of action the brokerage mailed to the member;
(h) Documentation on the
review, resolution, or disposition of the matter, if applicable, including the reason
for the decision and the date of the resolution or disposition; and
(i) Notations of oral and
written communications with the member.
(4) The CCO shall retain
the documentation on NEMT service denials for three calendar years, even if the
CCO, its brokerage, or subcontractor that denied the service is no longer a Medicaid
enrolled provider before the end of the three years. The Authority may request this
information at any time during the three year retention period.
(5) The Authority may request
and the CCO shall provide other reports or information not specified in sections
(1-4) of this rule.
Stat. Auth.: ORS 413.042 & 414.625
Stats. Implemented: ORS 414.625
Hist.: DMAP 40-2014, f. &
cert. ef. 7-1-14
JUMP BACK TO OARs 410-141-0000 through 410-141-0860

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