410-141-3870 Care Coordination: Service Coordination (1) Coordinated Care Organizations (CCOs) must ensure all services accessed by members are coordinated according to the needs of members, following the requirements in OAR 410-141-3860, OAR 410-141-3865 and in this rule. (2) Upon enrollment, CCOs must act promptly to ensure services are coordinated for members needing Urgent Care Services or Emergency Services as defined in OAR 410-120-0000, even if the Member has not yet selected a Primary Care Provider (PCP) or completed a Health Risk Assessment (HRA). (3) CCOs must formally designate a position or team as primarily responsible to coordinate individual services accessed by the Member and must provide information to the Member on how to contact their designated person or team initially and when the designated position or team changes. (4) CCOs shall utilize a Care Profile for all members as defined in OAR 410-141-3500. The Member Care Profile must identify: (a) The Member’s identifying demographic information; (b) The Member’s communication preferences and needs (e.g. preferred language, method of communication, Alternate Formats, Auxiliary Aids and Services); (c) The Member's care team, along with their contact information, role, and any assigned Care Coordination responsibilities. This must include, but is not limited to; (A) The persons or teams formally designated by the CCO as primarily responsible for coordinating the services accessed by the Member; (B) All providers serving the Member, including, at minimum, their Primary Care Provider; and (C) The identified individuals from all entities serving the member, such as those listed in 410-141-3860(2). (d) A summary of the Member’s needs; and (e) The Member’s preferences, when available, to the extent the Member desires to participate; and (f) The Member’s health risk score and risk level, as described in OAR 410-141-3860; (g) Any open or closed Care Plans; and (h) An overview of the supports, services, activities, and resources that have been or shall be deployed to meet the Member’s identified needs. (5) CCOs must ensure services are actively coordinated for members when requested by the Member, their representative or guardian, an involved provider or entity, or when required by the Member’s needs and risk level as identified in the Member’s Care Profile. This coordination is accomplished through the development and implementation of a Care Plan that scales in complexity relative to the needs, goals, preferences, and circumstances of the Member. (a) CCOs shall consider the Member’s identified risk level to determine if a Care Plan is required. (A) Members in the no- or low-risk levels do not require a Care Plan unless the Member’s needs change resulting in a higher risk level or when the Member requests it; (B) Members within the moderate-risk and high-risk levels, or who require Long Term Service and Supports (LTSS) must have a Care Plan developed. (C) For Members identified as moderate or high risk who decline participation in Care Plan development, CCOs shall ensure Care Plans at minimum document: (i) The Member’s physical, developmental, behavioral, oral and social needs (including Health Related Social Needs and Social Determinants of Health and Equity), when available; and (ii) The services and activities the CCO have or will deploy to focus on mitigation of the Member’s identified risks and level; and (iii) The outreach attempts and opportunities for engagement the CCO continues to provide to the Member; and (iv) The reason the Member has declined or is otherwise unable to participate in the development of their Care Plan. (D) For Members receiving Long Term Services and Supports (LTSS), the CCO shall have access to or integrate any service or Care Plans developed by entities listed in OAR 410-141-3865(6) into the Member’s Care Profile or Care Plan. (b) The Care Plan is developed or revised as required in (5)(d) of this rule and in alignment with: (A) The Member’s identified needs and risk level; and (B) With identification of the Member’s goals and preferences, when available, to the extent the Member desires or is able to participate; and (C) By incorporating information from any relevant assessments, treatment and service plans from providers or community partners involved in the Member’s care, to the maximum extent feasible; (D) In consultation with any other provider, case manager, or entity providing services to, or coordinating care for, the Member; (E) In consultation with a clinician that has the appropriate clinical qualifications and expertise to review and revise the Care Plan considering the Member’s complex physical, developmental, behavioral or oral health care needs including clinical subjectivity; (F) In accordance with a Member’s updated risk level as described in (4)(f) of this rule; (G) With the Member, their representative or guardian’s participation to the extent they desire or are able to participate. The Member, their representative or guardian shall be satisfied with and understand the Care Plan, including any of their own roles and responsibilities. (i) If participation in creating a Member’s Care Plan may be significantly detrimental to the Member’s care or health, the Member, the Member’s caregiver, or the Member’s family may be excluded from the development of a Care Plan; (ii) The CCO must document the reasons for the exclusion, including a specific description of the risk or potential harm to the Member, and describe what attempts were made to address the concern(s); and (iii) This decision must be reviewed prior to each significant Care Plan update resulting from a health-related circumstance change as set forth in OAR 410-141-3865(3)(g). The decision to continue the exclusion shall be documented. (H) In accordance with state quality assurance and utilization review standards, as applicable. (c) After development of the Care Plan, CCOs must make it promptly available to the Member, the Member’s representative or guardian and to all relevant providers rendering services to the Member who shall coordinate and provide services according to it: (A) The Member, the Member’s representative or guardian must be provided immediate electronic access, or a copy in the Member’s preferred method of communication and in the Member’s preferred language. Auxiliary Aids and Services and Alternate Formats must be made available upon request of the member at no cost within five (5) business days of the request. (B) If the CCO requires Care Plans to be approved, approval must be timely, according to a Member’s needs; and (C) If providing the Member with a copy of or access to their full Care Plan may be significantly detrimental to their care or health, as determined by the Member’s care team, CCOs may withhold from the Member, only those parts of the plan that are determined to be detrimental. The CCO must: (i) document the reasons for withholding the full or partial Care Plan, including a specific description of the risk or potential harm to the Member, and describe what attempts were made to address the concern(s); and (ii) This decision to withhold the Care Plan in full or in part must be reviewed prior to each Care Plan update, and the decision to continue withholding the Care Plan in full or in part shall be documented. (d) Open Care Plans must be reviewed and revised at least annually, or (A) When a Member, Member representative or guardian, or any provider serving the Member requests a review or revision; or (B) Upon a change in health-related circumstances as described in OAR 410-141-3865(3)(g). (e) The Care Plan may be closed and the Member shall continue with Care Profile tracking when; (A) No longer warranted by the Member’s risk level or circumstances; or (B) Requested by the Member, their representative or guardian when the member no longer desires to participate; or (C) There is no contact with the Member, their representative or guardian after a minimum of three (3) attempts of outreach, utilizing at least two (2) mixed modalities (e.g., paper, digital or verbal) including the Member’s preferred method of communication and language, over a sixty (60) day period and with consultation and agreement of all available care team Members. (D) If the associated risk level of a Member remains a moderate, high or LTSS and the Member no longer wishes to participate the CCO must close the Care Plan and transition to a CCO directed Care Plan as outlined in (5)(a)(B) and (5)(a)(C) of this rule. (6) CCOs shall ensure Care Coordination for all members, regardless of where the Member is receiving services. (a) If members experience a Care Setting Transition CCOs must ensure: (A) Members are transitioned into the most appropriate independent and integrated community settings and provided follow-up services as medically necessary and appropriate prior to discharge to facilitate successful handoff to community providers; (B) Appropriate discharge planning and Care Coordination for adults who were Members upon entering the Oregon State Hospital (OSH) and who shall return to their home CCO upon discharge from the Oregon State Hospital; (C) Care Coordination and discharge planning for out of service area placements, for which an exception shall be made to allow the Member to retain Home CCO enrollment while the Member’s placement is a Temporary Residential Placement as defined in OAR 410-141-3500, or elsewhere in accordance with OAR 410-141-3815. CCOs shall, prior to discharge, coordinate care in accordance with a Member’s discharge plan. (b) Coordinate and authorize care when it has been deemed medically appropriate and medically necessary to receive services outside of the service area because a provider specialty is not otherwise contracted with the CCO; (c) Coordinate the Member’s care when they are temporarily outside their enrolled service area; (d) If members are transitioning between CCOs or to or from fee-for-service (FFS) as set forth in OAR 410-141-3850; (e) Post Hospital Extended Care must be provided in accordance with OAR 411-070-0033: (A) Post Hospital Extended Care (PHEC) is a benefit of up to one hundred (100) days included within the Global Budget and the CCO shall pay for the full one hundred (100) day PHEC benefit when the full one hundred (100) days is required by the discharging provider. CCOs shall make the benefit available to non-Medicare Members who meet Medicare criteria for a post-Hospital Skilled Nursing Facility placement. (B) CCOs shall notify the Member’s local ODHS APD office prior to the Member being admitted to PHEC. Upon receipt of such notice, CCO and the Member’s APD office must promptly begin appropriate discharge planning. (C) CCOs shall notify the Member and the PHEC facility of the proposed discharge date from such PHEC facility no less than two (2) full days prior to discharge. (D) CCOs shall ensure that all of a Member’s post-discharge services and care needs are in place prior to discharge from the PHEC, including but not limited to Durable Medical Equipment (DME), medications, home and Community based services, discharge education or home care instructions, scheduling follow-up care appointments, and provide follow-up care instructions that include reminders to: (i) attend already-scheduled appointments with Providers for any necessary follow-up care appointments the Member may need; or (ii) schedule follow-up care appointments with Providers that the Member may need to see; (iii) or both (i) and (ii). (E) CCOs shall provide the PHEC benefit according to the criteria established by Medicare, as cited in the Medicare Coverage of Skilled Nursing Facility Care available by calling 1-800-MEDICARE or at www.medicare.gov/publications (F) CCOs are not responsible for the PHEC benefit unless the Member was enrolled with the CCO at the time of the hospitalization preceding the PHEC facility placement. (7) In addition to the care planning requirements above, for LTSS or Special Health Care Needs Members as defined in OAR 410-120-0000 that are assessed according to OAR 410-141-3865(5) to have an ongoing special condition that requires a course of treatment or regular care monitoring or identified as high risk: (a) CCOs must consider the above members, according to their needs, during Interdisciplinary Team Meetings which are convened and facilitated as needed according to the Member’s Care Plan, including a post-transition meeting of the interdisciplinary team within fourteen (14) days of a transition between levels, settings or episodes of care. These meetings must: (A) Include the Member, their representative or guardian, unless the Member declines or the Member’s participation is determined to be significantly detrimental to the Member’s health, in accordance with (5)(b)(G) of this rule; (B) Invite and consider relevant information from all providers and other entities serving the Member including but not limited to those listed in OAR 410-141-3860(2); and (C) Provide a forum to: (i) Describe the clinical interventions recommended to the treatment team and identify the frequency of necessary Interdisciplinary Team Meetings appropriate to meet the Care Plan needs; (ii) Create a space for the Member to provide feedback on their care, self-reported progress towards their Care Plan goals, and their strengths exhibited in between current and prior meeting; (iii) Identify coordination gaps and strategies to improve Care Coordination with the Member’s service providers; (iv) Develop strategies to identify, address, monitor and follow up on needed referrals for specialty care, routine health care services (including medication monitoring), other community programs or social need services; and (v) Align and update the Member’s individual Care Plan and share the plan in accordance with (5)(c) of this rule. (b) CCOs must implement a mechanism to provide direct access to specialists, e.g., a standing referral or an approved number of visits, as appropriate for the Member’s condition and identified needs. Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605 Statutes/Other Implemented: ORS 414.570 - 414.686 History: DMAP 94-2025, amend filed 12/22/2025, effective 01/01/2026 DMAP 140-2024, amend filed 12/06/2024, effective 01/01/2025 DMAP 83-2024, minor correction filed 04/01/2024, effective 04/01/2024 DMAP 37-2024, amend filed 01/25/2024, effective 02/01/2024 DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022 DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021 DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020 DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020