justicedao/ipfs_state_laws huggingface dataset:
111-080-0045 Eligibility Violations (1) Unintentional Violation: (A) OEBB will remove from coverage an ineligible OEBB member due to eligibility or enrollment violations. Removal from all benefit plans will be retroactive to the date the individual is determined to have no longer been eligible, or the effective date of coverage if eligibility criteria was never met unless in conflict with federal healthcare reform. (B) When an eligibility or enrollment violation has been discovered and investigated, OEBB will notify the member and the Educational Entity with the outcome. If the outcome includes rescission of coverage, OEBB will give a 30 day notice of such rescission prior to terminating coverage retroactively to the date the member was no longer eligible for benefits. (C) The member may be responsible for any claims paid during the period of time the member was enrolled inappropriately. (2) Intentional Violation: (A) The ineligible member shall be removed from coverage by OEBB. The ineligible member’s coverage will be retroactively terminated to the date the individual is determined to have no longer been eligible, or the effective date of coverage if eligibility criteria was never met. (B) OEBB may terminate the eligible employee along with remaining dependents from all plans excluding basic and mandatory plans selected by the educational entity. This will be a prospective termination lasting for a period of 12 months. The prospective termination will be effective the first day of the following month that the Intentional Violation was discovered. Statutory/Other Authority: ORS 243.860 – 243.886 Statutes/Other Implemented: ORS 243.864(1)(a) History: OEBB 12-2011, f. & cert. ef. 6-22-11 OEBB 8-2011(Temp), f. & cert. ef. 2-15-11 thru 8-13-11 OEBB 16-2010, f. & cert. ef. 12-10-10
111-080-0050 Policy Term Violations (1) An OEBB-contracted insurance carrier may remove from coverage and/or deny the claims of an OEBB member due to policy term violations. Removal from coverage for policy term violations is at the discretion of the insurance carrier. (A) If a policy term violation results in a termination from the plan or carrier that the violation was committed, it will not prevent the member from continuing enrollment in other OEBB types of coverages (e.g., medical, dental, vision, life, etc.), as long as they remain an employee and eligible for these benefits. (B) If an eligible employee commits a policy term violation and loses coverage, OEBB will remove the entire family from the insurance plan since the benefits are extended to his or her dependents through the eligible employee. If the eligible employee chooses to, and it is offered, they can enroll in a different carrier plan (if applicable) during open enrollment and cover themselves and dependents during the upcoming plan year. (C) If a dependent commits a policy term violation, OEBB will remove only the dependent from the insurance plan. If the eligible employee chooses to and it is offered, they can enroll in a different carrier plan (if applicable) during open enrollment and cover the dependent during the upcoming plan year, or as defined by the carrier. (D) The OEBB member who is removed from an OEBB sponsored insurance plan may appeal the decision through the carrier that terminated coverage. (E) When a policy term violation has been discovered and investigated, the applicable insurance carrier will notify OEBB and the member with the outcome. (2) The insurance carrier may do the following when a member has violated a provision of the policy the OEBB member has enrolled in, committed fraudulent activity or misrepresentation: (A) The insurance carrier may retain the value of any expenditure it made related to the member who committed the fraudulent activity or misrepresentation. (B) The insurance carrier may deny future enrollments of the individual in accordance with the carrier’s policies. Statutory/Other Authority: ORS 243.860 - 243.886 Statutes/Other Implemented: ORS 243.864(1)(a) History: OEBB 12-2011, f. & cert. ef. 6-22-11 OEBB 8-2011(Temp), f. & cert. ef. 2-15-11 thru 8-13-11 OEBB 16-2010, f. & cert. ef. 12-10-10
111-080-0055 Eligibility Verifications and Reviews (1) OEBB shall plan and conduct eligibility verifications and reviews to monitor compliance with OEBB administrative rules. Reviews shall include, but are not be limited to the following: (a) Dependent eligibility; (b) Employee eligibility; (c) Election change limitations; and (c) Plan enrollment limitations. (2)(a) Employee eligibility, election change and plan enrollment reviews may occur on a random basis throughout the year, or if anomalies in data warrant a formal review. (b) The Eligible Employee and Entity are responsible to submit documentation upon request. (3) Dependent eligibility verifications shall be completed at least once every five years per Entity. (a) Entities may have a formal dependent eligibility verification and review completed by a third party vendor on or after October 1, 2013. The use of a third party vendor for a dependent eligibility verification and review may meet the once every five years requirement provided the vendor meets the standards and criteria set in the OEBB verification and review plan and agrees to report all findings via a secure electronic file. All requests to substitute a third party vendor for this purpose must be pre-approved by OEBB. (b) The Eligible Employee, Eligible Early Retiree or COBRA participant is responsible to submit documentation upon request. In the event the required documentation is not provided to sufficiently prove the dependent meets eligibility requirements, or the documentation provided is insufficient, the dependent’s coverage will be terminated. Retroactive terminations may occur if the documentation provided shows the dependent was not eligible for coverage and the member misrepresented the dependent as being an eligible dependent as defined by OAR 111-080-0045. (4) If an Eligible Employee does not complete the dependent eligibility review and moves to a different Entity under OEBB, their terminated dependent records will be locked in the MyOEBB benefit management system. The Eligible Employee must submit documentation to OEBB to be verified before the dependent records are unlocked. Statutory/Other Authority: ORS 243.860 - 243.886 Statutes/Other Implemented: ORS 243.864(1)(a) History: OEBB 9-2017, amend filed 11/07/2017, effective 11/07/2017 OEBB 18-2013, f. & cert. ef. 10-23-13 OEBB 9-2013(Temp), f. & cert. ef. 7-12-13 thru 1-7-14
111-080-0060 Dependent Eligibility Verifications and Review Appeals (1) Following the termination of dependents due to a dependent eligibility verification review, Eligible Employees, Eligible Early Retirees, or COBRA participants may file an appeal and submit requested documentation within 60 days from the date coverage ended. If approved, coverage will be reinstated retroactively with no lapse in coverage. (2) For Eligible Employees, if the appeal and submitted requested documentation is received by OEBB after 60 days from the date the coverage ended, and dependents are verified, OEBB will unlock the dependent records in the MyOEBB benefit management system. Coverage can be added back following and consistent with a Qualified Status Change (QSC) during the current plan year, or during the next open enrollment period. Adding a dependent to dental or vision coverage at open enrollment will result in the 12 month waiting period being applied where only preventive and routine services will be covered for the first 12 months of coverage. (3) For Eligible Early Retirees, if the appeal and submitted documentation is received by OEBB after 60 days from the date the coverage ended, and dependents are verified, OEBB will unlock the dependent records in the MyOEBB benefit management system. Coverage can be added back following and consistent with a Qualified Status Change (QSC) during the current plan year, or during the next open enrollment to the plans that they were previously enrolled in. Statutory/Other Authority: ORS 243.860 to 243.886 Statutes/Other Implemented: ORS 243.864(1)(a) History: OEBB 9-2017, adopt filed 11/07/2017, effective 11/07/2017
111-080-0070 Exempt Hospitals (1) As specified in ORS 243.879, these payment limits do not apply to reimbursements paid by a carrier or third-party administrator to: (a) Type A or type B hospitals (defined in ORS 442.470); (b) Rural critical access hospitals (defined in ORS 315.613); or (c) Hospitals that are located in a county with a population of less than 70,000 on August 15, 2017, classified as a sole community hospital by the Centers for Medicare and Medicaid Services, and have Medicare payments composing at least 40 percent of the hospital’s total annual patient revenue. (2)(a) Total annual patient revenue for a hospital will be calculated using the Allowed Amount for all inpatient and outpatient claim records in the state’s All Payer All Claims (APAC) database for that hospital in a calendar year, and (b) Total Medicare payments to a hospital will be calculated using the Allowed Amount for all inpatient and outpatient claim records paid by Medicare in the APAC for that hospital in a calendar year. (3) OEBB will review the calculation under section (2) of this rule at least every three years using the most recent available data in APAC. Statutory/Other Authority: ORS 243.860 to 243.886 Statutes/Other Implemented: ORS 243.879 & ORS 243.864(1)(a) History: OEBB 6-2020, amend filed 12/22/2020, effective 12/22/2020 OEBB 2-2019, adopt filed 10/21/2019, effective 10/22/2019
114-001-0000 Notice to Interested Persons Except as permitted by ORS 183.335(5), prior to adoption, amendment, or repeal of any rule, the Long Term Care Ombudsman shall give notice of the intended action: (1) In the Secretary of State’s Bulletin referred to in ORS 183.360 at least 15 days prior to the effective date. (2) By mailing a copy of the notice to persons on the Long Term Care Ombudsman’s mailing list established pursuant to ORS 183.33 (7). (3) By mailing a copy of the notice to the following persons, organizations, or publications: (a) United Press International; (b) The Associated Press; (c) Capitol Press Room; (d) Oregon Registered Care Providers; (e) Long-Term Care Ombudsman Screening Committees; (f) Oregon Association of Health Care; (g) Oregon Association of Homes for the Aging; (h) Oregon Area Agencies on Aging; (i) Governor’s Commission on Senior Services; (j) Senior Services Division; (k) United Seniors; (l) Oregon State Council; (m) Oregon Citizens for Better Nursing Care; (n) American Association of Retired Persons. Statutory/Other Authority: ORS 441 & 183 History: LTCO 2-1988, f. 6-22-88, cert. ef. 7-1-88
114-001-0005 Model Rules of Procedure Pursuant to ORS 183.341, the Long-Term Care Ombudsman adopts the Attorney General’s Model Rules of Procedure under the Administrative Procedure Act as amended and effective March 3, 1988. [ED. NOTE: The full text of the Attorney General’s Model Rules of Procedures is available from the the office of the Attorney General or from the Long Term Care Ombudsman.] Statutory/Other Authority: ORS 441 & 183 History: LTCO 1-1988, f. 3-20-88, cert. ef. 6-1-88
114-001-0010 Fee for Copies of Public Records The Ombudsman shall provide within a reasonable time copies of any public records in its files upon written request from any person and may charge a fee reasonably calculated to cover its costs. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-002-0000 Goals The goals of the Ombudsman Program are to identify and be responsive to citizen needs and concerns with respect to all aspects of Oregon’s Long-Term Care System, including but not necessarily limited to the sufficient quality of provider service, government rules and regulations, and any administrative or other actions impacting Long-Term Care residents; to cause or promote such change in the Long-Term Care System that would be of benefit to Long-Term Care Residents. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-003-0000 Appointment of Screening Committee Members (1) All screening committee members shall be appointed by the Ombudsman. (2) There shall be at least one local screening committee in each area planning district. (3) Except for individuals already appointed by the Ombudsman as screening committee members as of August 30, 1988, screening committee members shall be individuals who are concerned with the provisions of quality care in long term care facilities and who do not have a conflict of interest with the Ombudsman Program. (4) Each local screening committee shall elect a chairman, vice-chairman, secretary and treasurer and shall meet, at a minimum, once a month. The chairman of the local screening committee may appoint a subcommittee to serve at the chairman’s pleasure which is responsible for screening and approving potential designees. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-003-0010 Duties of the Local Screening Committee (1) Duties of the local screening committee shall consist of the following: (a) Publicizing the Ombudsman Program’s goals, needs and benefits; (b) Recruiting potential designees; (c) Screening potential designees, including checking references; (d) Referring approved applicants for designees to the Ombudsman within seven days of approval by the local screening committee; (e) Filing an annual report with the Ombudsman which includes, but is not limited to: (A) General activities conducted by the local screening committee; (B) The number of designee applicants screened; (C) The number of designee applicants approved; (D) The number of designees certified, assigned or serving as back up designees in the local screening committee’s area; (E) Problems or concerns of the local screening committee and recommendations to bring about resolution; and (F) Any other activities which have been approved by the Ombudsman and which promote the goals of the Ombudsman Program. (2) The local screening committee shall: (a) Interview applicants for designees within 21 days of the local screening committee’s receipt of application, whenever possible; (b) Vote on whether a designee applicant is recommended to the Ombudsman for appointment as a designee. The majority of the local screening committee or its subcommittee responsible for screening designee applicants must approve an applicant before recommending the applicant to the Ombudsman; and (c) Refer to the Ombudsman, the application of any designee applicant who is not approved by the local screening committee, with an explanation as to the reason for disapproval. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-004-0000 Appointment of Designees (1) The Ombudsman shall review each designee applicant approved by a local screening committee. The Ombudsman shall approve the applicant if the applicant meets the qualifications of a designee as set forth in OAR 114-004-0010. (2) Once the Ombudsman approves the applicant, the applicant must meet the requirements set forth in OAR 114-004-0020(1). (3) Upon successful completion of the requirements set forth in OAR 114-004-0020(1) by the designee applicant, the Ombudsman shall appoint the applicant as a designee. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-004-0010 Designee Qualifications (1) Designees shall not have a conflict of interest with the Ombudsman Program. (2) Designees shall have experience with long term care facilities or residents thereof or elderly individuals at risk of institutionalization or requiring assistance with the activities of daily living including the ability to communicate well with the elderly as well as long term care facility staff, to understand laws, rules and regulations, and to be assertive, yet objective. (3) Designees with experience in either social service, gerontology, nursing or paralegal work shall be preferred. (4) Designees must be willing to donate 16 hours of their time per month to perform the duties of a designee. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-004-0020 Designee Training (1) A designee applicant who has been approved by the local screening committee and by the Ombudsman shall, before being appointed as a designee by the Ombudsman: (a) Complete 48 hours of training provided, sponsored or approved by the Ombudsman Program; (b) Maintain a log of all training hours completed including but not limited to: (A) Training hours provided by the Ombudsman Program; (B) Approved home study hours; and (C) Approved training relating to Long Term Care issues, but not directly provided by the Ombudsman Program such as community workshops, seminars and association meetings. (c) Take a certification assessment examination covering training areas upon completion of the 48 hours of training; and (d) Receive a passing score of at least 70 percent on the certification assessment examination. (2) Designees must attend a minimum of four hours of continuing education seminars or workshops on a quarterly basis which are offered by the Ombudsman, subject to the availability of funds, or which have been approved by the Ombudsman and are offered by another organization. Training sessions which may be approved by the Ombudsman include programs offered by the Senior Services Division, the local health department, local Legal Aid, and the Area Agency on Aging. If a designee attends training not offered by the Ombudsman Program, the designee must submit verification to the Ombudsman that the quarterly training requirements were met by the designee. (3) Training subjects may include: (a) Patients’ rights; (b) Patient abuse and protective services; (c) The long term care system, including involved governmental agencies; (d) Communicating with the frail elderly; (e) The goals of the Ombudsman Program and the role of the Ombudsman and designees; (f) Investigation procedures; (g) Complaint investigation and resolution; (h) Regulatory law and rules; (i) Reporting techniques; (j) Techniques on mediation, conciliation and persuasion; (k) Appropriate referrals to state agencies; and (l) Other related topics to the long term care system. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-004-0030 Designee Contracts (1) Prior to being assigned to a long term care facility, a designee shall sign a contract with the Ombudsman Program which meets the requirements of ORS 441.131(3) and (6). (2) Noncompliance with the terms of the contract is cause for immediate termination of the contract. (3) Termination of a designee’s contract may be initiated by the Ombudsman or the designee in writing for any or no cause, without prior notice. (4) Upon termination of a designee’s contract, the designee must return all designee identification, manuals, confidential material and reports to the Ombudsman. (5) Each designee’s job performance may be reviewed at any time by the Ombudsman Program for the following purposes: (a) To assure designee compliance with contractual commitment; (b) To assess and review job performance; and (c) To assure compliance with the rules and Ombudsman Program goals and philosophy. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-004-0040 Designee Assignments (1) The Ombudsman shall assign a designee to particular long term care facilities or to act as a back-up designee. Designees shall not be assigned to a long term care facility where an immediate family member is a resident. (2) Each designee’s contract shall identify the long term care facility or facilities specifically assigned to that designee, unless the designee is assigned as a back-up designee. A designee shall not have access, as a designee, to any long term care facility other than the ones specifically named in the designee’s contract, unless the designee is requested to enter another long term care facility by that facility’s assigned designee, the District Facilitator or the Office of the Long Term Care Ombudsman. (3) A back-up designee’s contract shall allow the designee access, as a designee, to any long term care facility when requested to by the assigned designee, the District Facilitator or the Office of the Long Term Care Ombudsman. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-004-0050 Duties of Designees A designee shall: (1) Visit each assigned long term care facility on a regular basis: (a) Upon arrival and departure, inform a specified staff member; (b) Review any problems or concerns relating to the assigned long term care facility with administrators or persons in charge or their representatives provided that confidentiality requirements are met; and (c) Visit individual residents and resident councils. (2) Maintain liaison with appropriate agencies and the Ombudsman Program; (3) Submit in writing monthly reports to the Ombudsman Program on forms provided by the Ombudsman Program; (4) Keep residents and long term care staff informed of the Ombudsman Program; (5) Periodically review the patient’s bill of rights with residents, families, guardians, administrators and staff; (6) Investigate complaints made by residents or for residents of long term care facilities about administrative actions that may adversely affect a resident’s health, safety, welfare or rights; (7) Attempt to resolve problems between residents and the long term care facility through mediation, negotiation, persuasion and referral; (8) Report all apparent cases of patient abuse pursuant to ORS 441.630; and (9) Perform other related duties as specified by the Office of the Long Term Care Ombudsman. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89
114-004-0060 Complaints Against Designees and Rights of Designees (1) Any complaints regarding inappropriate actions or inactions relating to the official conduct of designees shall be referred to the Ombudsman. (2) The ombudsman shall investigate any complaint concerning designees. If the Ombudsman finds reasonable cause to believe that a designee has acted inappropriately or contrary to law and rule, the Ombudsman shall take appropriate action. Appropriate action may include a reprimand, requiring additional training, temporary suspension, or termination of the designee. (3) A designee, who is not satisfied with any action taken against the designee by the Ombudsman as a result of a complaint against the designee, may request, in writing, an informal conference with the Ombudsman to discuss and refute the complaint, findings and action taken by the Ombudsman. An informal conference shall be held within 14 days of receipt of the written request made by the designee to the Ombudsman. After considering the information submitted at the informal conference the Ombudsman may affirm, modify or rescind the initial action taken against the designee. Statutory/Other Authority: ORS 441 History: LTCO 1-1989, f. 1-19-89, cert. ef. 2-1-89