justicedao/ipfs_state_laws huggingface dataset:
410-141-3880 Grievances & Appeals: Grievance Process Requirements (1) A member and, with the written consent of the member, a provider or an authorized representative may file a grievance at any time either orally or in writing, on behalf of a member. The grievance may be filed with the MCE or the Authority. If the grievance is filed with the Authority, it shall be promptly forwarded to the MCE. (2) For standard resolution of a grievance, the MCE shall resolve each grievance and provide notice of the disposition as expeditiously as the member’s health condition requires. The MCE shall: (a) Within five business days from the date of the MCEs receipt of the grievance, notify the member in their preferred language that a decision on the grievance has been made and what that decisions is; or (b) Promptly, but in no event more than five business days after the date of the MCE’s receipt of the grievance, notify the member in their preferred language that there shall be a delay in the MCE’s decision of up to 30 days from the date on which the grievance was received by the MCE . The written notice shall specify why the additional time is necessary. (3) The MCE shall ensure that the individuals who make decisions on grievances follow all requirements in OAR 410-141-3875 MCE Grievance and Appeals System General Requirements. (4) When informing members of the MCE’s decision, the MCE: (a) May provide its decision related to oral grievances orally but shall also, in call instances respond to oral grievances in writing. Both oral and written responses shall be made in the member’s preferred language; (b) Shall address each aspect of the grievance and explain the reason for the decision; (c) Shall respond in writing to written grievances in the member’s preferred language. In addition to written responses, the MCE may also respond orally in the member’s preferred language; and (d) Shall notify members who are dissatisfied with the disposition of a grievance that they may present their grievance to the Department of Human Services (Department) Client Services Unit or the Authority’s Ombudsperson. (5) In compliance with Title VI of the Civil Rights Act and ORS Chapter 659A, the MCE shall review and report to the Authority, as outlined in the CCO contract, member complaints related to their race and ethnicity, gender identity, sexual orientation, socioeconomic status, country of origin, and disability status. (6) If an MCE receives a grievance related to a member’s entitlement of continuing benefits in the same manner and same amount during the transition of transferring from one MCE to another MCE as defined in OAR 410-141-3850, the MCE shall log the grievance and work with the receiving or sending MCE to ensure continuity of care during the transition. Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651 Statutes/Other Implemented: ORS 414.610 - 414.685 History: DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3895 Grievances & Appeals: Expedited Appeal (1) Each MCE shall establish and maintain an expedited review process for all oral and written appeals when the member or the provider indicates that taking the time for a standard resolution could seriously jeopardize the member’s life, health, or ability to attain, maintain, or regain maximum function as set forth in OAR 410-120-1860. Oral appeals timeframes shall begin when there is established contact made between the member and an MCE representative. (2) The MCE shall ensure that punitive action is not taken against a provider who requests an expedited resolution. (3) A request for an expedited appeal for a service that has already been provided (post-service) to the member will not be granted. The MCE shall transfer the appeal to the timeframe for standard resolution as set forth in 410-141-3890 (4). (4) For expedited resolution of an appeal and notice to affected parties, the MCE shall complete the review of the expedited appeal in a timeframe that is no longer than 72 hours after the MCE receives the appeal. The MCE shall: (a) Inform the member of the limited time available for receipt of materials or documentation for the review; (b) Make reasonable efforts to call the member and the provider to tell them of the resolution within 72 hours after receiving the request; (c) Mail written confirmation of the resolution to the member within three days; (d) Extend the timeframes by up to 14 days if: (A) The member requests the extension; or (B) The MCE shows (to the satisfaction of the Authority upon its request) that there is need for additional information and how the delay is in the member's interest. (e) If the MCE extends the timeframes not at the request of the member, the MCE shall: (A) Make reasonable efforts (including as necessary multiple calls at different times of day) to give the member prompt oral notice of the delay; (B) Within two days, give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision. (5) If the MCE provides an expedited appeal but denies the services or items requested in the expedited appeal, the MCE shall inform the member of the right to request an expedited contested case hearing and shall send the member a Notice of Appeal Resolution, in addition to Hearing Request and Information forms as set forth in OAR 410-141-3890. (6) If the MCE denies a request for expedited resolution on appeal, the MCE shall: (a) Transfer the appeal to the timeframe for standard resolution in accordance with OAR 410-120-1860; (b) Make reasonable efforts to give the member and requesting provider prompt oral notice of the denial and follow up within two days with a written notice. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 & 414.727 History: DMAP 60-2022, amend filed 06/24/2022, effective 07/01/2022 DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021 DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3905 Grievances & Appeals: Expedited Contested Case Hearings (1) An MCE shall have a system in place to ensure its members and providers have access to expedited review for MCE’s action by requesting an expedited 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. Processes for expedited contested case hearings are provided in OAR 410-120-1860 Contested Case Hearing Procedures. (2) A member or provider who believes that taking the time for a standard resolution of a request for a contested case hearing could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function may request an expedited contested case hearing. (3) A request for an expedited hearing for a service that has already been provided (post-service) to the member will not be granted. (4) The member may not request an expedited contested case hearing without first completing an appeal or expedited appeal with the MCE, subject to the exception in OAR 410-141-3900(3). When a member files a hearing request prior to completion of an MCE appeal or expedited appeal, the Authority shall follow procedures set forth in OAR 410-141-3900. (5) Expedited hearings are requested using Authority form MSC 443 or other Authority-approved appeal or hearing request forms. (6) The MCE shall submit relevant documentation to the Authority within two working days. The Authority shall decide within two working days from the date of receiving the relevant documentation whether the member is entitled to an expedited contested case hearing. (7) If the Authority denies a request for an expedited contested case hearing, the Authority shall: (a) Handle the request for a contested case hearing in accordance with OAR 410-120-1860; and (b) Make reasonable efforts to give the member prompt oral notice of the denial and follow up within two days with a written notice. (8) If a member requests an expedited hearing, the Authority shall request documentation from the MCE, and the MCE shall submit relevant documentation including clinical documentation to the Authority within two working days. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 & 414.727 History: DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021 DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3915 Grievances & Appeals: System Recordkeeping (1) Each MCE shall maintain records of grievances, appeals, Notices of Adverse Benefit Determinations (NOABDs) and prior authorizations and shall review the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the state quality strategy as stated in 42 CFR 438.416 and in alignment with contractual requirements. (2) Consistent with record retention requirements in OAR 410-141-3520, MCEs must maintain yearly logs of all appeals, grievances, NOABDs and prior authorizations for 10 years, which must include information about the reasons for each grievance, appeal, NOABD and prior authorization denial, as well as the resolution and supporting reasoning. (3) The MCE must review the log monthly for completeness, accuracy, and compliance with required procedures. (4) MCEs shall submit for the Authority’s review the Grievance and Appeals Log, samples of NOABDs, prior authorization documentation and other reports as required under the MCE contract. (5) The Grievance System Report and Grievance and Appeals Log shall be forwarded to the MCE’s Quality Improvement committee to comply with the Quality Improvement standards as follows: (a) Review of completeness, accuracy, and timeliness of documentation; (b) Compliance with written procedures for receipt, disposition, and documentation; and (c) Compliance with applicable OHP rules. Statutory/Other Authority: ORS 413.042 & ORS 414.065 Statutes/Other Implemented: ORS 414.065 & 414.727 History: DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025 DMAP 28-2021, amend filed 06/28/2021, effective 07/01/2021 DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3930 Transportation: Out-of-Service Area and Out-of-State Transportation (1) A CCO shall provide NEMT services outside the CCO’s service area under any and all of the following circumstances: (a) The member is receiving covered services that are not available, in accordance with OAR 410-141-3515, in the CCO’s service area; (b) The member is receiving covered services outside of Oregon, but the location is contiguous to the CCO’s service area and no more than 75 miles from the Oregon border; (c) The member is receiving in-patient services at a facility outside the CCO’s service area due to unavailability within the CCO’s service area and the member requires additional covered services within the service area where the inpatient service facility is located; and (d) The member is receiving covered services outside the State of Oregon because the required covered service is not available within 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. Statutory/Other Authority: ORS 413.042 & ORS 414.625 Statutes/Other Implemented: ORS 414.625 History: DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3935 Transportation: Attendants for Child and Special Needs Transports (1) This rule applies to NEMT for children 12 years of age and under who are eligible for NEMT services to and from OHP-covered medical services. The rule also applies to members 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 covered services and other purposes authorized by the CCO in accordance with OAR 410-141-3930(2) 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 410-141-3940 (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 18 years or older authorized by the member’s parent or guardian. (6) CCOs shall have the right to 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) Neither the CCO nor its subcontractor shall 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. (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. Statutory/Other Authority: ORS 413.042 & ORS 414.625 Statutes/Other Implemented: ORS 414.625 History: DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3940 Transportation: 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 411.439. (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. Statutory/Other Authority: ORS 413.042 & ORS 414.625 Statutes/Other Implemented: ORS 414.625 History: DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3945 Transportation: 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 and the length of transport requires a personal care attendant, but the member does not have one; or (b) Necessitated by the member’s medical condition consistent with section (1) above of this rule. (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 providers of ground or air ambulance services have been licensed by the Authority 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 the ambulance service provider has been licensed by both the Authority and the contiguous state in which it is operating. Statutory/Other Authority: ORS 413.042 & ORS 414.625 Statutes/Other Implemented: ORS 414.625 History: DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-3965 Reports and Documentation (1) CCOs shall maintain documentation of rides denied and rides provided to members. (2) The CCO shall retain the documentation on NEMT service denials for 10 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 10 years. The Authority may request this information at any time during the 10-year retention period. (3) The Authority may request and the CCO shall provide other reports or information not specified in this rule. Statutory/Other Authority: ORS 413.042 & ORS 414.625 Statutes/Other Implemented: ORS 414.625 History: DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020
410-141-5005 FINANCIAL SOLVENCY REGULATION: CCO Financial Solvency Requirements (1) A CCO shall assume the risk for providing capitated services under the CCO Contract. (2) 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. (3) A CCO shall comply with all applicable laws relating to solvency requirements of CCOs and the terms of the Contract. Solvency requirements shall include the following components: (a) Maintenance of Restricted Reserve Funds as required by OAR 410-141-5185; (b) Protection against catastrophic and unexpected loss or expenses related to capitated services for a CCOs Loss Protection Program; A CCO’s Loss Protection Program: (A) May include stop loss insurance coverage, reinsurance or such other alternative protection(s) as may be approved by the Authority, and (B) Shall be subject to the Authority’s review and approval. (c) Any material change to a CCO’s Loss Protection Program shall be submitted to the Authority in writing and shall be subject to the Authority’s review and approval; (d) Maintenance of professional liability coverage of not less than $1,000,000 per person per incident and not less than $1,000,000 in the aggregate either through binder issued by an insurance carrier or by self-insurance with proof of same acceptable to the Authority; and (e) Management systems, practices and procedures that capture, compile, and evaluate information and data concerning financial operations. Such systems shall include, without limitation, the following features and functionalities: (A) Determination of future budget requirements for the next three quarters. (B) Determination of incurred but not reported expenses. (C) Tracking additions and deletions of Members and accounting for capitation payments. (D) Tracking claims payment. (E) Tracking all monies collected from third party resources on behalf of Members. (F) Documentation of, and reports on the use of, incentive payment mechanisms, risk-sharing, and risk-pooling, as applicable. Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605 Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430 History: DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025 DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020
410-141-5030 FINANCIAL SOLVENCY REGULATION: Notification of Adverse Financial Condition (1) A CCO required to furnish an annual audited financial report shall require the independent certified public accountant to report in writing to the CCO’s Board, or to the audit committee of the CCO, any determination by the independent certified public accountant that: (a) The CCO has materially misstated its financial condition as reported to the Authority as of the date of the balance sheet currently under audit; (b) The CCO does not meet the minimum capital and surplus requirements under these rules; or (c) The CCO’s risk-based capital, as determined in accordance with OAR 410-141-5195 to 5220 is below the Company Action Level threshold for the CCO. (2) The CCO shall require the independent certified public accountant to submit the report no later than the fifth business day after the independent certified public accountant makes such a determination under subsection (1). A CCO that has received a report under this section shall both forward a copy of the report to the Authority and provide the independent certified public accountant with evidence that the report was furnished to the Authority no later than the fifth business day after receiving the report. If the independent certified public accountant does not receive such evidence within the required period, the independent certified public accountant shall furnish to the Authority a copy of its report no later than the fifth business day after the end of the period within which the CCO was required to submit the report. (3) An independent certified public accountant shall not be liable to any person for any statement made in connection with the requirements of subsection (1) if the statement is made in good faith and in compliance with subsection (1). (4) If the accountant, after the date of the audited financial report filed pursuant to OAR 410-141-5020, becomes aware of facts that might have affected the report, the Authority notes the obligation of the accountant to act as prescribed in Volume 1, Section AU 561 of the Professional Standards of the AICPA. Statutory/Other Authority: ORS 413.042, 414.572, 414.591 & 414.605 Statutes/Other Implemented: ORS 414.570-414.686 & 415.001-415.430 History: DMAP 143-2024, amend filed 12/29/2024, effective 01/01/2025 DMAP 58-2019, adopt filed 12/18/2019, effective 01/01/2020