reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3640 - MCE Assessment: Notice of Proposed Action

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Prior to issuing a notice of proposed
			 action, the Authority shall notify the MCE of a potential deficiency or failure
			 to report that could give rise to the imposition of a penalty. The Authority
			 shall issue a 30-day notification letter within 30 calendar days of the report
			 or payment due date. The MCE shall have 30 calendar days from the date of the
			 notice to respond. The Authority may consider the response, if any, and any
			 amended report under OAR 410-141-3615  in its notice of proposed action. In all
			 cases that the Authority has determined that an MCE has an MCE assessment
			 deficiency or failure to report, the Authority shall issue a notice of proposed
			 action. The Authority may not issue a notice of proposed action if the issue is
			 resolved satisfactorily within 59 days from the date of mailing the 30-day
			 notification letter.
(2) The
			 Authority shall issue a notice of proposed action within 60 calendar days from
			 the date of mailing the 30-day notification letter.
(3) Contents of the notice of proposed action
			 must include:
(a) The applicable calendar
			 quarter;
(b) The basis for
			 determining the corrected amount of assessment for the quarter;
(c) The corrected assessment due for the
			 quarter as determined by the Authority;
(d) The amount of assessment paid for the
			 quarter by the MCE;
(e) The
			 resulting deficiency, which is the difference between the amount received by
			 the Authority for the calendar quarter and the corrected amount due as
			 determined by the Authority;
(f)
			 Statutory basis for the penalty;
(g) Amount of penalty per day of
			 delinquency;
(h) Date upon which
			 the penalty began to accrue;
(i)
			 Date the penalty stopped accruing or circumstances under which the penalty will
			 stop accruing;
(j) The total
			 penalty accrued up to the date of the notice;
(k) Instructions for responding to the
			 notice; and
(l) A statement of the
			 MCE's right to a hearing.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3645 - MCE Assessment: Hearing Process

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Any MCE that receives a notice of
			 proposed action may request a contested case hearing pursuant to ORS
			 183.411 through
			 183.500.
(2) The MCE may request a hearing by
			 submitting a written request within 20 days of the date of the notice of
			 proposed action.
(3) Prior to the
			 hearing, the MCE shall meet with the Authority for an informal conference:
(a) The informal conference may be used to
			 negotiate a written settlement agreement;
(b) If the settlement agreement includes a
			 reduction or waiver of penalties, the agreement must be approved and signed by
			 the Director of the Authority.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3650 - MCE Assessment: Final Order of Payment

Current through Register Vol. 63, No. 7, July 1, 2024
The Authority shall issue a final order of payment for
				deficiencies or penalties when:
(1)
			 The MCE did not make a timely request for a hearing;
(2) Any part of the deficiency or penalty was
			 upheld after a hearing;
(3) Upon
			 agreement of the MCE and the Authority.
Statutory/Other Authority: ORS
				  413.042 & ORS
				  414.025
Statutes/Other Implemented: ORS
				  414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3655 - Assessment: Remedies Available after Final Order of Payment

Current through Register Vol. 63, No. 7, July 1, 2024
Any amounts due and owing under the final order of payment and
				any interest thereon may be recovered by Oregon as a debt to the state, using
				any available legal and equitable remedies which include but are not limited
				to:
(1) Collection activities
			 including but not limited to deducting the amount of the final deficiency or
			 penalty from any sum then or later owed to the MCE by the Authority;
(2) Every payment obligation shall bear
			 interest at the statutory rate of interest in ORS
			 82.010 accruing from the date of
			 the final order of payment and continuing until the payment obligation,
			 including interest, has been discharged.
Statutory/Other Authority: ORS
				  413.042 & 414.025
Statutes/Other Implemented: ORS
				  414.065 & 2017 HB
				  2391
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3700 - CCO Application and Contracting Procedures

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority shall establish an
			 application process for entities seeking contracts as CCOs, in conformity with
			 this OAR 410-141-3700  and OAR 410-141-3705. The following definitions apply
			 with respect to that application process:
(a)
			 "Applicant" means the entity submitting an application to be a CCO, or to enter
			 into or amend a contract for coordinated care services;
(b) "Application" means an applicant's
			 written response to a Request for Applications;
(c) "Request for Applications (RFA)" means
			 the document used for soliciting applications for 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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3705 - Criteria for CCOs

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In
			 administering the procurement process described in OAR
			 410-141-3700, the Authority
			 shall require applicants to describe 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 CCOs proposed service area. The Authority shall develop
			 an RFA that includes, at a minimum, the elements described in this rule:
(a) This rule lists legal requirements for
			 CCOs, followed by corresponding application requirements that CCO applicants
			 shall be required to address in the RFA;
(b) The Authority shall interpret the
			 qualifications and expectations for CCO contracting within the context of the
			 laws establishing health system transformation, as well as the Oregon Health
			 Policy Boards adopted reports and policies;
(c) The Authoritys evaluation of CCO
			 applications shall account for the developmental nature of the CCO system:
(A) The Authority recognizes that CCOs and
			 partner organizations 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;
(B) An applicant who does not yet satisfy an
			 RFA criterion must, at a minimum, have plans in place to meet the criterion.
			 Unless otherwise specified in law or in the RFA, the Authority may use
			 discretion in assessing whether the applicant is likely to make sufficient
			 progress in implementing those plans to merit selection as a CCO candidate.
			 Depending on the applicants level of readiness, the Authority may consider
			 invoking its authority under OAR
			 410-141-3700(4)(f)
			 to deem an applicant "potentially eligible;"
(C) Contract provisions, including an
			 approved Transformation and Quality Strategy (TQS) and work plan for
			 implementing health services transformation, shall describe how the CCO will
			 comply with transformation requirements under these rules throughout the term
			 of the CCO contract to maintain compliance.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3710 - Contract Termination and Close-Out Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule applies to any termination of
			 an MCE contract, including but not limited to non-renewal under OAR
			 410-141-3725, expiration of the contract at the end of its term, or termination
			 during the term of the contract initiated by either party. Consistent with OAR
			 410-141-3725, MCEs shall abide by all requirements in this rule regardless of
			 whether termination notice is provided by the Authority or the MCE.
(2) The party initiating the termination
			 shall render written notice of termination to the other party by certified
			 mail, return receipt requested, or in person with proof of delivery and a
			 contemporaneous copy emailed to the other party's contract
			 administrator.
(3) The notice of
			 termination shall specify the circumstances giving rise to termination and the
			 date on which such termination shall become effective.
(4) After receipt of an MCE's notification of
			 intent not to renew or notice of termination, the Authority shall issue written
			 notice to the MCE specifying:
(a) The
			 effective date of termination;
(b)
			 The MCE's operational and reporting requirements; and
(c) Timelines for submission of
			 deliverables.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3715 - CCO Governance; Public Meetings and Transparency

Current through Register Vol. 63, No. 7, July 1, 2024
(1) CCOs shall establish, maintain, and
			 operate with a governance structure and community advisory council (CAC) that
			 is consistent with the requirements of ORS
			 414.625 and applicable health system transformation laws.
(2) Consumer Representative means a person
			 serving on a CAC who is currently or was within the previous six months a
			 recipient of medical assistance and is at least 16 years of age, or a parent,
			 guardian, or primary caregiver of an individual who is or was within the
			 previous six months a recipient of medical assistance.
(3) Each CCO's governing body must include:
(a) At least one member representing persons
			 that share in the financial risk of the organization;
(b) A representative of a dental care
			 organization selected by the coordinated care organization;
(c) The major components of the health care
			 delivery system;
(d) At least two
			 health care providers in active practice, including:
(A) A physician licensed under ORS chapter
			 677 or a nurse practitioner certified under ORS
			 678.375,
			 whose area of practice is primary care; and
(B) A mental health or chemical dependency
			 treatment provider.
(e)
			 At least two members from the community at large, to ensure that the
			 organization's decision-making is consistent with the values of the members and
			 the community; and
(f) At least two
			 members of the CAC:
(A) At least one of the
			 CAC representatives on the CCO's governing body must be a current CAC Consumer
			 Representative;
(B) CAC members of
			 the governing body shall have full voting rights.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3720 - Service Area Change for Existing CCOs

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For purposes of this rule, the following
			 definitions apply:
(a) "Applicant" means a
			 coordinated care organization (CCO) as defined in ORS
			 414.572 with a CCO contract with
			 the Authority that submits an application seeking a contract amendment for a
			 new service area. The CCO is described for purposes of this rule as the
			 applicant upon its submission of the CCO Letter of Intent to Apply;
(b) "Document Review" means the review
			 conducted by the Authority, occurring at the point 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;
(c)
			 "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;
(d) "SAC packet" means the packet of
			 application documents that the Authority provides to CCOs applying for a
			 SAC;
(e) "Service Area Change" or
			 "SAC" means a change in a CCO's service area as specified in the Authority's
			 contract with the CCO;
(f) "Service
			 Area Need" means when the Authority identifies a need, as defined in section
			 (3) of this rule, for existing CCOs to apply to the Authority for a SAC to
			 serve a service area.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3725 - CCO Contract Renewal Notification

Current through Register Vol. 63, No. 7, July 1, 2024
(1) No later than 134 days prior to the end
			 of a benefit period, the Authority shall provide each CCO with notice of the
			 proposed changes to the terms and conditions of the contract for the next
			 benefit period that the Authority submits to the Centers for Medicare and
			 Medicaid Services for approval.
(2)
			 If a CCO declines a contract renewal with the Authority, the CCO must notify
			 the Authority of its intention not to enter into the contract renewal no later
			 than 14 days after the Authority's notice of proposed changes as described in
			 section (1).
(3) A CCO's notice to
			 the Authority of intent not to enter into a contract renewal terminates the
			 contract at the end of the benefit period unless:
(a) The Authority at its discretion requires
			 the contract to remain in force into the next benefit period and be amended as
			 proposed by the Authority until 90 days after the CCO has in accordance with
			 criteria prescribed by the Authority:
(A)
			 Notified each of its members and contracted providers of the termination of the
			 contract;
(B) Provided to the
			 Authority a plan to transition its members to other CCOs; and
(C) Provided to the Authority a plan for
			 closing out its CCO business.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3730 - Community Health Assessment and Community Health Improvement Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) CCOs shall
			 comply with the requirements in ORS
			 414.627 and
			 414.629,
			 as well as any requirements specified in the contract regarding the Community
			 Health Assessment (CHA) and the Community Health Improvement Plan (CHP). To the
			 extent a CCO shares all or part of a Service Area, the CCO must develop a
			 shared CHA and CHP with all of the following organizations and entities: local
			 public health authorities, hospitals, other CCOs, and, if a federally
			 recognized tribe has already developed or will develop their own CHA or CHP,
			 CCOs must invite the tribe to participate in the shared CHA and CHP. These
			 entities will be referred to as the Collaborative CHA/CHP Partners. This
			 collaboration shall be documented in the CHA and CHP documents, inclusive of
			 CHP progress reports.
(2) The CCOs'
			 CACs shall oversee, with the Collaborative CHA/CHP Partners, the development of
			 the shared CHA.
(3) In developing
			 and maintaining a CHA, CCOs shall, with the Collaborative CHA/CHP Partners,
			 meaningfully and systematically engage representatives of local and tribal
			 governments, community partners and stakeholders, and critical populations to
			 assess the Community health needs of Contractor's Service Area. The following
			 must be engaged in the CHA process, without limitation:
(a) County and city government
			 representatives;
(b) Federally
			 recognized tribes (if not already collaborating on a shared CHA);
(c) SDOH-E partners, as defined in OAR
			 410-141-3735;
(d) Local mental
			 health authorities and community mental health programs;
(e) Physical, behavioral, and oral health
			 care providers;
(f) Federally
			 Qualified Health Centers;
(g)
			 Indian Health Care Providers;
(h)
			 Traditional Health Workers;
(i)
			 School nurses, school mental health providers, and other individuals
			 representing child and adolescent health services;
(j) Culturally specific organizations,
			 including Regional Health Equity Coalitions; and
(k) Representatives from populations who are
			 experiencing health and health care disparities.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3735 - Social Determinants of Health and Equity; Health Equity

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule defines health disparities and
			 the Social Determinants Of Health and Equity (SDOH-E), establishes requirements
			 for the Supporting Health for All through Reinvestment Initiative (SHARE
			 Initiative), establishes the role of the Community Advisory Councils in
			 supporting SDOH-E, establishes requirements for collecting data on race,
			 ethnicity, and primary language, and establishes requirements for developing
			 health equity infrastructure within a Coordinated Care Organization (CCO). This
			 rule provides structure and guidance to CCOs to support long-term,
			 community-specific investment and partnership in SDOH-E.
(2) The following definitions apply for
			 purposes of this rule:
(a) "Adjusted Net
			 Income" is the pre-tax net income reported by a CCO for a calendar year (or a
			 partial year, if relevant) pursuant to OAR
			 410-141-5015, adjusted by the
			 Authority pursuant to section 3(a)(E) of this rule for items such as the
			 following:
(A) Excessive administrative
			 expenses, including management bonuses;
(B) Improper allocation of expenses across
			 lines of businesses;
(C)
			 Non-operating revenues and expenses;
(D) Adjustments to base data made as part of
			 the capitation rate development;
(E) Expenses not supported by legitimate
			 business purposes;
(F) Payments or
			 transfers to subcontractors, parent companies, affiliates, or
			 subsidiaries.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3740 - Traditional Health Workers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Authority requires that all CCO members based on their health needs must have
			 access to certified traditional health workers (THWs) who are part of the
			 members care team in clinical and community-based settings to ensure members
			 have improved access to appropriate services. The THWs, as a part of the
			 members care team, must participate in processes affecting the members care and
			 service needs. THW is defined in OAR
			 950-060-0010.
(2) CCOs shall develop and implement a plan
			 for integrating and utilizing THWs, in accordance with this rule and the CCO
			 contract:
(a) THW integration and utilization
			 plans shall include:
(A) Information on THW
			 access and usage for CCO members;
(B) Benchmarks and measurement of baseline
			 data for integration and utilization of THWs;
(C) Evaluations of the CCOs progress in
			 reaching those benchmarks.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3800 - CCO Enrollment for Children Receiving Health Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Pursuant to OAR
			 410-141-3805, the Authority or Oregon Youth Authority (OYA) shall select CCOs
			 for a child receiving services in an area where a CCO is available.
(2) 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
			 410-141-3805  (Coordinated Care Enrollment Requirements), 410-141-3810  (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 consistent with OAR
			 410-141-3805;
(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, shall
			 consider whether the Authority shall enroll the child in a CCO.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3805 - Mandatory MCE Enrollment Exceptions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In addition to the definitions in OAR
			 410-120-0000, the following definitions apply:
(a) "Eligibility Determination" means an
			 approval or denial of eligibility and a renewal or termination of eligibility
			 as set forth in OAR 410-200-0015;
(b) "Newly Eligible" means recently
			 determined through the eligibility determination process as having the right to
			 obtain state health benefits, satisfying the appropriate conditions;
(c) "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;
(d) "Healthier
			 Oregon" and "Healthier Oregon Cover All Kids" means the benefit packages
			 described in OAR 410-134-0003;
(e)
			 Compact of Free Association (COFA) Dental Program means the benefit package
			 described in OAR 410-120-1210;(f) Veteran Dental Program means the benefit
			 package described in OAR 410-120-1210.
(f) "Citizenship Waived Medical (CWM)
			 Benefits Package" means the benefit package described in OAR 410-134-0005(2),
			 which ended on June 30, 2023;
(g)
			 "Citizenship Waived Medical Plus (CWM) Benefit Package" means the benefit
			 package described in OAR 410-134-0005(2), which was previously referred to as
			 CWX and ended on June 30, 2023.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3815 - CCO Enrollment for Temporary Out-of-Area Behavioral Health Treatment Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) 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
			 410-141-3805  and OAR 410-141-3810  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 410-141-3800  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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3820 - Covered Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) General
			 standard. The OHP Benefit Package includes treatments and health services which
			 pair together with a condition on the same line of the Health Evidence Review
			 Commission (HERC) Prioritized List of Health Services adopted under OAR
			 410-141-3830, to the extent that such line appears in the funded portion of the
			 Prioritized List of Health Services. Coverage of these services is included in
			 the benefit package when provided as specified in any relevant Statements of
			 Intent and Guideline Notes of the Prioritized List of Health Services. The
			 Benefit Package also covers the additional services described in this rule.
(a) As used in OAR 410-141-3820  and OAR
			 410-141-3825, the word "health services" has the meaning given in ORS
			 414.025(13);
(b) Services are covered with respect to an
			 individual member only when the services are medically or orally necessary and
			 appropriate as defined in OAR 410-120-0000  and at the time they are provided,
			 except that services shall also meet the prudent layperson standard defined in
			 ORS 743A.012.
(c) HRSN Services are covered with respect to
			 an individual member only when the Member belongs to an HRSN Covered Population
			 as defined in OAR 410-120-0000, and the HRSN Services are Clinically
			 Appropriate as defined in OAR 410-120-0000;
(d) Benefit Package coverage of prescription
			 drugs is discussed in OAR 410-141-3855;
(e) The Benefit Package is subject to the
			 exclusions and limitations described in OAR 410-141-3825.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3826 - Responsibility for Particular Covered Services Based on Plan Type

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Coordinated
			 Care Organization (CCO) responsibility for particular Covered Services, as that
			 responsibility is described in the CCO contract, is determined by the member's
			 plan type, as follows:
(a) Universally Offered
			 Newborn Nurse Home Visiting Program, commonly known as Family Connects Oregon
			 (FCO): FCO is governed by ORS
			 433.301 and described in OAR
			 Chapter 333, Division 6;
(A) The CCO is
			 responsible for care coordination for FCO services for an eligible member if
			 the CCO is responsible for the member's physical health services (plan types
			 CCOA and CCOB);
(B) The Oregon
			 Health Authority's (Authority) fee-for-service (FFS) program is responsible for
			 FCO services for all other plan types that include physical health
			 services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3825 - Excluded Services and Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The following services are excluded from
			 the Oregon Health Plan Benefit Package, except as otherwise provided in OAR
			 410-141-3820:
(a) Any service identified for
			 exclusion in OAR 410-120-1200  or 410-120-1210;
(b) Any service identified in applicable
			 provider guides as a non-covered service, unless the service is identified as
			 specifically covered under the OHP administrative rules;
(c) Any service that is not a funded service,
			 even if it is provided for a condition that appears in the funded region of the
			 list, or if the service in question is a funded service when provided for an
			 unfunded diagnosis on the prioritized list;
(d) Services that, when provided, are funded
			 services on the Prioritized List of Health Services, but which are otherwise
			 excluded from the OHP Benefit Package for the client in question;
(e) Diagnostic services not reasonably
			 necessary to establish a diagnosis or guide management or treatment decisions,
			 regardless of whether the condition or treatment in question is a funded
			 service;
(f) Services requested by
			 OHP clients in an emergency care setting that do not satisfy the coverage rules
			 in OAR 410-141-3820;
(g) Services
			 provided to an OHP client outside the territorial limits of the United States,
			 except in those instances in which the country operates a Medical Assistance
			 (Title XIX) program;
(h) Services
			 other than inpatient care provided to an OHP client who is in the custody of a
			 law enforcement agency or an inmate of a non-medical public institution,
			 including juveniles in detention facilities, per OAR 410-141-3810;
(i) Services received while the client is
			 outside the MCE's service area, except for services that were:
(A) Ordered or referred by the client's
			 primary care provider; or
(B)
			 Urgent or emergency services; or
(C) Otherwise covered pursuant to rule or the
			 MCE contract;
(D) This exclusion
			 does not apply if the client was outside the MCE's service area because of
			 circumstances beyond the client's control. Factors to be considered include but
			 are not limited to death of a family member outside of the MCE's service area.
			 If the client successfully establishes this fact, including during the
			 grievance and appeal process, then this exclusion does not apply.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3830 - Prioritized List of Health Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Health
			 Evidence Review Commission (HERC) Prioritized List of Health Services
			 (Prioritized List) is the listing of physical and behavioral health services
			 generated and maintained by HERC. The Authority may apply criteria listed in
			 Statements of Intent and Practice Guidelines (Guideline Notes, Ancillary
			 Guideline Notes, and Diagnostic Guideline Notes) from the Prioritized List to
			 codes and lines not explicitly specified in that guideline note and to services
			 such as diagnostic, ancillary and excluded irrespective of their inclusion on
			 the lines of the Prioritized List. The HERC maintains the most current list on
			 their website:
https://www.oregon.gov/OHA/HPA/DSI-HERC/Pages/Prioritized-List.aspx
.
			 For a hard copy, contact the Division within the Oregon Health Authority
			 (Authority).
(2) This rule,
			 effective January 1, 2024, incorporates by reference the January 1, 2024
			 Prioritized List, funded through line 469 and including all line items,
			 diagnosis and treatment codes, guideline notes, statements of intent, coding
			 specifications and annotations. This Prioritized List dated January 1, 2024
			 supersedes the October 1, 2024 Prioritized List for services provided after
			 January 1, 2024, and includes interim modifications reported as required under
			 ORS 414.690(7) and
			 (8).
Statutory/Other Authority: ORS
				  414.065 & ORS
				  413.042
Statutes/Other Implemented: ORS
				  414.065 & ORS
				  414.727
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3835 - MCE Service Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Coverage of services is outlined by MCE
			 contract and Oregon Health Plan (OHP) benefits coverage in OAR 410-120-1210  and
			 OAR 410-120-1160.
(2) A member may
			 access urgent and emergency services 24 hours a day, seven (7) days a week
			 without prior authorization.
(3)
			 The MCE may not require a member to obtain the approval of a primary care
			 physician to gain access to behavioral assessment and evaluation services. A
			 member may self-refer to assessment, evaluation, and behavioral health services
			 from the Provider Network. Members may obtain primary care services in a
			 behavioral health setting, and behavioral health services in a primary care
			 setting without authorization.
(4)
			 A member may access the following outpatient behavioral health services from
			 within the MCE's Provider Network, without Prior Authorization, including but
			 not limited to:
(a) "Assertive Community
			 Treatment" as defined in OAR 309-019-0105, "Enhanced Care Services" as defined
			 in OAR 309-019-0105, "Enhanced Care Outreach Services" as defined in OAR
			 309-019-0105, "Wraparound" as defined in OAR 309-019-0105, "Behavior Supports,
			 Crisis Care" as defined in OAR 309-019-0105, "Respite Care" as defined in OAR
			 309-019-0105, and "Intensive Outpatient Services and Supports" as defined in
			 OAR 309-019-0165;
(b) Behavioral
			 Health Peer Delivered Services as defined in OAR 309-019-0125  from within the
			 MCE's Provider Network;
(c)
			 Medication-Assisted Treatment for Substance Use Disorders as defined in OAR
			 309-019-0105, including opioid and opiate use disorders, within the MCE's
			 Provider Network without Prior Authorization of payment during the first thirty
			 (30) days of treatment.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3840 - Emergency and Urgent Care Services

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3845 - Health-Related Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The goals of
			 Health-Related Services (HRS) are to promote the efficient use of resources and
			 address members' social determinants of health to improve health outcomes,
			 alleviate health disparities, and improve overall community well-being.
			 Health-related services are provided as a supplement to covered health care
			 services:
(a) HRS may be provided as flexible
			 services or as community benefit initiatives, as those terms are defined
			 below;
(b) CCOs have the
			 flexibility to identify and provide health-related services beyond the list of
			 examples in
			 45
			 CFR §§
										158.150,
			 158.151,
			 as long as the HRS satisfy the requirements of this rule;
(c) As allowed under
			 42 CFR
			 438.6(e), MCEs may offer
			 additional services that are separate from HRS and delivered at the complete
			 discretion of the CCO;
(d) HRS may
			 be used to pay for non-covered health care services including physical health,
			 mental health, behavioral health, oral health, and tribal-based
			 services.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3850 - Transition of Care

Current through Register Vol. 63, No. 7, July 1, 2024
(1) This rule
			 applies to care of a Medicaid member who is enrolled in a CCO (the "receiving
			 CCO") immediately after disenrollment from a "predecessor plan," which may be
			 another CCO (including disenrollment resulting from termination of the
			 predecessor CCO's contract) or Medicaid fee-for-service (FFS). This rule does
			 not apply to a member who is ineligible for Medicaid or who has a gap in
			 coverage following disenrollment from the predecessor plan.
(2) For purposes of this rule, the following
			 additional definitions apply:
(a) "Continued
			 Access to Services" means making available to the member services,
			 prescriptions, and prescription drug coverage consistent with the access they
			 previously had including permitting the member to retain their current
			 provider, even if that provider is not in the CCO network;
(b) "Medically Fragile Children (MFC)" as
			 defined by OAR 411-300-0110  means children that have a health impairment that
			 requires long-term, intensive, specialized services on a daily basis, who have
			 been found eligible for MFC services by the Department of Human Services
			 (DHS);
(c) "Transition of Care
			 Period" means the period of time after the effective date of enrollment with
			 the receiving CCO, during which the receiving CCO must provide continued access
			 to services. The transition of care period lasts for:
(A) Ninety (90) days for members who are
			 dually eligible for Medicaid and Medicare; or
(B) For other members, the shorter of:
(i) Thirty (30) days for physical and oral
			 health and sixty (60) days for behavioral health; or
(ii) Until the enrollee's new PCP (oral or
			 behavioral health provider, as applicable to medical care or behavioral health
			 care services) reviews the member's treatment plan; or the minimum or
			 authorized prescribed course of treatment has been completed.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3855 - Pharmaceutical Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Prescription
			 drugs are a covered service for conditions that are described in the funded
			 region of the Prioritized List of Health Services, as described in OAR
			 410-141-3820. MCEs shall pay for covered prescription drugs except:
(a) As otherwise provided, mental health
			 drugs that are in Standard Therapeutic Class 7 (ataractics-tranquilizers) or
			 Standard Therapeutic Class 11 (psychostimulants-antidepressants) (based on the
			 National Drug Code (NDC) as submitted by the manufacturer to First Data
			 Bank);
(b) Depakote, Lamictal, and
			 their generic equivalents and those drugs that the Authority specifically
			 carved out from capitation according to section (10) of this rule;
(c) Drugs covered under Medicare Part D when
			 the member is fully dual eligible; and
(d) Prescriptions for Physician Assisted
			 Suicide under the Oregon Death with Dignity Act, for which payment is governed
			 by OAR 410-121-0150.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3860 - Care Coordination: Administration, Systems and Infrastructure

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Coordinated
			 Care Organizations (CCOs) must coordinate services for members in accordance
			 with 42 CFR §
									438.208, OAR 410-141-3865, OAR 410-141-3870  and this rule. This coordination must encompass all services accessed to
			 address the member's physical, developmental, behavioral, dental and social
			 needs (including Health-Related Social Needs (HRSN) and Social Determinants of
			 Health and Equity (SDOH-E). To meet these requirements, CCO's must:
(a) Identify the needs of their members on an
			 initial and ongoing basis as described in OAR 410-141-3865;
(b) Ensure coordinated services are provided
			 to their members as described in OAR 410-141-3870; and
(c) Ensure their members are informed about
			 the availability of Care Coordination and how to access or request it initially
			 and ongoing.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3865 - Care Coordination: Identification of Member Needs

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In order to coordinate a member's
			 services as described in this rule, OAR 410-141-3860  and OAR 410-141-3870,
			 Coordinated Care Organizations (CCOs) must have mechanisms in place to identify
			 the member's physical, developmental, behavioral, dental and social needs
			 (including Health Related Social Needs and Social Determinants of Health and
			 Equity), goals, and preferences of members on an initial and ongoing
			 basis.
(2) CCOs must conduct a
			 Health Risk Assessment (HRA) within ninety (90) days of enrollment, or sooner
			 if a member's health condition requires, and must:
(a) Conduct the HRA according to the
			 evaluation checklist provided by the Oregon Health Authority (OHA) and
			 available on the Quality Assurance Material Submission and Review
			 page;
(b) Make the HRA available to
			 members, their representative or guardian orally, in writing, or
			 online;
(c) Document all attempts
			 made to reach the member in accordance with OAR 410-141-3520;
(d) Review and document a member's HRA in
			 their Care Profile or Care Plan, if applicable, in accordance with OAR
			 410-141-3870;
(e) Share with other
			 entities and providers serving the member the results of any HRA to prevent
			 duplication of those activities; and
(f) When the member, their representative or
			 guardian has not returned or responded to the HRA, the CCO must:
(A) Follow up with the member if additional
			 information, or support with completion, is needed. This shall include making a
			 minimum of three (3) attempts to contact the member to facilitate completion
			 and identification of the member's needs. The attempts to reach a member shall
			 utilize at least two (2) mixed modalities (e.g., telephonic, text, email,
			 letter), on different days, and at different times;
(B) Use other available data sources,
			 including but not limited to those identified in OAR 410-141-3860(8) and (3)  of
			 this rule, to identify sufficient information to assign a risk level to the
			 member; and
(C) Ensure services are
			 coordinated for members regardless of their participation in or completion of
			 the HRA.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3870 - Care Coordination: Service Coordination

Current through Register Vol. 63, No. 7, July 1, 2024
(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 as defined in OAR 410-120-0000 (270) or
			 Emergency Services as defined in OAR 410-120-0000(95), 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 person or team as primarily responsible to coordinate
			 services accessed by the member and must provide information to the member on
			 how to contact their designated person or team.
(4) CCOs shall utilize a Care Profile for all
			 members as defined in OAR 410-141-3500.
(a)
			 The member Care Profile must identify:
(A)
			 The member's identifying and 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;
(i) The person or team formally
			 designated by the CCO as primarily responsible for coordinating the services
			 accessed by the member;
(ii) All
			 providers serving the member, including, at minimum, their Primary Care
			 Provider; and
(iii) The appropriate
			 individuals from all entities serving the member, such as those listed in
			 410-141-3860(2).
(D) The
			 member's needs, goals and preferences determined on an initial and ongoing
			 basis as described in OAR 410-141-3865;
(E) The member's health risk score and risk
			 category as described in OAR 410-141-3860;
(F) Any open or closed Care Plans;
			 and
(G) An overview of the
			 supports, services, activities, and resources deployed to meet the member's
			 identified needs.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3880 - Grievances & Appeals: Grievance Process Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3885 - Grievances And Appeals: Notice of Action/Adverse Benefit Determination

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When a Managed
			 Care Entity (MCE) has made an adverse benefit determination, the MCE shall give
			 the requesting provider, the Member and the member's representative a written
			 Notice of Adverse Benefit Determination (NOABD). The notice shall:
(a) Comply with the Authority's formatting
			 and readability standards in OAR 410-141-3585  and
			 42 CFR §
										438.10 and be written in plain language
			 sufficiently clear that a layperson could understand the notice and make an
			 informed decision about appealing and following the process for requesting an
			 appeal;
(b) For timing of notices,
			 follow timelines required for the specific service authorization or type via
			 oral and written mechanisms for any service request of the member or the
			 member's provider outlined in OAR 410-141-3835  MCE Service Authorization or
			 otherwise specified in this rule.