Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1865 - Denial, Reduction, or Termination of Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 purpose of this rule is to describe the requirements governing the denial,
			 reduction, or termination of medical assistance and access to the Authority
			 administrative hearings process for clients requesting or receiving medical
			 assistance services paid for by the Authority on a fee-for-service basis.
			 Grievance, complaint, and appeal procedures for clients receiving services from
			 an MCE shall be governed exclusively by the procedures in OAR 410-141-3260  and
			 where applicable OAR 410-141-3475.
(2) When the Authority authorizes a course of
			 treatment or covered service, but subsequently acts (as defined in
			 42 CFR
			 431.201) to terminate, suspend, or reduce the
			 course of treatment or a covered service, the Authority or its designee shall
			 mail a written notice to the client at least ten days before the date of the
			 termination or reduction of the covered service unless there is documentation
			 that the client had previously agreed to the change as part of the course of
			 treatment or as otherwise provided in
			 42 CFR
			 431.213.
(3) The written client notice must inform the
			 client of the action the Authority has taken or intends to take and reasons for
			 the action; a reference to the particular sections of the statutes and rules
			 involved for each reason identified in the notice; the client's right to
			 request an administrative hearing; an explanation of the circumstances under
			 which benefits may continue pending resolution of the hearing; and how to
			 contact the Authority for additional information. The Authority is not required
			 to grant a hearing if the sole issue is a federal or state law requiring an
			 automatic change adversely affecting some or all recipients.
(4) The Authority shall have the following
			 responsibilities in relation to continuation or reinstatement of benefit under
			 this rule:
(a) If the client requests an
			 administrative hearing by the tenth day following the date of the client
			 notice, or before the effective date of the action proposed in the notice, if
			 applicable, and requests that the services be continued, the Authority shall
			 continue the services. The service shall be continued until whichever of the
			 following occurs first, but may not exceed ninety days from the date of the
			 client's request for an administrative hearing):
(A) The current authorization expires;
			 or
(B) A decision is rendered about
			 the case that is the subject of the administrative hearing; or
(C) The client is no longer eligible for
			 medical assistance benefits or the health service, supply, or item that is the
			 subject of the administrative hearing is no longer a covered benefit in the
			 client's medical assistance benefit package; or
(D) The sole issue is one of federal or state
			 law or policy, and the Authority promptly informs the client in writing that
			 services are to be terminated or reduced pending the hearing
			 decision.