Chapter 410-141

410-141-3830 Prioritized List of Health Services (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 li…

410-141-3835 MCE Service Authorization (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…

410-141-3840 Emergency and Urgent Care Services (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 thes…

410-141-3845 Flexible Services (1) The goals of Flexible Services 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. Flexible Services…

410-141-3846 Palliative Care Program. (1) Definitions. (a) "Assessment" means procedures by which a qualified practitioner of the healing arts identifies strengths, weaknesses, problems, and needs to determine a member's need for palliative care services. (b) "Palliative care int…

410-141-3850 Transition of Care (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 predece…

410-141-3855 Pharmaceutical Services (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. CCOs shall pay for covered prescription drugs except: (a) As othe…

410-141-3860 Care Coordination: Administration, Systems and Infrastructure (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. The rules in this division relating to t…

410-141-3865 Care Coordination: Identification of Member Needs (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, d…

410-141-3870 Care Coordination: Service Coordination (1) Coordinated Care Organizations (CCOs) must ensure all services accessed by members are coordinated according to the needs of members, following the requirements in OAR 410-141-3860, OAR 410-141-3865 and in this rule. (2) Up…

410-141-3875 MCE Grievances & Appeals: Definitions and General Requirements (1) The following definitions apply for purposes of this rule and OAR 410-141-3835 through OAR 410-141-3915: (a) “Appeal” means a review by an Managed Care Entities (MCE), pursuant to OAR 410-141-3890 of …

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 w…

410-141-3885 Grievances & Appeals: Notice of Action/Adverse Benefit Determination (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 Ben…

410-141-3890 Grievances & Appeals: Appeal Process (1) A member, member representative, or provider with the member’s written consent, may file an oral or written appeal with the Managed Care Entity (MCE) to: (a) Express disagreement with an adverse benefit determination; or (b) O…

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 membe…

410-141-3900 Grievances & Appeals: Contested Case Hearings (1) A Managed Care Entity (MCE) shall have a system in place to ensure its members and providers acting on behalf of a member can request that the Authority review a final adverse determination by the MCE in a contested c…

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 conduct…

410-141-3910 Grievances & Appeals: Continuation of Benefits (1) A member who may be entitled to continuing benefits may request and receive continuing benefits in the same manner and same amount while an appeal or contested case hearing is pending: (a) A member can request contin…

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 a…

410-141-3920 Transportation: NEMT General Requirements (1) A Coordinated Care Organization (CCO) shall provide all non-emergency medical transportation (NEMT) services for its members. For purposes of OAR 410-141-3920 to 410-141-3965, references to a “member” include any individu…

410-141-3925 Transportation: Vehicle Equipment and Driver Standards (1) 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 pro…

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 accordan…

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 …

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 t…

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…

410-141-3955 Transportation: Member Service Modifications and Rights (1) For the purposes of this rule, “direct threat” means a significant risk to the health or safety of others and which: (a) Cannot be eliminated or reduced to an acceptable level through the provision of auxili…

410-141-3960 Transportation: Member Reimbursed Mileage, Meals, and Lodging (1) A Coordinated Care Organization (CCO) may prior authorize a member’s mileage, meals, and lodging to covered medical service in order for the member to qualify for reimbursement. (2) A CCO may disallow …

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 s…

410-141-5000 FINANCIAL SOLVENCY REGULATION: Definitions When used and not otherwise defined in OAR 410-141-5005 through OAR-141-5380, the following terms shall have the meaning given in this section: (1) “AICPA” means the American Institute of Certified Public Accountants. (2) “A…

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, an…

410-141-5010 FINANCIAL SOLVENCY REGULATION: Procedure for General Financial Reporting and for Determining Financial Solvency Matters (1) The Authority shall determine financial solvency of a CCO in accordance with OAR 410-141-5005 through OAR 410-141-5469, and the terms of the CC…

410-141-5015 FINANCIAL SOLVENCY REGULATION: Financial Statement Reporting (1) Financial reports to the Authority. A CCO shall submit the following to the Authority: (a) On or before April 30 of each year, an unaudited financial statement for the 12-month period ending the 31st da…

410-141-5020 FINANCIAL SOLVENCY REGULATION: Annual Audited Financial Statements and Auditor’s Report (1) Annual audited financial statements shall report the financial position of the CCO as of the end of the most recent calendar year and the results of its operations, cash flows…

410-141-5025 FINANCIAL SOLVENCY REGULATION: Qualifications of Independent Certified Public Accountant (1) The Authority shall not recognize any person as a qualified independent certified public accountant for the purposes of OAR 410-141-5020, or accept an annual audited financia…

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…

410-141-5035 FINANCIAL SOLVENCY REGULATION: Accountant's Letter of Qualifications (1) An accountant shall furnish the CCO, in connection with and for inclusion in the filing of the annual audited financial report, a letter stating the following: (a) That the accountant is indepen…

410-141-5040 FINANCIAL SOLVENCY REGULATION: Independent Certified Public Accountants Workpapers (1) For the purpose of this section, workpapers are the records kept by an independent certified public accountant of the procedures followed, the tests performed, the information obta…

410-141-5045 FINANCIAL SOLVENCY REGULATION: Corporate Governance Annual Disclosure Filing (1) A CCO shall file a corporate governance annual disclosure (CGAD) report with the Authority, as described in this section, no later than June 1 of each calendar year. (2) A CGAD Report sh…

410-141-5050 FINANCIAL SOLVENCY REGULATION: Requirements for Reinsurance (1) Except with the prior written approval of the Authority, as outlined in the terms of the CCO Contract, a CCO may not reinsure risks written or insured by other CCOs or other insurers. (2) A CCO may cede …

410-141-5055 FINANCIAL SOLVENCY REGULATION: Requirements for Obtaining Credit for Reinsurance (1) The Authority shall not allow financial statement credit for reinsurance to a cedent CCO as either an asset or a reduction from liability on account of reinsurance ceded unless the r…

410-141-5060 FINANCIAL SOLVENCY REGULATION: Qualified Trust Agreements (1) As used in this section: (a) “Beneficiary” includes any successor by operation of law of the named beneficiary, including without limitation any liquidator, rehabilitator, receiver or conservator. (b) “Gra…

410-141-5065 FINANCIAL SOLVENCY REGULATION: Letters of Credit; Other Security (1) A letter of credit for purposes of OAR 410-141-5055 must be clean, irrevocable, unconditional and issued or confirmed by a Qualified United States Financial Institution. The letter of credit shall c…

410-141-5070 FINANCIAL SOLVENCY REGULATION: Assets, Liabilities, Reserves (1) In any determination of the financial condition of a CCO, only assets owned by the CCO are allowed which consist of the following: (a) Cash in the possession or control of the CCO, including the true ba…

410-141-5075 FINANCIAL SOLVENCY REGULATION: Disallowance of Certain Reinsurance Transactions (1) The Authority shall disallow as an asset or as a credit against liabilities any reinsurance found by the Authority to have been arranged for the purpose principally of deception as to…

410-141-5080 FINANCIAL SOLVENCY REGULATION: Transparency (1) Pursuant to ORS 414.018 and 414.593(2), interactions between the Authority and CCOs shall be done in a transparent and public manner. (2) The Authority shall publicly disclose all information pertaining to CCOs required…

410-141-5085 ASSET VALUATION AND PERMITTED INVESTMENTS: Definitions As used in OAR 410-141-5085 to 410-141-5165: (1) “Amply secured obligation” means an obligation which is not in default and as to which no default is imminent, and which satisfies the requirements of one or more …

410-141-5090 ASSET VALUATION AND PERMITTED INVESTMENTS: Calculation of Value; Books and Records (1) Securities held by a CCO, other than bonds or other evidences of debt to which OAR 410-141-5095, applies, must be valued in the discretion of the Authority at their market value, a…

410-141-5095 ASSET VALUATION AND PERMITTED INVESTMENTS: Assets Other Than Securities; Bonds; Real Property; Mortgages; Compensating Balances (1) Each bond or other evidence of debt having a fixed term and rate of interest may be valued as follows, if amply secured and not in defa…

410-141-5100 ASSET VALUATION AND PERMITTED INVESTMENTS: Investments Used to Provide Compensating Balances Investments of a CCO of the kind described in OAR 410-141-5105(2) that are made for the purpose of providing compensating balances for other persons will not be prohibited by…

410-141-5105 ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Required Capitalization (1) Funds of a CCO at least equal to its required capitalization shall be invested and kept invested as follows: (a) In amply secured obligations of the United States, a state or a polit…