Oregon Administrative Code

410-141-3540 Member Protections (1) In the event of a finding of MCE impairment by the Authority, or of a termination of the MCE contract, members of the MCE shall be offered disenrollment from the MCE and enrollment in accordance with the Authority’s rules. (2) For the purpose o…

410-141-3545 Coordinated Care Organization Behavioral Health Provider, Treatment and Facility Certification and Licensure Behavioral health treatment services are covered for eligible OHP clients when provided by a CCO under the following circumstances: (1) Provider Organizations…

410-141-3550 Resolving Disputes between MCEs and the Authority (1) If an MCE has a dispute with the Authority as a result of a decision that is perceived as adversely affecting an MCE, the MCE may submit a request to the Director of the Authority, or the Director’s designee, requ…

410-141-3555 Resolving Disputes between Health Care Entities and CCOs that Concern CCO Contact Award (1) The dispute resolution process described in this rule applies only when, under ORS 414.635: (a) An entity is applying to the Authority for contract award as a CCO (applicant);…

410-141-3560 Resolving Contract Disputes Between Health Care Entities and CCOs (1) Pursuant to ORS 414.635, Coordinated Care Organizations (CCOs) and Health Care Entities (HCEs) shall participate in good faith contract negotiations. This rule covers the termination, extension, an…

410-141-3565 Managed Care Entity Billing (1) Providers shall submit all claims for MCE members in the following timeframes: (a) Submit initial claims within no more than 120 days of the date of service for all cases, except as provided for in section (1)(b) of this rule. MCEs may…

410-141-3570 Managed Care Entity Encounter Claims Data Reporting (1) MCEs shall meet the data content and submission standards as required by HIPAA 45 CFR Part 162, the Authority's electronic data transaction rules (OAR 943-120-0100 through 943-120-0200), the Authority's 837 tech…

410-141-3575 MCE Member Relations: Marketing (1) The following definitions apply for purposes of OAR 410-141-3575 through 410-141-3585: (a) “Alternate Format” means any alternate approach to presenting print information to an individual with a disability. This term includes, at a…

410-141-3580 MCE Member Relations: Potential Member Information (1) In addition to the requirements below, information for potential members shall comply with the marketing requirements and prohibitions in 42 CFR § 438.104 and OAR 410-141-3575 and any requirements or guidelines a…

410-141-3585 MCE Member Relations: Education and Information (1) Managed Care Entity’s (MCEs) may engage in activities for existing members related to outreach, health promotion, and health education. MCE must obtain approval of the Authority prior to distribution of any written …

410-141-3590 MCE Member Relations: Member Rights and Responsibilities (1) MCEs shall: (a) Have written policies and procedures that ensure that members have the rights and responsibilities included in this rule; (b) Communicate these policies and procedures to participating provi…

410-141-3591 MCE Interoperability Requirements (1) Interoperability and Access to Health Information (a) MCEs shall comply with all federal regulations set forth in the CMS Interoperability and Patient Access Final Rule. (b) All MCEs shall review the Office of National Coordinato…

410-141-3600 MCE Assessment: Definitions The following definitions apply for purposes of OAR 410-141-3600 through 3655: (1) "Deficiency" means the amount by which the assessment as correctly computed exceeds the assessment, if any, reported by the managed care entities (MCEs). (2…

410-141-3601 MCE Assessment: General Administration (1) The purpose of these rules is to govern the administration, enforcement, and collection of the managed care assessment on MCEs. (2) MCEs shall pay an assessment on the gross amount of premium equivalents received during a ca…

410-141-3605 MCE Assessment: Disclosure of Information (1) Except as otherwise required by law, the Authority may not publicly divulge or disclose the amount of income, expense, or other particulars set forth or disclosed in any report or return required in the administration of …

410-141-3610 MCE Assessment: Calculation, Report, Due Date, Verification (1) The MCE assessment on the premium equivalents paid to an MCE on or after January 1, 2018, is based on calendar quarters. Calendar quarter start dates are January 1, April 1, July 1, and October 1. For pu…

410-141-3615 MCE Assessment: Filing an Amended Report (1) The claims for refunds or payments of additional MCE assessment must be submitted by the MCE on an Authority approved form. The MCE must provide all information required on the report. The Authority may audit the MCE, requ…

410-141-3620 MCE Assessment: Determining the Date Filed (1) For the purposes of these rules, any reports, requests, appeals, payments, or other response by the MCE must be either: (a) Received by the Authority before the close of business on the date due; or (b) If mailed, postma…

410-141-3625 MCE Assessment: Authority to Audit Records (1) The MCE must maintain financial records necessary and adequate to determine the amount of premium equivalents for any period for which an MCE assessment may be due. (2) The Authority may audit the MCE's records at any ti…

410-141-3630 MCE Assessment: Determining Assessment Liability on Failure to File (1) In the case of a failure by the MCE to file a report or to maintain necessary and adequate records, the Authority shall determine the MCE assessment liability according to the best of its informa…

410-141-3635 MCE Assessment: Financial Penalty for Failure to File a Report or Failure to Pay Assessment When Due (1) An MCE that fails to file a report or pay an MCE assessment in full when due is subject to a penalty of up to $500 per day of delinquency. The penalty accrues fro…

410-141-3640 MCE Assessment: Notice of Proposed Action (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 notif…

410-141-3645 MCE Assessment: Hearing Process (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 not…

410-141-3650 MCE Assessment: Final Order of Payment 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 agree…

410-141-3655 Assessment: Remedies Available after Final Order of Payment 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 n…

410-141-3700 CCO Application and Contracting Procedures (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…

410-141-3705 Criteria for CCOs (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 Heal…

410-141-3710 Contract Termination and Close-Out Requirements (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 cont…

410-141-3715 CCO Governance; Public Meetings and Transparency (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.…

410-141-3720 Service Area Change for Existing CCOs (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 co…

410-141-3725 CCO Contract Renewal Notification (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 subm…

410-141-3730 Community Health Assessment and Community Health Improvement Plans (1) CCOs shall comply with the requirements in ORS 414.575, 414.577 and 414.578, as well as any requirements specified in the contract regarding the Community Health Assessment (CHA) and the Community…

410-141-3735 Social Determinants of Health and Equity; Health Equity (1) This rule defines health disparities and the Social Determinants Of Health and Equity (SDOH-E), establishes requirements for Supporting Health for All through Reinvestment (SHARE), establishes the role of th…

410-141-3740 Traditional Health Workers (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 member’s care team in clinical and community-based settings to ensure members ha…

410-141-3800 CCO Enrollment for Children Receiving Health Services (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 p…

410-141-3805 Mandatory MCE Enrollment Exceptions (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…

410-141-3810 Disenrollment from MCEs (1) Member-initiated requests for disenrollment. (a) All member-initiated requests for disenrollment from an MCE shall be initiated orally or in writing by the primary person in the benefit group enrolled with an MCE where primary person and b…

410-141-3815 CCO Enrollment for Temporary Out-of-Area Behavioral Health Treatment Services (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 upo…

410-141-3820 Covered Services (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-…

410-141-3825 Excluded Services and Limitations (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 iden…

410-141-3826 Responsibility for Particular Covered Services Based on Plan Type (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)…

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…