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Oregon Bulletin

March 1, 2012

Oregon Health Authority, Division of Medical Assistance Programs, Chapter 410

Rule Caption: Align with OAR chapter 461, division 155 medical eligibility rules.

Adm. Order No.: DMAP 2-2012(Temp)

Filed with Sec. of State: 1-26-2012

Certified to be Effective: 1-26-12 thru 7-10-12

Notice Publication Date:

Rules Amended: 410-120-0006

Rules Suspended: 410-120-0006(T)

Subject: The General Rules Program administrative rules govern the Division’s payments for services provided to clients, and medical assistance eligibility determinations made by the Oregon Health Authority. In coordination with the Department of Human Services’ (Department) temporary revision of medical eligibility rules in chapter 461 the Division is temporarily amended OAR 410-120-0006 to assure that the Division’s medical eligibility rule aligns with and reflects information found in Department’s medical eligibility rules. In OAR 410-120-0006, the Division adopts in rule by reference Department eligibility rules and must update OAR 410-120-0006 in conjunction. The Division intends to file this rule permanently on or before July 10, 2012.

Rules Coordinator: Darlene Nelson—(503) 945-6927

410-120-0006

Medical Eligibility Standards

As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedure consistent with applicable law. As outlined in 943-001-0020, the Authority, and the Department of Human Services (Department) work together to adopt rules to assure that medical assistance eligibility procedures and determinations are consistent across both agencies.

(1) The Authority adopts and incorporates by reference the rules established in OAR Chapter 461, and in effect January 25, 2012, for all medical eligibility requirements for medical assistance when the Authority conducts eligibility determinations.

(2) Any reference to OAR Chapter 461 in Oregon Administrative Rules or contracts of the Authority are deemed to be references to the requirements of this rule, and shall be construed to apply to all eligibility policies, procedures and determinations by or through the Authority.

(3) For purposes of this rule, references in OAR chapter 461 to the Department or to the Authority shall be construed to be references to both agencies.

(4) Effective on or after July 1, 2011 the Authority shall conduct medical eligibility determinations using the OAR chapter 461 rules which are in effect on the date the Authority makes the medical eligibility determination.

(5) A request for a hearing resulting from a determination under this rule, made by the Authority shall be handled pursuant to the hearing procedures set out in division 25 of OAR Chapter 461. References to “the Administrator” in division 25 of chapter 461 or “the Department” are hereby incorporated as references to the” Authority.”

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.042 & 414.065
Hist.: DMAP 10-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 18-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12; DMAP 21-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-11-12; DMAP 25-2011(Temp), f. 9-28-11, cert. ef. 10-1-11 thru 1-11-12; DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12; DMAP 1-2012(Temp), f. & cert. e.f 1-13-12 thru 7-10-12; DMAP 2-2012(Temp), f. & cert. ef. 1-26-12 thru 7-10-12


 

Rule Caption: Align with OAR chapter 461, division 155 medical eligibility rules.

Adm. Order No.: DMAP 3-2012(Temp)

Filed with Sec. of State: 1-31-2012

Certified to be Effective: 1-31-12 thru 2-1-12

Notice Publication Date:

Rules Amended: 410-120-0006

Subject: The General Rules Program administrative rules govern the Division’s payments for services provided to clients, and medical assistance eligibility determinations made by the Oregon Health Authority. In coordination with the Department of Human Services’ (Department) temporary revision of medical eligibility rules in chapter 461, the Division is temporarily amended OAR 410-120-0006 to assure that the Division’s medical eligibility rule aligns with and reflects information found in Department’s medical eligibility rules. In OAR 410-120-0006, the Division adopts in rule by reference Department eligibility rules and must update OAR 410-120-0006 in conjunction. The Division intends to file this rule permanently on or before July 10, 2012.

Rules Coordinator: Cheryl Peters—(503) 945-6527

410-120-0006

Medical Eligibility Standards

As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedure consistent with applicable law. As outlined in 943-001-0020, the Authority, and the Department of Human Services (Department) work together to adopt rules to assure that medical assistance eligibility procedures and determinations are consistent across both agencies.

(1) The Authority adopts and incorporates by reference the rules established in OAR Chapter 461, and in effect January 31, 2012, for all medical eligibility requirements for medical assistance when the Authority conducts eligibility determinations.

(2) Any reference to OAR Chapter 461 in Oregon Administrative Rules or contracts of the Authority are deemed to be references to the requirements of this rule, and shall be construed to apply to all eligibility policies, procedures and determinations by or through the Authority.

(3) For purposes of this rule, references in OAR chapter 461 to the Department or to the Authority shall be construed to be references to both agencies.

(4) Effective on or after July 1, 2011 the Authority shall conduct medical eligibility determinations using the OAR chapter 461 rules which are in effect on the date the Authority makes the medical eligibility determination.

(5) A request for a hearing resulting from a determination under this rule, made by the Authority shall be handled pursuant to the hearing procedures set out in division 25 of OAR Chapter 461. References to “the Administrator” in division 25 of chapter 461 or “the Department” are hereby incorporated as references to the” Authority.”

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.042 & 414.065
Hist.: DMAP 10-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 18-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12; DMAP 21-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-11-12; DMAP 25-2011(Temp), f. 9-28-11, cert. ef. 10-1-11 thru 1-11-12; DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12; DMAP 1-2012(Temp), f. & cert. e.f 1-13-12 thru 7-10-12; DMAP 2-2012(Temp), f. & cert. ef. 1-26-12 thru 7-10-12; DMAP 3-2012(Temp), f. & cert. ef. 1-31-12 thru 2-1-12


 

Rule Caption: Align with OAR chapter 461, division 155 medical eligibility rules.

Adm. Order No.: DMAP 4-2012(Temp)

Filed with Sec. of State: 1-31-2012

Certified to be Effective: 2-1-12 thru 7-10-12

Notice Publication Date:

Rules Amended: 410-120-0006

Subject: The General Rules Program administrative rules govern the Division’s payments for services provided to clients, and medical assistance eligibility determinations made by the Oregon Health Authority. In coordination with the Department of Human Services’ (Department) temporary revision of medical eligibility rules in chapter 461, the Division is temporarily amended OAR 410-120-0006 to assure that the Division’s medical eligibility rule aligns with and reflects information found in Department’s medical eligibility rules. In OAR 410-120-0006, the Division adopts in rule by reference Department eligibility rules and must update OAR 410-120-0006 in conjunction. The Division intends to file this rule permanently on or before July 10, 2012.

Rules Coordinator: Cheryl Peters—(503) 945-6527

410-120-0006

Medical Eligibility Standards

As the state Medicaid and CHIP agency, the Oregon Health Authority (Authority) is responsible for establishing and implementing eligibility policies and procedure consistent with applicable law. As outlined in 943-001-0020, the Authority, and the Department of Human Services (Department) work together to adopt rules to assure that medical assistance eligibility procedures and determinations are consistent across both agencies.

(1) The Authority adopts and incorporates by reference the rules established in OAR Chapter 461, and in effect February 1, 2012,for all medical eligibility requirements for medical assistance when the Authority conducts eligibility determinations.

(2) Any reference to OAR Chapter 461 in Oregon Administrative Rules or contracts of the Authority are deemed to be references to the requirements of this rule, and shall be construed to apply to all eligibility policies, procedures and determinations by or through the Authority.

(3) For purposes of this rule, references in OAR chapter 461 to the Department or to the Authority shall be construed to be references to both agencies.

(4) Effective on or after July 1, 2011 the Authority shall conduct medical eligibility determinations using the OAR chapter 461 rules which are in effect on the date the Authority makes the medical eligibility determination.

(5) A request for a hearing resulting from a determination under this rule, made by the Authority shall be handled pursuant to the hearing procedures set out in division 25 of OAR Chapter 461. References to “the Administrator” in division 25 of chapter 461 or “the Department” are hereby incorporated as references to the” Authority.”

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.042 & 414.065
Hist.: DMAP 10-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 18-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12; DMAP 21-2011(Temp), f. 7-29-11, cert. ef. 8-1-11 thru 1-11-12; DMAP 25-2011(Temp), f. 9-28-11, cert. ef. 10-1-11 thru 1-11-12; DMAP 36-2011, f. 12-13-11, cert. ef. 1-1-12; DMAP 1-2012(Temp), f. & cert. e.f 1-13-12 thru 7-10-12; DMAP 2-2012(Temp), f. & cert. ef. 1-26-12 thru 7-10-12; DMAP 3-2012(Temp), f. & cert. ef. 1-31-12 thru 2-1-12; DMAP 4-2012(Temp), f. 1-31-12, cert. ef. 2-1-12 thru 7-10-12


 

Rule Caption: Adoption of rules governing the Rural Medical Practitioners Insurance Subsidy Program.

Adm. Order No.: DMAP 5-2012(Temp)

Filed with Sec. of State: 1-31-2012

Certified to be Effective: 1-31-12 thru 7-28-12

Notice Publication Date:

Rules Adopted: 410-500-0000, 410-500-0010, 410-500-0020, 410-500-0030, 410-500-0040, 410-500-0050, 410-500-0060

Subject: The Rural Medical Practitioners Insurance Subsidy Program administrative rules govern Division payments to medical professional liability insurance carriers from the Rural Medical Liability Subsidy Fund. Payments from the fund will subsidize the cost of premiums charged by carriers to qualified practitioners for policies issued, in force or renewed on or after January 1, 2012. The rules identify medical practitioner criteria for participation in the program, as well as insurance carrier requirements for submitting requests for subsidy payments.

Rules Coordinator: Cheryl Peters—(503) 945-6527

410-500-0000

Purpose

(1) Effective retroactive to January 1, 2012, the Rural Medical Practitioners Insurance Subsidy Program (Program) has been established in the Oregon Health Authority (Authority).

(2) The purpose of the Program is to provide payments from the Rural Medical Liability Subsidy Fund to authorized medical professional liability insurance carriers to subsidize the cost of premiums charged by carriers to qualified practitioners for policies issued, in force or renewed on or after January 1, 2012, in the manner provided in these rules.

(3) Payment of premium subsidies in accordance with these rules is the sole purpose of the Authority’s responsibility under this Program. The Authority does not accept or assume any liability for claims involving a carrier or a practitioner, or disputes between them.

Stat. Auth.: ORS 413.022 & 2011 OL Ch. 560
Stats. Implemented: ORS 413.022
Hist.: DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12

410-500-0010

Definitions

For the purposes of OAR 410-500-0000 through 410-500-0060, the following definitions shall apply:

(1) Carrier means a medical professional liability insurer holding a valid certificate of authority from the Director of the Department of Consumer and Business Services (DCBS) that authorizes the transaction of insurance as defined in ORS 731.066(1) and 731.072(1), and does not include DCBS listed insurers pursuant to 735.300 to 735.365 and 735.400 to 735.495.

(2) Medical assistance has the same meaning given that term in ORS 414.025.

(3) Medicare means medical coverage provided under Title XVIII of the Social Security Act.

(4) Office of Rural Health (Office) has the meaning established in ORS 442.475.

(5) Practitioner means a physician licensed under ORS chapter 677 or a nurse practitioner certified under ORS 678.375 who has a rural practice that meets criteria established by the Office of Rural Health that applied as of January 1, 2004, for the purposes of ORS 315.613. Practitioner does not include a physician or nurse practitioner who is located in an urbanized area of Jackson County, as defined by the United States Census Bureau according to the most recent federal decennial census taken pursuant to the authority of the United States Department of Commerce under 13 U.S.C. 141(a), unless the practitioner is:

(a) A physician who specializes in obstetrics or who specializes in family or general practice and provides obstetrical services; or

(b) A nurse practitioner who is certified for obstetric care.

(6) Rural Medical Liability Subsidy Fund means a fund established in Section 3 of 2011 Oregon Laws chapter 560 to provide payments to medical professional liability insurance carriers to subsidize the cost of premiums charged by the carriers to qualifying practitioners.

(7) Rural Medical Practitioner Insurance Fund Program (Program) is the program established by the Authority to provide payments to authorized medical professional liability insurance carriers to subsidize the cost of premiums charged by the carriers to qualified practitioners from the Rural Medical Liability Subsidy Fund established in Section 3 of 2011 Oregon Laws chapter 560.

Stat. Auth.: ORS 413.022 & 2011 OL Ch. 560
Stats. Implemented: ORS 413.022
Hist.: DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12

410-500-0020

Eligibility Criteria for Rural Practitioners

(1) A practitioner who has a rural practice that meets the criteria established by the Office for the purposes of ORS 315.613 is eligible for a subsidy under this program if the practitioner:

(a) Holds an active, unrestricted license or certification;

(b) Is covered by a medical professional liability insurance policy issued by an authorized carrier with minimum limits of coverage of $1 million per occurrence and $1 million annual aggregate; and

(c) Is willing to serve patients with Medicare coverage and patients receiving medical assistance in at least the same proportion to the practitioner’s total number of patients as the Medicare and medical assistance populations represent of the total number of individuals determined by the Office to be in need of care in the areas served by the practice.

(2) A nurse practitioner who is employed by a licensed physician is eligible for a subsidy if they are covered by a medical professional liability insurance policy that names the nurse practitioner and separately calculates the premium for the nurse practitioner.

(3) A practitioner whose medical professional liability insurance coverage is provided through a health care facility, as defined in ORS 442.400, and who otherwise meets the requirements of section (4) of this section is eligible for a premium subsidy if the Office determines that practitioner:

(a) Is not an employee of the health care facility;

(b) Is covered by a medical professional liability insurance policy that names the practitioner and separately calculates the premium for the practitioner; and

(c) Fully reimburses the health care facility for the premium calculated for the practitioner.

(4) Eligibility by individual practitioners to participate in the Program must be requested each year using an annual attestation administered by the Office. Consistent with the requirements of this rule, the Office shall establish criteria and procedures for making the eligibility determinations and for an annual attestation procedure that must be used by practitioners.

(5) The Office shall determine the eligibility of practitioners to participate in the Program in accordance with this rule, and shall provide its eligibility determination to the Authority and the practitioner.

(a) If a practitioner disagrees with a determination about whether a particular practitioner qualifies for the Program, the Office shall conduct an informal review and issue its recommendation to the Authority.

(b) The Authority shall make the final determination of eligibility to participate in the Program. Appeals shall be handled in accordance with the procedure for administrative review described in OAR 410-500-0060.

(6) The Authority shall forward to each of the authorized carriers participating in this Program, the list of eligible practitioners that it receives from the Office. The list shall include the practitioner’s name, mailing address, specialty, and applicable professional license or certification number issued by either the Board of Medical Examiners or the Board of Nursing.

Stat. Auth.: ORS 413.022 & 2011 OL Ch. 560
Stats. Implemented: ORS 413.022
Hist.: DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12

410-500-0030

Determination of Subsidy Amount

(1) Beginning with the first calendar quarter in 2012, premium subsidy payments may be made to authorized carriers to subsidize the cost of premiums charged by the carrier to eligible practitioners, in accordance with these rules.

(a) Premium subsidies are paid as a percentage of the actual premium charged for medical professional liability insurance with limits of coverage of $1 million per occurrence and up to $3 million annual aggregate.

(b) Notwithstanding section (1)(a) of this rule, the premium subsidy for a practitioner referred to in 410-500-0030(3)(c) or (d) shall be the lesser of the percentage of the premium due or paid for the current calendar year and the premium paid in the previous calendar year. When determining the lesser amount, any step increases in the premium owing to the claims-made nature of the policy may not be considered.

(2) Within 30 days after the end of each billing period (monthly or quarterly), each authorized carrier must electronically submit a report to the Authority showing the following information for each eligible practitioner who has been determined eligible for a premium subsidy by the Office in accordance with OAR 410-500-0020, as of the end of the billing quarter under this Program.

(a) The information required to be submitted electronically (using Microsoft Excel or similar spreadsheet application) must include the following:

(A) Carrier’s name;

(B) Practitioner’s name and, for each practitioner:

(i) Oregon Board of Medical Examiners license number or Oregon State Board of Nursing certification number;

(ii) Practitioner’s specialty and specialty class;

(iii) ISO code;

(iv) Policy number;

(v) Policy effective date;

(vi) Billing period coverage start date;

(vii) Billing period coverage end date;

(viii) Billing frequency (annually, quarterly, monthly);

(ix) Current in-force annual premium for limits of coverage of $1 million per occurrence and up to $3 million annual aggregate;

(x) Premium subsidy percentage, calculated in accordance with section (3) of this rules;

(xi) Dollar amount of premium subsidy, calculated in accordance with these rules;

(xii) Explanation of any adjustments under this Program from previous reports;

(xiii) Policy coverage limits;

(xiv) Identification of practitioners who were not on the eligible list at the beginning of the quarter, including all of the foregoing information for eligible practitioners;

(xv) Claims-made step of practitioner, if applicable.

(b) In January of each calendar year, each authorized carrier must provide the Authority with a copy of its base rates and increased limits factors table; and the authorized carrier must inform the Authority of the base rates and increased limits factors table from their current rate filing for Oregon within 30 days of any change to those rates and table.

(c) When a carrier submits its report or rates, the submission is deemed to be a certification that the information included in the report is true, accurate and complete.

(d) Failure to make a timely submission may result in delay in processing the payment request. The payment of premium subsidies from the Rural Medical Liability Subsidy Fund is calculated by the Authority based on the funds available for the applicable billing period. In the event of insufficient funds, the risk of carrier delay in submission of a request for subsidy payment is on the carrier, because payments shall be based on the subsidy requests timely received for each applicable billing period.

(3) Subject to section (4) of this rule, the amount of the premium subsidy paid under this Program shall be calculated for eligible practitioners, as follows:

(a) Eighty percent of the actual premium charged for physicians specializing in obstetrics and nurse practitioners certified for obstetric care;

(b) Sixty percent of the actual premium charged for physicians specializing in family or general practice who provide obstetrical services;

(c) Forty percent of the actual premium charged for physicians and nurse practitioners engaging in one or more of the following practices:

(A) Family practice without obstetrical services;

(B) General practice without obstetrical services;

(C) Internal medicine;

(D) Geriatrics;

(E) Pulmonary medicine;

(F) Pediatrics;

(G) General surgery; or

(H) Anesthesiology;

(d) Fifteen percent of the actual premium charged for physicians and nurse practitioners other than those included in sections (3)(a) through (c).

(e) Using the information timely provided by carriers provided pursuant to section (2) of this rule, the information provided by the Office about eligible practitioners, and the provisions of this rule describing the calculation of the premium subsidy amounts, the Authority shall review the report for accuracy, and make the appropriate premium subsidy payments to the authorized carriers under this Program for undisputed items to the authorized carrier within 30 days of receipt.

(4) All payments authorized to be made by the Authority under this Program must be made from the Rural Medical Liability Subsidy Fund. No other funds have been established by the Legislative Assembly to make any premium subsidy payments under this Program.

(a) If the funds available for the Program in the Rural Medical Liability Subsidy Fund are insufficient to provide the maximum premium subsidy for all practitioners who qualify for the Program, the Authority shall reduce or eliminate subsidies for practitioners described in section (3)(d).

(b) If, after eliminating subsidies for practitioners described in section (3)(d), the funds in the Rural Medical Liability Subsidy Fund are insufficient to provide the maximum premium subsidies for the remaining practitioners, the Authority shall also reduce or eliminate the subsidies for practitioners described in section (3)(c).

(c) If the funds available for the Program in the Rural Medical Liability Subsidy Fund are insufficient to provide the subsidies for the remaining practitioners, the Program may not make payments that exceed the amounts remaining in the Fund.

(d) If the Authority is required to take any of the actions described in this rule due to insufficient funds to pay a premium subsidy, the Authority shall inform the affected participants and carriers about the action.

(5) An authorized carrier shall reduce the premium charged to a practitioner by the amount of any premium subsidy paid or to be paid under this Program. Each authorized carrier must provide its participating practitioners with the following information each quarter this Program is in effect:

(a) The quarterly premium due before the premium subsidy is applied;

(b) The amount of the premium subsidy; and

(c) The premium after the premium subsidy is applied.

(6) The authorized carrier shall display these three figures on each billing statement of a participating practitioner.

Stat. Auth.: ORS 413.022 & 2011 OL Ch. 560
Stats. Implemented: ORS 413.022
Hist.: DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12

410-500-0040

Authorized Carriers

(1) Carriers seeking to participate in the Program must provide written notice and certification to the Authority in writing not less than 30 days prior to the beginning date of a calendar quarter. However, for the first quarter of 2012, that notification may occur up to and including, but not later than January 31, 2012, for subsidy payments applicable to the first calendar quarter of 2012. The initial carrier written notification and certification required in this rule must be signed by an individual authorized to represent the carrier and delivered to the Authority at the following address: Oregon Health Authority, 500 Summer St NE, E-44, Salem, OR 97301, Attention: Rural Medical Practitioners Insurance Subsidy Program.

(a) The written notification must certify to the Administrator of the Program the following:

(A) That the carrier is a medical professional liability insurer holding a valid certificate of authority from the Director of DCBS that authorizes the transaction of insurance as defined in ORS 731.066(1) and 731.072(1), and does not include DCBS listed insurers pursuant to 735.300 to 735.365 and 735.400 to 735.495;

(B) That the carrier understands that the Authority may confirm the representations in paragraph (A) with DCBS, and that DCBS’ determination about whether the carrier holds a valid certificate of authority to engage in professional liability insurance in the state of Oregon and the other criteria in paragraph (A) shall be relied upon by the Authority in determining whether an insurer is an authorized carrier under this Program; and

(C) That the carrier agrees to comply with the terms and conditions of the rules applicable to this Program in effect at the time of initial certification and those rules in effect when any request for subsidy payment is submitted to the Authority for payment.

(D) The Authority shall confirm in writing that the carrier meets the criteria as an authorized carrier for purposes of this Program. If the Authority determines that an entity is not eligible to participate as a carrier in this Program, the Authority shall provide notice to the entity of its determination and shall deny participation in the Program. A request to appeal that determination shall be handled by the Authority in accordance with the procedure for administrative review described in OAR 410-500-0060.

(b) An insurer’s failure to provide the notice and certification to the Authority within the time established in this rule means that the insurer is not authorized to submit a request for premium subsidy payment for the next calendar quarter and also means that the insurer’s otherwise eligible practitioners shall be ineligible to receive a premium subsidy for that quarter.

(c) An authorized carrier must provide, and continue to provide, to the Authority accurate, complete and truthful information concerning their qualification for participation in the Program. A carrier must notify the Authority in writing of a material change in any status or condition that relates to their eligibility to participate in the Program.

(2) An authorized carrier choosing not to continue to participate in the Program shall notify the Authority at least 90 days prior to the beginning date of the next calendar quarter. The carrier shall notify its insured practitioners participating in the Program of its intent to not participate at least 60 days prior to the date of the next calendar quarter.

(3) Authorized carriers understand and agree that the Authority may determine that funds available for the Program are insufficient to provide maximum premium subsidy for all qualified practitioners, and that the Authority may reduce or eliminate subsidies. There is no guarantee of any amount of premium subsidy that may be provided to any carrier.

Stat. Auth.: ORS 413.022 & 2011 OL Ch. 560
Stats. Implemented: ORS 413.022
Hist.: DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12

410-500-0050

Program Integrity

(1) The Authority shall analyze and monitor the operation of the Program and audit and verify the accuracy and appropriateness of subsidy payments, or other program integrity actions. To promote the integrity of the administration of the program, the carrier shall:

(a) Develop and maintain adequate financial and other documentation which supports the actual premium payments and coverage records for which payment has been requested. Payment shall be made only for services that are adequately documented. Documentation must be completed before the service is billed to the Authority. The records must be accurate and in sufficient detail to substantiate the data reported in relation to a request for premium subsidy payment;

(b) Have policies and procedures to ensure the maintenance of the applicable records;

(c) Upon written request from the Authority, the Oregon Secretary of State (Secretary), other federal or state oversight agency or their authorized representatives, furnish requested documentation immediately or within the time-frame specified in the written request. Copies of the documents may be furnished unless the originals are requested. At their discretion, official representatives of the Authority or Secretary or other oversight agency, may review and copy the original documentation in the carrier’s place of business. Upon the written request of the carrier, the Program or the Secretary or other oversight agency may, at their sole discretion, modify or extend the time for provision of such records if, in the opinion of the Program or the Secretary or other oversight agency good cause for such extension is shown;

(d) Failure to comply with requests for documents and within the specified time-frames means that the records subject to the request may be deemed by the Authority not to exist for purposes of verifying appropriateness of payment, and accordingly subjects the carrier to possible denial or recovery of payments made by the Authority or to other actions;

(e) The Authority may communicate with and coordinate any program integrity actions with the federal and state oversight authorities, including but not limited to DCBS if documentation is missing or is inconsistent with claims made for payment of subsidies.

(2) When the Authority determines that an overpayment has been made to a carrier, the amount of overpayment is subject to recovery. The Authority may take appropriate action to redress payment errors or false claims for payment under the Program.

(a) If an authorized carrier determines that a subsidy payment request is incorrect, the carrier shall submit a correction within 30 calendar days of the discovery of the error and refund the amount of any overpayment at that time.

(b) If the Authority determines that an authorized carrier received a premium subsidy for an insured eligible practitioner that exceeded the amount that should have been paid, the Authority shall notify the authorized carrier and require the carrier to remit the overpayment to the Authority within 30 days of the date of the notification. Overpayment collection repayment from a carrier does not prevent the authorized carrier from collecting the appropriate premium from the insured; however, the Authority’s ability to recover an overpayment from a carrier is not limited by whether the carrier recovers any amount from its insured.

(c) The Authority may recover overpayments made to a carrier by direct reimbursement, offset, civil action, or other actions authorized by law:

(A) The carrier must make a direct reimbursement to the Authority within 30 calendar days from the date of the notice of the overpayment;

(B) The Authority may grant the carrier an additional period of time to reimburse the Authority upon written request made within 30 calendar days from the date of the notice of overpayment if the carrier provides a statement of facts and reasons sufficient to show that repayment of the overpayment amount should be delayed pending appeal because there is a reason to believe that the overpayment is not correct or is less than the amount in the notice, and the carrier has timely filed a request for administrative review of the overpayment determination, or that carrier accepts the amount of the overpayment but is authorized in writing by the Authority to make repayment over a period of time;

(3) Appeals of overpayment determinations are handled by the Authority in accordance with the procedure for administrative review described in OAR 410-500-0060.

(4) If the carrier does not timely request an administrative review, the overpayment is final and the amount of the overpayment shall be due and payable to the Authority.

(5) The Authority may withhold payment on pending premium subsidy payment requests and on subsequently received premium subsidy payment requests for the amount of the overpayment when overpayments are not paid in accordance with the requirements of this rule;

(6) The Authority may file a civil action in the appropriate court and exercise all other civil remedies available to the Authority in order to recover the amount of an overpayment.

(7) A noncompliant carrier may be terminated from participation in the Program.

(8) An authorized carrier’s failure to reduce the premium charged to a qualified practitioner by the amount of the premium subsidy paid under this Program or other noncompliance with Program requirements may result in termination of the carrier from the Program and recovery of any premium payments made to the carrier that were not expended in accordance with the requirements of this Program, if the authorized carrier fails to cure the deficiency within the time and in the manner prescribed by the Authority.

Stat. Auth.: ORS 413.022 & 2011 OL Ch. 560
Stats. Implemented: ORS 413.022
Hist.: DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12

410-500-0060

Appeals: Administrative Review

(1) Administrative review, for purposes of these rules, shall be the process for any appeals made to the Authority under this Program. An administrative review is an appeal process that allows an opportunity for the Administrator of the Program or designee to review a decision. Administrative review is not a contested case.

(2) A request for administrative review must be received by the Authority not later than 30 calendar days after the date of the Authority’s notice.

(3) If administrative review is timely requested, the practitioner or the carrier must provide the Authority with a copy of all relevant records and other materials relevant to the appeal, not later than 10 days before the review is scheduled.

(4) If the Administrator or designee decides that a preliminary meeting between the practitioner or carrier and Authority staff may assist the review, the Administrator or designee shall notify the individual requesting the review of the date, time, and place the meeting is scheduled.

(5) The administrative review meeting shall be conducted as follows:

(a) It will be conducted by the Administrator, or designee;

(b) No minutes or transcript of the review shall be made;

(c) The individual requesting the review does not have to be represented by counsel during an administrative review meeting and shall be given ample opportunity to present relevant information;

(d) Authority staff shall not be available for cross-examination, but Authority staff may attend and participate in the review meeting;

(e) Failure to appear without good cause constitutes acceptance of the Authority’s determination;

(f) The Administrator may combine similar administrative review proceedings involving the same individual or similar facts, including the meeting, if the Administrator determines that joint proceedings may facilitate the review;

(g) The Administrator or designee may request the practitioner or carrier making the appeal to submit, in writing, new information that has been presented orally. In such an instance, a specific date for receiving such information shall be established.

(6) The results of the administrative review shall be sent to the participants involved in the review, within 30 calendar days of the conclusion of the administrative review meeting, or such time as may be agreed to by the participants or designated by the Authority.

(7) The Authority’s final decision on administrative review is the final decision on appeal and binding on the parties. Under ORS 183.484, this decision is an order in other than a contested case. ORS 183.484 and the procedures in OAR 137-004-0080 to 137-004-0092 apply to the Authority’s final decision on administrative review.

(8) These rules shall be construed in accordance with the laws of the State of Oregon without regard to principles of conflicts of law. The courts of the State of Oregon are empowered to resolve any disputes, with venue in Marion County.

Stat. Auth.: ORS 413.022 & 2011 OL Ch. 560
Stats. Implemented: ORS 413.022
Hist.: DMAP 5-2012(Temp), f. & cert. ef. 1-31-12 thru 7-28-12


 

Rule Caption: Adopts Attorney General’s model rules with the exception to the postmark date.

Adm. Order No.: DMAP 6-2012(Temp)

Filed with Sec. of State: 2-1-2012

Certified to be Effective: 2-1-12 thru 7-4-12

Notice Publication Date:

Rules Amended: 410-120-1860

Subject: The General Rules program administrative rules govern Division payments for services to clients. The Division needs to amend OAR 410-120-1860 because basing timeliness of a hearing request on the date of a postmark would create operational conflicts due to the number of client documents received, the number of staff opening mail, and the expense of changing procedures about saving envelopes. This amendment avoids these conflicts by continuing current contested case procedures under which the timeliness of a hearing request is based on the date the Authority receives it, not the date of the postmark.

Rules Coordinator: Cheryl Peters—(503) 945-6527

410-120-1860

Contested Case Hearing Procedures

(1) These rules apply to all contested case hearings provided by the Division of Medical Assistance Programs (Division) involving a client’s medical or dental benefits, except as otherwise provided in OAR 410-141-0263. The hearings are conducted in accordance with the Attorney General’s model rules at 137-003-0501 and following. When the term “agency” is used in the Attorney General’s model rules, it shall refer to the Division for purposes of this rule Except for 137-003-0528(1)(a), the method described in 137-003-0520(8)-(10) is used in computing any period of time prescribed in this division of rules (OAR 410 division 120) applicable to timely filing of client requests for hearing. Due to operational conflicts, the procedures needing revision and the expense of doing so, 137-003-0528(1)(a), which allows hearing requests to be treated as timely based on the date of postmark, does not apply to Division contested cases.

(2) Medical provider appeals and administrative reviews involving the Division are governed by OAR 410-120-1560 through 410-120-1700

(3) Complaints and appeals for clients requesting or receiving medical assistance from a Prepaid Health Plan (PHP) shall be governed exclusively by the procedures in OAR 410-141-0260. This rule describes the procedures applicable when those clients request and are eligible for a Division contested case hearing.

(4) Contested Case Hearing Requests:

(a) A client has the right to a contested case hearing in the following situations upon the timely completion of a request for a hearing:

(A) The Authority acts to deny client services, payment of a claim, or to terminate, discontinue or reduce a course of treatment, or issues related to disenrollment in a Fully Capitated Health Plan (FCHP), Physician Care Organization (PCO), Dental Care Organization (DCO) or Chemical Dependency Organization (CDO); or

(B) The right of a client to request a contested case hearing is otherwise provided by statute or rule, including OAR 410-141-0264(10) describing when a client of a PHP may request a state hearing.

(b) To be timely, a request for a hearing is complete when the Division receives the Authority’s Administrative Hearing request form (DMAP 443) not later than the 45th day following the date of the decision notice;

(c) In the event a request for hearing is not timely, the Division will determine whether the failure to timely file the hearing request was caused by circumstances beyond the control of the client and enter an order accordingly. In determining whether to accept a late hearing request, the Division requires the request to be supported by a written statement that explains why the request for hearing is late. The Division may conduct such further inquiry as the Division deems appropriate. In determining timeliness of filing a hearing request, the amount of time that the Division determines accounts for circumstances beyond the control of the client is not counted. The Division may refer an untimely request to the Office of Administrative Hearings for a hearing on the question of timeliness;

(d) In the event the claimant has no right to a contested case hearing on an issue, the Division may enter an order accordingly. The Division may refer a hearing request to the Office of Administrative Hearings for a hearing on the question of whether the claimant has a right to a contested case hearing;

(e) A client who requests a hearing shall be referred to as a claimant. The parties to a contested case hearing are the claimant and, if the claimant has requested a hearing about a decision of a PHP, the claimant’s PHP;

(f) A client may be represented by any of the persons identified in ORS 183.458. A PHP that is a corporation may be represented by any of the persons identified in 410.190.

(5) Expedited hearings:

(a) A claimant who feels his or her medical or dental problem cannot wait for the normal review process may be entitled to an expedited hearing;

(b) Expedited hearings are requested using Authority Form 443;

(c) Division staff will request all relevant medical documentation and present the documentation obtained in response to that request to the Division Medical Director or the Medical Director’s designee for review. The Division Medical Director or the Medical Director’s designee will decide if the claimant is entitled to an expedited hearing within, as nearly as possible, two working days from the date of receiving the documentation applicable to the request;

(d) An expedited hearing will be allowed, if the Division Medical Director or the Medical Director’s designee, determines that the claimant has a medical condition which is an immediate, serious threat to claimant’s life or health and claimant has been denied a medical service.

(6) Informal conference:

(a) The Division hearing representative and the claimant, and their legal representative if any, may have an informal conference, without the presence of the Administrative law Judge (ALJ), to discuss any of the matters listed in OAR 137-003-0575. The informal conference may also be used to:

(A) Provide an opportunity for the Division and the claimant to settle the matter;

(B) Provide an opportunity to make sure the claimant understands the reason for the action that is subject of the hearing request;

(C) Give the claimant and the Division an opportunity to review the information that is the basis for that action;

(D) Inform the claimant of the rules that serve as the basis for the contested action;

(E) Give the claimant and the Division the chance to correct any misunderstanding of the facts;

(F) Determine if the claimant wishes to have any witness subpoenas issued for the hearing; and

(G) Give the Division an opportunity to review its action.

(b) The claimant may, at any time prior to the hearing date, request an additional informal conference with the Authority representative, which may be granted if the Authority representative finds, in his or her sole discretion, that the additional informal discussion will facilitate the hearing process or resolution of disputed issues;

(c) The Division may provide to the claimant the relief sought at any time before the Final Order is served;

(d) Any agreement reached in an informal conference shall be submitted to the ALJ in writing or presented orally on the record at the hearing.

(7) A claimant may withdraw a hearing request at any time. The withdrawal is effective on the date it is received by the Division or the ALJ, whichever is first. The ALJ will send a Final Order confirming the withdrawal to the claimant’s last known address. The claimant may cancel the withdrawal up to the tenth calendar day following the date such an order is effective.

(8) Contested case hearings are closed to non-participants in the hearing.

(9) Proposed and Final Orders:

(a) In a contested case, an ALJ assigned by the Office of Administrative Hearings will serve a proposed order on all parties and the Division, unless, prior to the hearing, the Division notifies the ALJ that a final order may be served. The proposed order issued by the ALJ will become a final order if no exceptions are filed within the time specified in subsection (b) unless the Division notifies the parties and the ALJ that the Division will issue the final order;

(b) If the ALJ issues a proposed order, and a party adversely affected by the proposed order may file exceptions to the proposed order or present argument for the Division’s consideration:

(A) The exceptions must be in writing and reach the Division not later than 10 working days after date the proposed order is issued by the ALJ;

(B) After receiving the exceptions, if any, the Division may adopt the proposed order as the final order or may prepare a new order. Prior to issuing the final order, the Authority will issue an amended proposed order.

(10) A hearing request is dismissed by order when neither the party nor the party’s legal representative, if any, appears at the time and place specified for the hearing. The order is effective on the date scheduled for the hearing. The Division will cancel the dismissal order on request of the party on a showing that the party was unable to attend the hearing and unable to request a postponement for reasons beyond his or her control.

(11) The final order is effective immediately upon being signed or as otherwise provided in the order. A final order resulting from the claimant’s withdrawal of the hearing request is effective the date the claimant withdraws. When claimant fails to appear for the hearing and the hearing request is dismissed by final order, the effective date of the order is the date of the scheduled hearing.

(12) All contested case hearing decisions are subject to judicial review under ORS 183.482 in the Court of Appeals.

[ED. NOTE: Forms referenced are available from the agency.]

Stat. Auth.: ORS 183.341 & 413.042
Stats. Implemented: ORS 183.411 - 183.470, 414.025, 414.055 & 414.065
Hist.: AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 13-1984(Temp), f. & ef. 4-2-84; AFS 37-1984, f. 8-30-84, ef. 9-1-84; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0053; HR 19-1990, f. & cert. ef. 7-9-90; HR 35-1990(Temp), f. & cert. ef. 10-15-90; HR 32-1990, f. 9-24-90, cert. ef. 10-1-90; HR 41-1990, f. & cert. ef. 11-26-90; HR 11-1991(Temp), f. & cert. ef. 3-1-91; HR 34-1991, f. & cert. ef. 8-26-91; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0760; HR 7-1996, f. 5-31-96 & cert. ef. 6-1-96; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 41-2000, f. & cert. ef. 12-1-00; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; DMAP 6-2012(Temp), f. & cert. ef. 2-1-12 thru 7-4-12


 

Rule Caption: Adopts Attorney General’s model rules with the exception to the postmark date.

Adm. Order No.: DMAP 7-2012(Temp)

Filed with Sec. of State: 2-7-2012

Certified to be Effective: 2-7-12 thru 8-4-12

Notice Publication Date:

Rules Amended: 410-141-0264

Subject: The Managed Care Rules Program administrative rules govern the Division payments for services provided to clients. The Division temporarily amended OAR 410-141-0264 effective to February 1, 2012, This rule needs to be amended because basing timeliness of a hearing request on the date of a postmark would create operational conflicts due to the number of client documents received, the number of staff opening mail, and the expense of changing procedures about saving envelopes. This amendment avoids these conflicts by continuing current contested case procedures under which the timeliness of a hearing request is based on the date the Division receives it, not the date of the postmark. The Division intends to permanently amend this rule.

Rules Coordinator: Cheryl Peters—(503) 945-6527

410-141-0264

Administrative Hearings

The Division of Medical Assistance Programs (Division) may have specific definitions for common terms. Please use OAR 410-141-0000, Definitions, in conjunction with this rule.

(1) An individual who is or was a Division member (see definition) at the time of the Notice of Action is entitled to an administrative hearing by the Division if a Prepaid Health Plan (PHP) has denied requested services, payment of a claim, or terminates, discontinues or reduces a course of treatment, or any other “action.”

(a) If the Division member initiates an administrative hearing directly with the Division, the decision in the Notice of Action is the document that will trigger the right to request a state administrative hearing:

(b) If the Division member requests an administrative hearing after receiving a Notice of Appeal Resolution, the decision in the Notice of Appeal Resolution is the document that will trigger the right to request a state administrative hearing:

(c) Client (see definition) administrative hearings are governed by OAR 410-120-1860, 410-120-1865, and this rule.

(2) A written hearing request must be received by the Hearings Unit at the Division not later than the 45th day following the date of the Notice of Action, or if the hearing request was initiated after an appeal, not later than the 45th day following the Notice of Appeal Resolution.

(3) Effective, February 1, 2012, , the method described in OAR 137-003-0520(8)–(10) is used in computing any period of time prescribed in the division of rules in OAR 410 division 120 and 141 applicable to timely filing of requests for hearing. Due to operational conflicts, the procedures needing revision and the expense of doing so, 137-003-0520(9) and 137-003-0528(1)(a), which allows hearing requests to be treated as timely based on the date of postmark, does not apply to Division hearing requests.

(4) If, at the Division member’s request, the PHP continued or reinstated services while an appeal was pending, the benefits must be continued pending the administrative hearing until one of the following occurs:

(a) The Division member withdraws the request for an administrative hearing;

(b) Ten calendar days pass after the PHP mails the Notice of Appeal Resolution, providing the resolution of the appeal against the Division member, unless the Division member within the 10-day timeframe, has requested a Division administrative hearing with continuation of benefits until the Division administrative hearing decision is reached;

(c) A final order is issued in a Division administrative hearing adverse to the Division member; or

(d) The time period or service limits of a previously authorized service have been met.

(5) The Division representative (see definition) shall review the administrative hearing request, documentation related to the administrative hearing issue, and computer records to determine whether the claimant or the person for whom the request is being made is or was a Division member at the time the action was taken, and whether the hearing request was timely.

(6) PHPs shall immediately transmit to the Division any administrative hearing request submitted on behalf of a Division member, including a copy of the Division member’s Notice of Action and, if applicable, Notice of Appeal Resolution.

(7) If the Division member files a request for an administrative hearing with the Division, the Division will send a copy of the hearing request to the PHP.

(8) PHPs shall review an administrative hearing request, which has not been previously received or reviewed as an appeal, using the PHP’s appeal process as follows:

(a) The appeal shall be reviewed immediately and shall be resolved, if possible, within 16 calendar days, pursuant to OAR 410-141-0262;

(b) The PHP’s Notice of Appeal Resolution shall be in writing and shall be provided to the Division member.

(9) When an administrative hearing is requested by a Division member, the PHP shall cooperate with providing relevant information required for the hearing process to the Division, as well as the results of the review by the PHP of the appeal and the administrative hearing request, and any attempts at resolution by the PHP.

(10) Information about Division members used for administrative hearings is handled in confidence consistent with ORS 411.320, 42 CFR 431.300 et seq, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules, and other applicable federal and state confidentiality laws and regulations. The Division will safeguard the Division member’s right to confidentiality of information used in the administrative hearing as follows:

(a) The Division, the Division member and their representative, the PHP and any practitioner (see definition) whose authorization, treatment, services, items, or request for payment is involved in the administrative hearing have a right to use this information for purposes of resolving the administrative hearing without a signed release from the Division member. The Division may also use this information, pursuant to OAR 410-120-1360(4), for health oversight purposes, and for other purposes authorized or required by law. The information may also be disclosed to the Office of administrative hearings and the Administrative Law Judge assigned to the administrative hearing, and to the Court of Appeals if the Division member seeks judicial review of the final order;

(b) Except as provided in subsection (a), the Division will ask the Division member to authorize a release of information regarding the administrative hearing to other individuals. Before any information related to the administrative hearing is disclosed under this subsection, the Division must have an authorization for release of information documented in the administrative hearing file.

(11) The hearings request (DHS 443), along with the Notice of Appeal Resolution, shall be referred to the Office of Administrative Hearings and the hearing will be scheduled.

(a) The parties to the administrative hearing shall include the PHP, as well as the Division member and his or her representative, or the representative of a deceased Division member’s estate;

(b) The procedures applicable to the administrative hearing shall be conducted consistent with OAR 410-120-1860 and 410-120-1865;

(c) A final order should be issued or the case otherwise resolved by Division ordinarily within 90 calendar days from the earlier of the following: the date the Division member requested a PHP appeal (not including the number of days the Division member took to subsequently file for a Division administrative hearing) or the date the Division member filed for direct access to a Division administrative hearing. The final order is the final decision of the Division.

(12) If the final resolution of the administrative hearing is adverse to the Division member, that is, if the final order upholds the PHP’s action, the PHP may recover the cost of the services furnished to the Division member while the administrative hearing is pending, to the extent that they were furnished solely because of the requirements of this section and in accordance with the policy set forth in 42 CFR 438.420.

(13) The PHP must promptly correct the action taken up to the limit of the original request or authorization, retroactive to the date the action was taken, if the hearing decision is favorable to the Division member, or Division and/or the PHP decides in the Division member’s favor before the hearing even if the Division member has lost eligibility after the date the action was taken:

(a) If the PHP, or a Division hearing decision reverses a decision to deny, limit, or delay services that were not furnished while the administrative hearing was pending, the PHP must authorize or provide the disputed services promptly and as expeditiously as the Division member’s health condition requires;

(b) If the PHP, or the Division hearing decision reverses a decision to deny authorization of services and the Division member received the disputed services while the administrative hearing was pending, the PHP must pay for the services in accordance with Division policy and regulations in effect when the request for services was made by the Division member.

Stat. Auth.: ORS 409.110 & 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 19-1996, f. & cert. ef. 10-1-96; HR 25-1997, f. & cert. ef. 10-1-97; OMAP 21-1998, f. & cert. ef. 7-1-98; OMAP 39-1999, f. & cert. ef. 10-1-99; OMAP 26-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 24-2003, f. 3-26-03 cert. ef. 4-1-03; OMAP 50-2003, f. 7-31-03 cert. ef 8-1-03; OMAP 35-2004, f. 5-26-04 cert. ef. 6-1-04; DMAP 22-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 45-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 7-2012(Temp), f. & cert. ef. 2-7-12 thru 8-4-12

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2011.

2.) Copyright 2012 Oregon Secretary of State: Terms and Conditions of Use

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