Oregon Health Authority, Division of Medical Assistance Programs, Chapter 410
Rule Caption: Align with Department of Human Services OAR chapter 461, medical eligibility rules
Adm. Order No.: DMAP 24-2013
Filed with Sec. of State: 5-29-2013
Certified to be Effective: 5-29-13
Notice Publication Date: 2-1-2013
Rules Amended: 410-120-0006
Rules Repealed: 410-120-0006(T)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) revision of medical eligibility rules in chapter 461, the Division is amending OAR 410-120-0006 to assure that the Division’s medical eligibility rule aligns with and reflects information found in the 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.
Rules Coordinator: Cheryl Peters—(503) 945-6527
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 May 29, 2013, 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.]
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; DMAP 9-2012(Temp), f. & cert. ef. 3-1-12 thru 7-10-12; DMAP 21-2012(Temp), f. 3-30-12, cert. ef. 4-1-12 thru 7-10-12; DMAP 25-2012(Temp), f. & cert. ef. 5-1-12 thru 7-10-12; Administrative correction 8-1-12; DMAP 35-2012(Temp), f. & cert. ef. 7-20-12 thru 1-15-13; DMAP 45-2012(Temp), f. & cert. ef. 10-5-12 thru 1-19-13; DMAP 50-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 53-2012(Temp), f. & cert. ef. 11-1-12 thru 4-29-13; DMAP 56-2012(Temp), f. 11-30-12, cert. ef. 12-1-12 thru 4-1-13; DMAP 60-2012, f. 12-27-12, cert. ef. 1-1-13; DMAP 65-2012(Temp), f. 12-28-12, cert. ef. 1-1-13 thru 6-29-13; DMAP 2-2013(Temp), f. & cert. e.f 1-8-13 thru 6-29-13; DMAP 3-2013(Temp), f. & cert. ef. 1-30-13 thru 6-29-13; DMAP 5-2013(Temp), f. & cert. ef. 2-20-13 thru 6-29-13; DMAP 7-2013(Temp), f. & cert. ef. 3-1-13 thru 6-29-13; DMAP 12-2013, f. 3-27-13, cert. ef. 4-1-13; DMAP 17-2013, f. & cert. ef. 4-10-13; DMAP 24-2013, f. & cert. ef. 5-29-13
Rule Caption: Authority requirements for approving transfer of 500 or more members from one CCO to another
Adm. Order No.: DMAP 25-2013
Filed with Sec. of State: 6-11-2013
Certified to be Effective: 6-11-13
Notice Publication Date: 4-1-2013
Rules Amended: 410-141-3080
Subject: This rule sets for the requirements as to when the Authority may approve the transfer of 500 or more members from one CCO to another CCO. This rule also sets for the timeframes for providing notice of transfer and prohibits members from transferring from one CCO to another no more than once during each enrollment period.
Rules Coordinator: Cheryl Peters—(503) 945-6527
Disenrollment from Coordinated Care Organizations
(1) At the time of recertification, a client may disenroll from one CCO in a service area and enroll in another CCO in that service area. The primary person in the household shall make this decision on behalf of all household members.
(2) A member who moves from one service area to another service area shall disenroll from the CCO in the previous service area and enroll with a CCO in the new service area.
The member must change their address with the Authority or Department within ten days of moving.
(3) A member who voluntarily enrolls in a CCO per OAR 410-141-3060 (19) may disenroll from their CCOs at any time and receive health care services on a fee-forservice basis or enroll in another CCO in their service area. This only applies to:
(a) Members who are eligible for both Medicare and Medicaid and
(b) Members who are American Indian and Alaskan Native beneficiaries;
(4) Notwithstanding other sections of this rule, members may request disenrollment for just cause at any time pursuant to state law or CFR 438.56. This includes:
(a) The CCO does not cover the service the member seeks, because of moral or religious objections;
(b) The member needs related services (for example a cesarean section and a tubal ligation) to be performed at the same time, not all related services are available within the network, and the member’s primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk; or
(c) The member is experiencing poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the member’s health care needs.
(5) The Authority may approve the disenrollment after medical review using the following just cause considerations:
(a) Required enrollment would pose a serious health risk; and
(b) The Authority finds no reasonable alternatives.
(6) The following applies to time lines for clients to change their CCO assignment:
(a) Newly eligible clients may change their CCO assignment within 90 days of their application for health services;
(b) Existing clients may change their CCO assignment within 30 days of the Authority’s automatic assignment in a CCO; or
(c) Clients may change their CCO assignment upon eligibility redetermination.
(d) Clients may change enrollment in their CCO once during each enrollment period.
(7) Pursuant to CFR 438.56, the CCO shall not request and the Authority shall not approve disenrollment of a member due to:
(a) A physical or behavioral disability or condition;
(b) An adverse change in the member’s health;
(c) The member’s utilization of services, either excessive or lacking;
(d) The member’s decisions regarding medical care with which the CCO disagrees;
(e) The member’s behavior is uncooperative or disruptive, including but not limited to threats or acts of physical violence, resulting from the member’s special needs, except when continued enrollment in the CCO seriously impairs the CCO’s ability to furnish services to this particular member or other members.
(8) A CCO may request the Authority to disenroll a member if the CCO determines:
(a) Except as provided in OAR 410-141-3050, the member has major medical coverage, including employer sponsored insurance (ESI) but excluding enrollment in a DCO;
(b) The CCO determines:
(A) The member has moved to a service area the CCO does not serve;
(B) The member is out of the CCO’s area for three months without making arrangements with the CCO;
(C) The member did not initiate enrollment in the CCO serving the member’s area; and
(D) The member is not in temporary placement or receiving out-of-area services.
(c) The member is in a state psychiatric institution;
(d) The CCO has verifiable information that the member has moved to another Medicaidjurisdiction; or
(e) The member is deceased.
(9) Before requesting disenrollment under the exception in section (7)(e) of this rule, a
CCO must take meaningful steps to address the member’s behavior, including but not limited to:
(a) Contacting the member either orally or in writing to explain and attempt to resolve the issue. The CCO must document all oral conversations in writing and send a written summary to the member. This contact may include communication from advocates, including peer wellness specialists, where appropriate, personal health navigators and qualified community health workers who are part of the member’s care team to provide assistance that is culturally and linguistically appropriate to the member’s need to access appropriate services and participate in processes affecting the member’s care and services;
(b) Developing and implementing a care plan in coordination with the member and the member’s care team that details the problem and how the CCO shall address it;
(c) Reasonably modifying practices and procedures as appropriate to accommodate the member’s circumstances;
(d) Assessing the member’s behavior to determine if it results from the member’s special needs or a disability;
(e) Providing education, counseling and other interventions to resolve the issue; and
(f) Submitting a complete summary to the Authority if the CCO requests disenrollment.
(10) The Authority may disenroll members of CCOs for the reasons specified in section (8) without receiving a disenrollment request from a CCO.
(11) The CCO shall request the Authority to suspend a member’s enrollment when the inmate is incarcerated in a State or Federal prison, a jail, detention facility or other penal institution for no longer than 12 months. The CCO shall request that the Authority disenroll a member when the inmate is incarcerated in a State or Federal prison, jail, detention facility or other institution for longer than 12 months. This does not include members on probation, house arrest, living voluntarily in a facility after adjudication of their case, infants living with inmates or inmates admitted for inpatient hospitalization. The CCO is responsible for identifying the members and providing sufficient proof of incarceration to the Authority for review of the request for suspension of enrollment or disenrollment. CCOs shall pay for inpatient services only during the time a member is an inmate and enrollment is otherwise suspended.
(12) Unless otherwise specified in these rules or in the Authority notification of disenrollment to the CCO, all disenrollments are effective at the end of the month the Authority approves the disenrollment, with the following exceptions;
(a) The Authority may specify a retroactive disenrollment effective date if the member has:
(A) Third party coverage including employee-sponsored insurance. The effective date shall be the date the coverage begins;
(B) Enrolls in a program for all-inclusive care for the elderly (PACE). The effective date shall be the day before PACE enrollment;
(C) Is admitted to the State Hospital. The effective date shall be the day before hospital admission; or
(D) Becomes deceased. The effective date shall be the date of death.
(b) The Authority may retroactively disenroll or suspend enrollment if the member is incarcerated pursuant to section (11) of this rule. The effective date shall be the date of the notice of incarceration or the day before incarceration, whichever is earlier.
(c) The Authority shall specify a disenrollment effective date if the member moves out of the CCO’s service area. The Authority shall recoup the balance of that month’s capitation payment from the CCO;
(d) The Authority may specify the disenrollment effective date if the member is no longer eligible for OHP;
(13) The Authority shall inform the members of a disenrollment decision in writing, including the right to request a contested case hearing to dispute the Authority’s disenrollment if the Authority disenrolled the member for cause that the member did not request. If the member requests a hearing, the disenrollment shall remain in effect pending outcome of the contested case hearing.
(14) For purposes of a client’s right to a contested case hearing, “disenrollment” does not include the Authority’s:
(a) Transfer of a member from a PHP to a CCO;
(b) Transfer of a member from a CCO to another CCO; or
(c) Automatic enrollment of a member in a CCO.
(15) The Authority may approve the transfer of 500 or more members from one CCO to another CCO if:
(a) The members’ provider has contracted with the receiving CCO and has stopped accepting patients from or has terminated providing services to members in the transferring CCO; and
(b) Members are offered the choice of remaining enrolled in the transferring CCO.
(16) Members may not be transferred under section (15) until the Authority has evaluated the receiving CCO and determined that the CCO meets criteria established by the Authority by rule, including but not limited to ensuring that the CCO maintains a network of providers sufficient in numbers and areas of practice and geographically distributed in a manner to ensure that the health services provided under the contract are reasonably accessible to members.
(17) The Authority shall provide notice of a transfer under section (15) to members that will be affected by the transfer at least 90 days before the scheduled date of the transfer.
(18) Except as otherwise allowed by rule, a member may transfer from one CCO to another CCO no more than once during each enrollment period.
Stat. Auth.: ORS
414.042, 414.615, 414.625, 414.635 & 414.651
Stats. Implemented: ORS 414.610 - 414.685
Hist.: DMAP 16-2012(Temp), f. & cert. ef. 3-26-12 thru 9-21-12; DMAP 37-2012, f. & cert. ef. 8-1-12; DMAP 47-2012(Temp), f. & cert. ef. 10-16-12 thru 4-13-13; DMAP 55-2012(Temp), f. & cert. ef. 11-15-12 thru 4-13-13; Administrative correction 4-22-13; DMAP 19-2013, f. & cert. ef. 4-23-13; DMAP 25-2013, f. & cert. ef. 6-11-13
State Archives • 800 Summer St. NE • Salem, OR 97310