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OREGON HEALTH AUTHORITY

 

DIVISION 1

PROCEDURAL RULES

943-001-0000

Model Rules of Procedure

The Oregon Health Authority adopts the Attorney General Model Rules applicable to rulemaking, effective January 1, 2010, with the exception of OAR 137-001-0080.

[ED. NOTE: The full text of the Attorney General's Model Rules of Procedure is available from the office of the Attorney General or the Oregon Health Authority.]

Stat. Auth.: ORS 183.341 & 413.042
Stats. Implemented: ORS 183.341 & 413.042
Hist.: OHA 1-2009(Temp), f. & cert. ef. 9-14-09 thru 3-12-10; OHA 2-2009, f. 12-31-09, cert. ef. 1-1-10

943-001-0005

Notice of Proposed Rulemaking and Adoption of Temporary Rules

(1) Except as provided in ORS 183.335(7) or (12) or 183.341, before permanently adopting, amending, or repealing an administrative rule, the Authority shall give notice of the intended action:

(a) To legislators specified in ORS 183.335(15) at least 49 days before the effective date of the rule;

(b) To persons on the interested parties lists described in section (2) of this rule for the pertinent OAR chapter or pertinent subtopics or programs within an OAR chapter at least 28 days before the effective date of the rule;

(c) In the Secretary of State's Bulletin referred to in ORS 183.360 at least 21 days before the effective date of the rule;

(d) To other persons, agencies, or organizations that the Authority is required to provide an opportunity to comment pursuant to state statute or federal law or as a requirement of receiving federal funding, at least 28 days before the effective date of the rule;

(e) To the Associated Press and the Capitol Press Room at least 28 days before the effective date of the rule; and

(f) In addition to the above, the Authority may send notice of intended action to other persons, agencies, or organizations that the Authority , in its discretion, believes to have an interest in the subject matter of the proposed rule at least 28 days before the effective date of the rule.

(2) Pursuant to ORS 183.335(8), the Authority shall maintain an interested parties list for each OAR chapter of rules for which the Authority has administrative responsibility, and an interested parties list for subtopics or programs within those chapters. A person, group, or entity that desires to be placed on the list to receive notices regarding proposed permanent adoption, amendment, or repeal of a rule must make the request in writing or by electronic mail to the rules coordinator for the chapter. The request must include either a mailing address or an electronic mail address to which notices may be sent.

(3) Notices under this rule may be sent by hand delivery, state shuttle, postal mail, electronic mail, or facsimile. The Authority recognizes state shuttle as "mail" and may use this means to notify other state agencies.

(a) An email notification under section (1) of this rule may consist of any of the following:

(A) An email that attaches the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(B) An email that includes a link within the body of the email, allowing direct access online to the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(C) An email with specific instructions within the body of the email, usually including an electronic Universal Resource Locator (URL) address, to find the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact.

(b) The Authority may use facsimile as an added means of notification, if necessary. Notification by facsimile under section (1) of this rule shall include the Notice of Proposed Rulemaking or Notice of Proposed Rulemaking Hearing and Statement of Need and Fiscal Impact, or specific instructions to locate these documents online.

(c) The Authority shall honor all written requests that notification be sent by postal mail instead of electronically if a mailing address is provided.

(4) If the Authority adopts or suspends a temporary rule, the Authority shall notify:

(a) Legislators specified in ORS 183.335(15);

(b) Persons on the interested parties list described in section (2) of this rule for the pertinent OAR chapter, subtopics, or programs within an OAR chapter;

(c) Other persons, agencies, or organizations that the Authority is required to notify pursuant to state statute or federal law or as a requirement of receiving federal funding; and

(d) The Associated Press and the Capitol Press Room; and

(e) In addition to the above, the Authority may send notice to other persons, agencies, or organizations that the Authority, in its discretion, believes to have an interest in the subject matter of the temporary rulemaking.

(5) In lieu of providing a copy of the rule or rules as proposed with the notice of intended action or notice concerning the adoption of a temporary rule, the Authority may state how and where a copy may be obtained on paper, by electronic mail, or from a specified web site.

Stat. Auth: ORS 183.341 & 413.042
Stats. Implemented: ORS 183.330, 183.335, & 183.341
Hist.: OHA 1-2011, f. & cert. ef. 7-1-11

943-001-0007

Delegation of Rulemaking Authority

Any officer or employee of the Oregon Health Authority who is identified on a completed Delegation of Authority form signed by the Director or Deputy Director of the Authority and filed with the Secretary of State, Administrative Rules Unit, is vested with the authority to adopt, amend, repeal, or suspend administrative rules as provided on that form until the delegation is revoked by the Director or Deputy Director of the Authority, or the person leaves employment with the Authority.

Stat. Auth: ORS 183.341 & 413.042
Stats. Implemented: ORS 183.330, 183.335, & 183.341
Hist.: OHA 1-2011, f. & cert. ef. 7-1-11

943-001-0009

Lay Representation in Contested Case Hearings

(1) Contested case hearings are conducted in accordance with the Attorney General’s model rules at OAR 137-003-0501 to 0700. Subject to the approval of the Attorney General, an officer or employee of the Oregon Health Authority (Authority) is authorized to appear on behalf of the agency in the following types of hearings conducted by the Authority:

(a) Eligibility and termination determinations related to medical assistance coverage.

(b) Suspension, reduction, or denial of medical assistance services, prior authorization, or medical management decisions.

(c) Enrollment or disenrollment decisions related to managed care plans.

(d) Eligibility for or termination of health insurance premium assistance, or determination of subsidy levels.

(e) Provider issues including provider enrollment or denial of enrollment, overpayment determinations, audits, and sanctions.

(f) Other administrative actions including criminal background checks, hardship waivers related to medical assistance, client overpayments related to medical assistance.

(g) Oregon State Hospital’s involuntary administration of a significant procedure to a patient or resident.

(2) The agency representative may not make legal argument on behalf of the agency.

(a) “Legal argument” includes arguments on:

(A) The jurisdiction of the agency to hear the contested case;

(B) The constitutionality of a statute or rule or the application of a constitutional requirement to an agency; and

(C) The application of court precedent to the facts of the particular contested case proceeding.

(b) “Legal argument” does not include presentation of motions, evidence, examination and cross-examination of witnesses or presentation of factual arguments or arguments on:

(A) The application of the statutes or rules to the facts in the contested case;

(B) Comparison of prior actions of the agency in handling similar situations;

(C) The literal meaning of the statutes or rules directly applicable to the issues in the contested case;

(D) The admissibility of evidence;

(E) The correctness of procedures being followed in the contested case hearing.

(3) When an agency officer or employee appears on behalf of the Authority, the administrative law judge shall advise the representative of the manner in which objections may be made and matters preserved for appeal. Such advice is of a procedural nature and does not change applicable law on waiver or the duty to make timely objection. Where such objections involve legal argument, the administrative law judge provide reasonable opportunity for the agency officer or employee to consult legal counsel and permit the Authority’s legal counsel to file written legal argument within a reasonable time after the conclusion of the hearing.

Stat. Auth: ORS 413.042
Stats Implemented: ORS 183.452
Hist.: OHA 2-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 23-2011, f. 10-31-11, cert. ef. 11-1-11

943-001-0010

Oregon Health Authority

(1) Effective June 26, 2009, 2009 Or. Laws Chapter 595 (House Bill 2009) created the Oregon Health Authority and transferred to the Oregon Health Authority certain duties, functions, and powers of:

(a) The Department of Administrative Services (DAS) related to the Public Employees’ Benefit Board (PEBB) and the Oregon Educators Board (OEBB);

(b) The Department of Consumer and Business Services (DCBS) related to the Oregon Medical Insurance Pool Board (OMIP);

(c) The Office of Private Health Partnerships (OPHP); and

(d) The Department of Human Services (DHS) with respect to health and health care. The transferred subject areas of DHS are generally described in Section 19(1)(a), Or. Laws Chapter 595 (House Bill 2009) as including but not limited to:

(A) Developing the policies for and the provision of publicly funded medical care and medical assistance in Oregon;

(B) Ensuring the promotion and protection of public health and the licensing of health care facilities;

(C) Developing the policies for and the provision of mental health treatment and treatment for substance use disorders;

(D) Administering the Oregon Prescription Drug Program; and

(E) Establishing responsibility for the Office for Oregon Health Policy and Research and all functions of the office.

(2) The transferred functions described in section (1)(d)(A)–(E) above are generally carried out as currently described in DHS rules by the Public Health Division, the Addictions and Mental Health Division, and the Division of Medical Assistance Programs.

(3) As used in these rules (OAR 943-001-0000 to 943-001-0015) the term “agency” means DHS, PEBB, OEBB, OMIP, and OPHP, and within the context of transfer responsibilities, DAS and DCBS.

(4) Effective June 26, 2009, the administration of new non-transferred duties, functions, and powers established by 2009 Or. Laws, Chapter 595 (House Bill 2009), or other 2009 laws, in the Oregon Health Authority or its constituent units is temporarily delegated to the Department of Human Services, subject to the supervision and oversight of the Oregon Health Authority, until operationally transferred, either in whole or in part, to the Oregon Health Authority.

(5) Operational transfer may occur, in whole or in part, in any program, business transaction, judicial, or administrative proceeding on the date specified by the Oregon Health Authority but no later than June 30, 2011.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032 - 413.037
Hist.: OHA 1-2009(Temp), f. & cert. ef. 9-14-09 thru 3-12-10; OHA 2-2009, f. 12-31-09, cert. ef. 1-1-10

943-001-0015

Transition Period Roles and Responsibilities

(1) Effective June 26, 2009, to maintain business continuity for the duties, functions, and powers transferred to the Oregon Health Authority, the agencies listed in OAR 943-001-0010(1)(a)–(d) shall continue to exercise their former duties, functions, and powers, subject to the supervision and oversight of the Oregon Health Authority, until superseded, by operational transfer, either in whole or in part, to the Oregon Health Authority, as follows:

(a) All rules shall remain in effect and ongoing rule filing processes may continue.

(b) All program administration, policies, and procedures remain in effect and may continue to be developed and implemented.

(c) Any judicial or administrative action, proceeding, contested case hearing, or administrative review matters, or new action, proceeding, or matter involving or relating to the duties or powers transferred to the Oregon Health Authority shall continue.

(d) Rights and obligations legally incurred under contracts, leases, and business transactions shall remain legally valid.

(e) Contract, grant, and business transaction procurement and administration duties, functions, and powers shall remain in effect and may continue.

(f) Any statutory obligations for taxes, assessments, fees, charges, or payments shall continue to be paid to or reimbursed by the appropriate agency.

(g) Any former statutorily required findings, determinations, or recommendations to be made by the agencies shall continue to be made by the agencies.

(h) Any former statutorily required filings, notices or service of papers, applications, notices or other documents to be mailed, provided to, or served on the agencies shall continue to be mailed, provided to, or served on the agencies and the agencies shall retainresponsibility to take any appropriate actions to protect the interests of the state concerning or arising from any filings, notices, or service.

(A) Mailing or service of notices or documents on the agencies shall be considered notice to the Oregon Health Authority. For example, any notice sent to the Department of Human Services Estate Administration Unit for purposes of ORS 113.145, 114.525 and 130.370 shall be considered notice to the Oregon Health Authority.

(B) Any filings, notices, or service made to the Oregon Health Authority may be transmitted by the Oregon Health Authority to the appropriate agency.

(2) Any and all remaining duties, functions, or powers of the agencies relating to the duties, functions, and powers transferred to the Oregon Health Authority that are not described in section (1) shall continue in effect or be exercised by the agencies until superseded by operational transfer, either in whole or in part, to the Oregon Health Authority.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 413.032 - 413.037
Hist.: OHA 1-2009(Temp), f. & cert. ef. 9-14-09 thru 3-12-10; OHA 2-2009, f. 12-31-09, cert. ef. 1-1-10

943-001-0020

Oregon Health Authority Shared Service and Cooperative Relationships with Department of Human Services

(1) The Oregon Health Authority (Authority) will cooperate and collaborate with the Department of Human Services (Department) in order to effectively coordinate services to individuals, families and communities and realize operational efficiencies in the administration of services that are shared between them (“shared services”).

(2) For all the programs, functions, and duties with respect to health or health care (generally described in Oregon Laws 2009, chapter 595, section 19(1)(a)), transferred to the Authority from the Department (“transferred program”) or for shared services, the Authority declares that:

(a) All transferred program rules shall remain in effect until superceded by adoption of Authority rules or adoption of rules by the Authority coordinating shared services with the Department.

(b) All transferred program administration, policies, and procedures remain in effect pending the completion of review and adoption by the Authority or adoption of such policies and procedures related to coordination of shared services with the Department.

(c) Any judicial or administrative action, proceeding, contested case hearing, or administrative review matters, or new action, proceeding, or matter involving or relating to the duties or powers transferred to the Authority are the responsibility of the Authority.

(d) Rights and obligations legally incurred under transferred program contracts, leases, and business transactions remain legally valid and are the responsibility of the Authority.

(e) Statutorily required filings, notices or service of papers, applications, notices or other documents to be mailed, provided to, or served on the Authority shall be mailed, provided to, or served on the Authority. Any notices required by ORS 113.145, 114.525 and 130.370 to be sent to the Authority may be consolidated with similar notices to the Department and sent to the Estate Administration Unit of the Department. Any notices required by 416.530 to be sent to the Authority may be consolidated with similar notices to the Department and sent to the Personal Injury Lien Unit of the Department Any consolidated notice shall be considered notice to the Authority as long as the Authority’s interest or claim in the matter is identified in the notice consistent with requirements in applicable statute.

(f) A reference to an Administrator or Assistant Director in any transferred program rule of the Authority means the Director of the Authority’s program that is covered by that chapter of the Oregon Administrative Rules or the Authority’s program specified in the rule.

(3) As the state Medicaid agency for the administration of funds from Titles XIX and XXI of the Social Security Act, the Authority is charged with the administration of the medical assistance program. The Authority is responsible for facilitating outreach and enrollment efforts to connect eligible individuals with all available publicly funded health programs.

(a) The Authority and the Department recognize that there are many points of interconnection between their programs and the individuals who receive services through these programs. In addition, there are areas of natural connection between the Authority and the Department based upon the former and current structures of the Department in the administration of the medical assistance program.

(b) The Authority shall work cooperatively with the Department in the administration of the medical assistance program and to facilitate the outreach and enrollment in the program, including making determinations of eligibility and service need for medical assistance. The Authority has designated the Department as the operating agency for home and community-based waiver services and as an Organized Health Care Delivery System.

(c) The Authority and the Department are authorized by state law to delegate to each other any duties, functions and powers that they deem necessary for the efficient and effective operation of their respective functions. The Authority and the Department will work together to adopt rules to assure that medical assistance eligibility requirements, procedures, and determinations are consistent across both agencies. The Authority has authorized the Department to determine medical eligibility for medical assistance. Where that responsibility is given to the Department under ORS Chapter 411, the Department has delegated to the Authority the duties, functions, and powers to make medical eligibility determinations in accordance with OAR 410-120-0006.

(d) Where statute establishes duties and functions of the Authority or the Department in relation to medical assistance as a public assistance program, the Authority and the Department shall cooperate in the effective administration of the program.

Stat. Auth.:ORS 413.042
Statutes Implemented: ORS 413.042
Hist.: OHA 3-2011(Temp), f. & cert. ef. 7-1-11 thru 12-27-11; OHA 24-2011, f. 10-31-11, cert. ef. 11-1-11

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