Oregon Health Authority
Health Systems Division: Medical Assistance Programs - Chapter 410
Division 141
OREGON HEALTH PLAN
410-141-3870
Care Coordination: Service Coordination
(1) Coordinated Care Organizations (CCOs) must ensure all services accessed by members are coordinated according to the needs of members, following the requirements in OAR 410-141-3860, OAR 410-141-3865 and in this rule.
(2) Upon enrollment, CCOs must act promptly to ensure services are coordinated for members needing Urgent Care Services as defined in OAR 410-120-0000(270) or Emergency Services as defined in OAR 410-120-0000(95), even if the member has not yet selected a Primary Care Provider (PCP) or completed a Health Risk Assessment (HRA).
(3) CCOs must formally designate a person or team as primarily responsible to coordinate services accessed by the member and must provide information to the member on how to contact their designated person or team.
(4) CCOs shall utilize a Care Profile for all members as defined in OAR 410-141-3500.
(a) The member Care Profile must identify:
(A) The member’s identifying and demographic information;
(B) The member’s communication preferences and needs (e.g. preferred language, method of communication, Alternate Formats, Auxiliary Aids and Services);
(C) The member's care team, along with their contact information, role, and any assigned Care Coordination Responsibilities. This must include, but is not limited to;
(i) The person or team formally designated by the CCO as primarily responsible for coordinating the services accessed by the member;
(ii) All providers serving the member, including, at minimum, their Primary Care Provider; and
(iii) The appropriate individuals from all entities serving the member, such as those listed in 410-141-3860(2).
(D) The member’s needs, goals and preferences determined on an initial and ongoing basis as described in OAR 410-141-3865;
(E) The member’s health risk score and risk category as described in OAR 410-141-3860;
(F) Any open or closed Care Plans; and
(G) An overview of the supports, services, activities, and resources deployed to meet the member’s identified needs.
(b) Upon a change in health-related circumstances, as described in OAR 410-141-3865(3)(g), the CCO must update the members Care Profile, determine if the development of a Care Plan is warranted and document the outcome and actions of the determination.
(5) CCOs must ensure services are actively coordinated for members when requested by the member, their representative or guardian, an involved provider or entity, or when required by the member’s needs as identified in the members Care Profile. This coordination is accomplished through the development and implementation of a Care Plan that scales in complexity relative to the needs, goals, preferences, and circumstances of the member.
(a) CCOs shall consider the member’s identified risk category to determine if a Care Plan is needed.
(A) Members in the no- or low-risk category do not require a Care Plan unless the member’s needs change resulting in a higher risk category or when the member requests it;
(B) Members within the moderate-risk and high-risk categories must have a Care Plan developed.
(b) The Care Plan is developed, or revised as required in (5)(d) of this rule:
(A) In alignment with the member’s needs, goals, preferences, and circumstances as detailed in the care profile;
(B) By incorporating information from any relevant assessments, treatment and service plans from providers involved in the member’s care, and if appropriate and with consent of the member or the member’s representative or guardian, information provided by community partners;
(C) In consultation with any other provider, case manager, or entity providing services to, or coordinating care for, the member;
(D) In consultation with a clinician that has the appropriate qualifications and clinical practice history to review and revise the Care Plan considering the members’ complex physical, developmental, behavioral or dental health care needs;
(E) In accordance with a members updated risk level as described in (4)(a)(E) of this rule.
(F) With the member, their representative or guardians participation to the extent they desire or are able. The member, their representative or guardian may be satisfied with and understand the Care Plan, including any of their own roles and responsibilities.
(i) If participation in creating a member’s Care Plan may be significantly detrimental to the member’s care or health, the member, the member’s caregiver, or the member’s family may be excluded from the development of a Care Plan;
(ii) The CCO must document the reasons for the exclusion, including a specific description of the risk or potential harm to the member, and describe what attempts were made to address the concern(s);
(iii) This decision must be reviewed prior to each significant Care Plan update resulting from a health-related circumstance change as set forth in OAR 410-141-3865(3)(g). The decision to continue the exclusion shall be documented.
(G) In accordance with state quality assurance and utilization review standards, as applicable.
(c) Upon completion of the Care Plan, CCOs must make it promptly available to the member, the members representative or guardian and to all relevant providers rendering services to the member who shall coordinate and provide services according to:
(A) The member, the member’s representative or guardian must be provided immediate electronic access, or a copy in the member’s preferred method of communication and in the member’s preferred language. Auxiliary Aids and Services and Alternate Formats must be made available upon request of the member at no cost within five (5) business days of the request.
(B) If the CCO requires Care Plans to be approved, approval must be timely, according to a member’s needs; and
(C) If providing the member with a copy of or access to their full Care Plan may be significantly detrimental to their care or health, as determined by the member’s care team, CCOs may withhold from the member, only those parts of the plan that are determined to be detrimental. CCOs must document the reasons for withholding the full or partial Care Plan, including a specific description of the risk or potential harm to the member, and describe what attempts were made to address the concern(s). This decision to withhold the Care Plan in full or in part must be reviewed prior to each plan update, and the decision to continue withholding the Care Plan in full or in part shall be documented.
(d) Open Care Plans must be reviewed and revised at least annually, or
(A) When a member, member representative or guardian, or any provider serving the member requests a review and revision; or
(B) Upon a change in health-related circumstances as described in OAR 410-141-3865 (3)(g).
(e) The Care Plan may be closed and the member shall continue with Care Profile tracking only when;
(A) Requested by the member, their representative or guardian; or
(B) No longer warranted by the member’s risk category or circumstances; or
(C) There is no contact with the member, their representative or guardian after a minimum of three (3) attempts of outreach, utilizing at least two mixed modalities (e.g., telephonic, text, email, letter) over a sixty (60) day period , and with consultation and agreement of all available care team members.
(6) CCOs shall ensure Care Coordination for all members, regardless of where the member is receiving services.
(a) If members experience a Care Setting Transition CCOs must ensure:
(A) Members are transitioned into the most appropriate independent and integrated community settings and provided follow-up services as medically necessary and appropriate prior to discharge to facilitate successful handoff to community providers;
(B) Appropriate discharge planning and care coordination for adults who were members upon entering the Oregon State Hospital and who shall return to their home CCO upon discharge from the Oregon State Hospital;
(C) Coordination of care and discharge planning for out of service area placements, for which an exception shall be made to allow the member to retain Home CCO enrollment while the member’s placement is a temporary residential placement as defined in OAR 410-141-3500, or elsewhere in accordance with OAR 410-141-3815. CCOs shall, prior to discharge, coordinate care in accordance with a member’s discharge plan.
(b) Coordinate and authorize care when it has been deemed medically appropriate and medically necessary to receive services outside of the service area because a provider specialty is not otherwise contracted with the cco.
(c) Coordinate the members care when they are temporarily outside their enrolled service area;
(d) If members are transitioning between CCOs or CCO to fee-for-service (FFS) as set forth in OAR 410-141-3850;
(e) Post Hospital Extended Care must be provided in accordance with OAR 411-070-0033:
(A) Post Hospital Extended Care Coordination (PHEC) is a twenty (20) day benefit included within the Global Budget and the CCO shall pay for the full twenty (20) day PHEC benefit when the full twenty (20) days is required by the discharging provider. CCOs shall make the benefit available to non-Medicare Members who meet Medicare criteria for a post-Hospital Skilled Nursing Facility placement.
(B) CCOs shall notify the Member’s local DHS APD office as soon as the Member is admitted to PHEC. Upon receipt of such notice, CCO and the Member’s APD office must promptly begin appropriate discharge planning.
(C) CCOs shall notify the Member and the PHEC facility of the proposed discharge date from such PHEC facility no less than two (2) full days prior to discharge.
(D) CCOs shall ensure that all of a Member’s post-discharge services and care needs are in place prior to discharge from the PHEC, including but not limited to Durable Medical Equipment (DME), medications, home and Community based services, discharge education or home care instructions, scheduling follow-up care appointments, and provide follow-up care instructions that include reminders to:
(i) attend already-scheduled appointments with Providers for any necessary follow-up care appointments the Member may need; or
(ii) schedule follow-up care appointments with Providers that the Member may need to see;
(iii) or both (i) and (ii).
(E) CCOs shall provide the PHEC benefit according to the criteria established by Medicare, as cited in the Medicare Coverage of Skilled Nursing Facility Care available by calling 1-800-MEDICARE or at www.medicare.gov/publications
(F) CCOs are not responsible for the PHEC benefit unless the Member was enrolled with the CCO at the time of the hospitalization preceding the PHEC facility placement.
(7) In addition to the care planning requirements above, for LTSS or Special Health Care Needs members as defined in OAR 410-141-3500 that are assessed according to OAR 410-141-3865(5) to have an ongoing special condition that requires a course of treatment or regular care monitoring or identified as high risk:
(a) CCOs must consider the above members, according to their needs, during Interdisciplinary Team Meetings which are convened and facilitated twice per month or more frequently, as needed, including a post-transition meeting of the interdisciplinary team within fourteen (14) days of a transition between levels, settings or episodes of care. These meetings must:
(A) Include the member, their representative or guardian, unless the member declines or the member’s participation is determined to be significantly detrimental to the member’s health, in accordance with (5)(b)(F) of this rule;
(B) Consider relevant information from all providers; and
(C) Provide a forum to:
(i) Describe the clinical interventions recommended to the treatment team;
(ii) Create a space for the member to provide feedback on their care, self-reported progress towards their Care Plan goals, and their strengths exhibited in between current and prior meeting;
(iii) Identify coordination gaps and strategies to improve care coordination with the member’s service providers;
(iv) Develop strategies to identify, monitor and follow up on needed referrals for specialty care, routine health care services (including medication monitoring), other community programs or social need services; and
(v) Align with and update the member’s individual Care Plan and share the plan in accordance with (5)(c) of this rule.
(b) CCOs must implement a mechanism to provide direct access to specialists, e.g., a standing referral or an approved number of visits, as appropriate for the member’s condition and identified needs.
Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
History:
DMAP 83-2024, minor correction filed 04/01/2024, effective 04/01/2024
DMAP 37-2024, amend filed 01/25/2024, effective 02/01/2024
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 62-2020, amend filed 12/16/2020, effective 01/01/2021
DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020