Temporary rule language in effect until 03/29/2027.
Oregon Health Authority
Health Systems Division: Medical Assistance Programs - Chapter 410
Division 141
OREGON HEALTH PLAN
410-141-3850
Transition of Care
(1) For purposes of this rule, the following definitions apply in addition to those found in OAR 410-120-0000 and 410-141-3500:
(a) “Continued Access to Services” means making available to the Member, to the highest degree possible, those services, prescriptions, and prescription drug coverage consistent with the access they previously had;
(b) “Predecessor Entity” means the healthcare delivery system, either a CCO or OHP Open Card, that an OHP Member is leaving. This can be another CCO after disenrollment resulting from the termination of the predecessor CCO’s contract.
(c) “Receiving Entity” means the healthcare delivery system, either a CCO or OHP Open Card, that an OHP Member is joining.
(d) “Transition of Care Period” means the period beginning on the Member’s enrollment date with the receiving entity, during which the receiving entity must provide Continued Access to Services. The Transition of Care Period lasts for 90 days for all Members and for all physical, oral and behavioral health services unless either of the following apply:
(A) The Member's new primary care provider (oral or behavioral health provider, as applicable to medical care or behavioral health care services) reviews the member's treatment plan within 90 days of the transition date; or
(B) Notwithstanding paragraph (A) of this subsection (b), a prescribed course of treatment has been authorized beyond 90 days of the transition date per subsection (e) of section (4) this rule.
(2) This rule applies to care of an OHP Member who is enrolled with a Receiving Entity after disenrollment from a Predecessor Entity. For Members transitioning from one CCO to another, this rule only applies to Members with ongoing OHP eligibility who have not had an enrollment gap of more than seven (7) days following disenrollment from a CCO.
(3) The Receiving Entity must implement and maintain a transition of care policy that, at a minimum, meets the requirements of this rule and 42 CFR § 438.62(b). A Receiving Entity must provide Continued Access to Services to its Members.
(4) During the Transition of Care Period the Receiving Entity must ensure that each Member:
(a) Is provided with Continued Access to Services and the support necessary to access those services such as Non-Emergent Medical Transportation (NEMT);
(b) May continue receiving services from the Member’s previous Provider:
(A) When the Receiving Entity is a CCO, regardless of whether the Provider participates in the receiving CCO’s network;
(B) When the Receiving Entity is OHP Open Card and when the provider is enrolled as a FFS provider;
(c) Is referred to appropriate in-network providers during the Transition of Care Period;
(d) Receives health-related social needs (HRSN) benefits in accordance with HRSN transition guidelines outlined in OAR 410-120-2000;
(e) Receives the entire course of treatment with the Member’s previous Provider, even if it extends beyond the Transition of Care Period, in the following situations:
(A) Prenatal and postpartum care;
(B) Transplant services through the first year after transplant;
(C) Radiation therapy or chemotherapy services for the current course of treatment;
(D) Prescriptions with a defined minimum course of treatment that exceeds the Transition of Care Period;
(E) Behavioral health services until an equivalent level of care can be established; or
(F) Services provided in an acute care facility other than a hospital and those treatment settings described in OAR 410-141-3815 (e.g., a skilled nursing facility).
(f) When identified as high risk in accordance with OAR 410-141-3865:
(A) Receives care coordination between the Predecessor and Receiving Entities that must:
(i) Include timely exchange of relevant clinical, care management, and utilization information;
(ii) Ensure continuity of care, including active care plans, authorizations, and any other documents necessary to maintain uninterrupted services;
(iii) Begin prior to the transition date and continue as needed throughout the Transition of Care Period to prevent gaps in services or care disruptions.
(B) Is provided a warm handoff that includes one of the following:
(i) A direct communication (e.g., email, letter, telehealth visit) between the Member and any community providers or healthcare providers; or
(ii) Facilitation by a transitional care team that supports the Member and bridges the connection and discharge transition planning between the hospitals, predecessor entity, healthcare providers and community providers.
(g) When this section allows the Member to continue using the Member’s previous Provider, the receiving CCO must reimburse non-participating providers consistent with OAR 410-120-1295 and at no less than Medicaid fee-for-service rates and with no requirement to pay out-of-network rates to providers not in-network for the receiving CCO;
(5) When permissible by federal law, the Receiving Entity is not financially responsible for a continuous inpatient hospitalization, or for other treatment settings described in OAR 410-141-3815, for which a Predecessor Entity was responsible (e.g., under a CCO Contract in accordance with OARs 410-141-3500, 410-141-3710, and 410-141-3805);
(6) The receiving CCO will honor prior authorizations from the Predecessor Entity:
(a) For six (6) months after the transition date; or
(b) For a minimum of 90 days after the transition date for any ongoing course of medication; or
(c) Excluding an ongoing course of medication per subsection (b) of this section (6), until the receiving entity reviews the Prior Authorization and determines a modification in coverage is necessary according to their policies. In making such a determination, the receiving CCO must follow all service authorization protocols in OAR 410-141-3835 and provide the CCO Member with written notice that complies with 42 CFR 438.404 and OAR 410-141-3885 of any decision to:
(A) Deny a service authorization request;
(B) Authorize a service in an amount, duration, or scope that is less than requested;
(C) Reduce a previously authorized service.
(7) For an event-triggered transition that involves 500 or more OHP Members, including but not limited to those resulting from state or federal policy changes, system transitions, or operational disruptions:
(a) The Authority reserves the right to issue additional guidance to facilitate a member-centered transition;
(b) The receiving entity may use the Predecessor Entity’s risk assessments for the purpose of transition of care activities.
(c) When the Authority is the Receiving Entity, the Authority will honor prior authorizations from the predecessor CCO for six (6) months after the transition date or until the Authority reviews the Prior Authorization and determines a modification in coverage is necessary;
(d) The Predecessor Entity must:
(A) Maintain adequate staffing, service access, and care coordination functions through the final day of its responsibility for the Member. The predecessor plan must not reduce or terminate staffing or services in a manner that disrupts continuity of care through the Member’s transition;
(B) In cases involving plan closures, provide the following notifications:
(i) Member notice of plan closure 60 days before the transition of care date;
(ii) Tribal member notice of plan closure 60 days before transition of care date;
(iii) Provider notification of plan closure.
(8) The Predecessor Entity must provide relevant clinical, care management, and utilization information within seven (7) calendar days of the request from the Receiving Entity.
(a) The Receiving Entity must not delay the provision of services if relevant clinical, care management, and utilization information are not available in a timely manner. In such instances, the Receiving Entity must approve claims for covered services for which it has not received relevant clinical, care management, and utilization information during the Transition of Care Period, as if the covered services were prior authorized;
(b) The receiving CCO must have a process for the electronic exchange of, at a minimum, the data classes and elements included in the content adopted at 45 CFR 170.213.
(c) CCOs must comply with the process established by the Authority for the electronic exchange of relevant clinical, care management, and utilization information between the Authority and CCOs for transitions involving OHP Open Card Members. The Authority must provide the details about the process and guidance to assist CCOs in complying with the process through one or more documents made available on the CCO Contract Forms webpage at https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.
(d) The receiving CCO must incorporate the information received from the Predecessor Entity into the CCO Member’s clinical and administrative records.
(e) With the approval and at the direction of a current or former member or the Member's Representative, the Receiving Entity must:
(A) Receive and process all such data for a current Member from any other payer that has provided coverage to the Member within the preceding five (5) years;
(B) While a Member is enrolled with the Receiving Entity and for up to five (5) years after disenrollment, send all such data to any other payer that currently covers the Member or a payer the Member or the Member's Representative specifically requests to receive the data; and
(C) Send data received from another payer under this subsection in the electronic form and format it was received.
(9) In addition to the notices required under 42 CFR 438.404, the Receiving Entity must provide notification of the following:
(a) A plain-language written notice at enrollment or as soon as the Transition of Care Period begins. This notice must explain the Member’s rights to Continued Access to Services during the Transition of Care Period, including the right to continue services with the Member’s previous Provider as provided by this rule, and any other protections under this rule.
(b) Member pharmacy coverage changes;
(c) Drug benefit changes and Prior Authorization coverage;
(d) Member disruption to mail order pharmacy services.
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
History:
DMAP 41-2026, temporary amend filed 09/30/2026, effective 10/01/2026 through 03/29/2027
DMAP 92-2022, temporary amend filed 12/21/2022, effective 01/01/2023 through 03/31/2023
DMAP 56-2021, amend filed 12/30/2021, effective 01/01/2022
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020