OAR 410-141-3515
Network Adequacy

(1) MCEs shall maintain and monitor a network of participating providers that is sufficient in number, provider type, and geographic distribution to ensure adequate service capacity and availability to provide available and timely access to medically appropriate and culturally responsive covered services to both current members and those the MCE anticipate will become enrolled as members.
(2) The MCE shall develop a provider network that enables members to access services within the standards defined below.
(3) The MCE shall meet access-to-care standards and that allow for appropriate choice for members. Services and supports shall be as close as possible to where members reside and, to the extent necessary, offered in nontraditional settings that are accessible to families, diverse communities, and underserved populations.
(4) MCEs shall meet quantitative network access standards defined in rule and contract.
(5) CCOs shall ensure access to integrated and coordinated care as outlined in OAR 410-141-3860 (Integration and Coordination of Care), which includes access to a primary care provider or primary care team that is responsible for coordination of care and transitions.
(6) In developing its provider network, the CCO shall anticipate access needs so that the members receive the right care at the right time and place, using a patient-centered, trauma informed approach. The provider network shall support members, especially those with behavioral health conditions, in the most appropriate and independent setting, including in their own home or independent supported living.
(7) CCOs shall ensure all members can access providers within acceptable travel time or distance to patient-centered primary care homes or PCPs; primary care, adult and pediatric; OB/GYN; behavioral health (mental health and substance use disorder), adult and pediatric; specialists, adult and pediatric; hospital; pharmacy; oral care, adult and pediatric; and additional provider types when it promotes the objectives of the Authority. Acceptable travel times and distances may not exceed the following, unless otherwise approved by the Authority:
(a) In urban areas, 30 miles, or 30 minutes;
(b) In rural areas, 60 miles, or 60 minutes.
(8) MCEs shall have an access plan that establishes a protocol for monitoring and ensuring access, outlines how provider capacity is determined, and establishes procedures for monthly monitoring of capacity and access and for improving access and managing access in times of reduced participating provider capacity. The access plan shall include how the CCO will meet the accommodation and language needs of individuals with LEP as defined in 410-141-3500 (Definitions) and people with disabilities in their service area in compliance with state and federal rules including but not limited to ORS 659A, Title VI of the Civil Rights Act of 1964, Section 1557 of the Affordable Care Act, the Americans with Disabilities Act, and Section 504 of the Rehabilitation Act of 1973.
(9) CCOs shall make the services it provides (including primary care, specialists, pharmacy, hospital, vision, ancillary, and behavioral health services or other services as necessary to achieve compliance with the requirements of 42 CFR 438, subpart K) as accessible to members for timeliness, amount, duration, and scope as those services are to other patients within the same service area. If the MCE is unable to provide those services locally by providers qualified and specialized to treat a member’s condition, it must arrange for the member to access care from providers outside the service area.
(10) MCEs shall have policies and procedures and a monitoring system to ensure that members who are aged, blind, or disabled, or who have complex or high health care needs, multiple chronic conditions, or have behavioral health conditions, or who are children receiving Department or OYA services have access to primary care, oral care (when the MCE or DCO is responsible for oral care), behavioral health providers, and referral, and involve those members in accessing and managing appropriate preventive, health, remedial, and supportive care and services. Specifically, MCEs shall monitor and have policies and procedures to ensure:
(a) Access to providers of pharmacy, hospital, vision, ancillary, and behavioral health services;
(b) Priority access for pregnant women and children ages birth through 5 years to health services, developmental services, early intervention, targeted supportive services, oral and behavioral health treatment.
(11) CCOs shall have policies and procedures that ensure scheduling and rescheduling of member appointments are appropriate to the reasons for and urgency of the visit. The member shall be seen, treated, or referred within the following timeframes:
(a) Physical health:
(A) Emergency care: Immediately or referred to an emergency department depending on the member’s condition;
(B) Urgent care: Within 72 hours or as indicated in initial screening and in accordance with OAR 410-141-3840 (Emergency and Urgent Care Services);
(C) Well care: Within four weeks, or as otherwise required by applicable care coordination rules, including OAR 410-141-3860 (Integration and Coordination of Care) through 410-141-3870 (Intensive Care Coordination).
(b) Oral care:
(A) Emergency oral care: Seen or treated within 24 hours;
(B) Urgent oral care: Within one week or as indicated in the initial screening in accordance with OAR 410-123-1060 (Definition of Terms);
(C) Routine oral care: Within eight weeks, unless there is a documented special clinical reason that makes a period of longer than eight weeks appropriate.
(c) Behavioral health:
(A) Urgent behavioral health care for all populations: Within 24 hours;
(B) Specialty behavioral health care for priority populations:
(i) In accordance with the timeframes listed below for assessment and entry, terms are defined in OAR 309-019-1015, with access prioritized per OAR 309-019-0135 (Entry and Assessment). If a timeframe cannot be met due to lack of capacity, the member must be placed on a waitlist and provided interim services within 72 hours of being put on a waitlist. Interim services must be comparable to the original services requested based on the level of care and may include referrals, methadone maintenance, HIV/AIDS testing, outpatient services for substance use disorder, risk reduction, residential services for substance use disorder, withdrawal management, and assessments or other services described in OAR 309-019-0135 (Entry and Assessment);
(ii) Pregnant women, veterans and their families, women with children, unpaid caregivers, families, and children ages birth through five years, individuals with HIV/AIDS or tuberculosis, individuals at the risk of first episode psychosis and the I/DD population: Immediate assessment and entry. If interim services are necessary due to capacity restrictions, treatment at appropriate level of care must commence within 120 days from placement on a waitlist;
(iii) IV drug users including heroin: Immediate assessment and entry. Admission for treatment in a residential level of care is required within 14 days of request, or, if interim series are necessary due to capacity restrictions, admission must commence within 120 days from placement on a waitlist;
(iv) Opioid use disorder: Assessment and entry within 72 hours;
(v) Medication assisted treatment: As quickly as possible, not to exceed 72 hours for assessment and entry;
(vi) Children with serious emotional disturbance as defined in 410-141-3500 (Definitions): Any limits that the Authority may specify in the contract or in sub regulatory guidance.
(C) Routine behavioral health care for non-priority populations: assessment within seven days of the request, with a second appointment occurring as clinically appropriate.
(12) MCEs shall implement procedures for communicating with and providing care to members who have difficulty communicating due to a medical condition, who need accommodation due to a disability, or who have limited English proficiency, living in a household where there is no adult available to communicate in English or there is no telephone:
(a) The policies and procedures shall ensure the provision of Oregon certified or Oregon qualified interpreter services by phone or in person if requested anywhere the member is attempting to access care or communicate with the MCE or its representatives;
(b) MCEs shall ensure the provision of certified or qualified interpreter services for all covered services including but not limited to, physical, behavioral health, or oral care (when the MCE or DCO is responsible for oral care) visits, and home health visits to interpret for members with hearing impairment or in the primary language of non-English-speaking members;
(c) All interpreters must be linguistically appropriate and capable of communicating in both English and the member’s primary language and be able to translate clinical information effectively. Interpreter services must enable the provider to understand the member’s complaint, make a diagnosis, respond to the member’s questions and concerns, and communicate instructions to the member;
(d) MCEs shall ensure the provision of services that are culturally appropriate as described in National CLAS Standards, demonstrating both awareness for and sensitivity to cultural differences and similarities and the effect on the member’s care. Whenever possible MCES shall ensure the provision of Oregon certified or Oregon qualified interpreters. If that is not possible then interpreters must adhere to generally accepted interpreter ethics principles, including client confidentiality; demonstrate proficiency in speaking and understand both spoken English and at least one other language and must be able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary, terminology and phraseology. For an individual with a disability, qualified interpreters can include, sign language interpreters, oral transliterators, and cued language transliterators as defined in 45 CFR 92.4;
(e) MCEs shall comply with requirements of the Americans with Disabilities Act of 1990 in providing access to covered services for all members and shall arrange for services to be provided by non-participating providers when necessary;
(f) MCEs shall collect and actively monitor data on language accessibility to ensure compliance with these language access requirements;
(g) MCEs shall report to the Authority such language access data and other language access related analyses in the form and manner set forth in this rule and as may otherwise be required in the MCE contract. The Authority shall provide supplemental instructions about the use of any required forms:
(A) Using the interpreter services self-assessment reporting template provided by the Authority, MCEs shall conduct an annual language access self-assessment and submit the completed language access self-assessment to the Authority on or before the third Monday of each January;
(B) MCEs shall complete a quarterly language access and interpreter services data report using the report form provided by the Authority. The quarterly language access and interpreter services data report shall be submitted to the Authority on or before the third Monday of each January, April, July, and October. Reporting for Calendar Year 2020 shall commence in April 2020. January reporting requirements shall commence at the beginning of Calendar Year 2021;
(C) MCEs shall complete and submit to the Authority any other language access reporting that may be required in the MCE contract.
(13) MCEs shall collect and actively monitor data on provider-to-enrollee ratios, interpretation utilization by the MCE and the MCE’s provider network, travel time and distance to providers, percentage of contracted providers accepting new members, wait times to appointment (including specific data for behavioral health wait times), and hours of operation. MCEs shall also collect and actively monitor data on call center performance and accessibility for both member services and NEMT brokerage services call centers.
(14) MCEs must submit a Delivery System Network (DSN) report annually to the Authority that includes access data and other access-related analyses in the form and manner required by the Authority, including but not limited to capacity reports on:
(a) Behavioral health access;
(b) Interpreter utilization by the MCE’s provider network;
(c) Behavioral health provider network.
(15) MCEs shall report the methodology for monitoring network adequacy to the Authority and the Authority-contracted External Quality Review Organization (EQRO).
(16) MCEs shall implement and require its providers to adhere to the following appointment and wait time standards:
(a) Wait times for scheduled appointments shall not exceed 60 minutes. After 30 minutes, members must be given an update on waiting time with an option of waiting or rescheduling the appointment. If the member requests to reschedule, they shall not be penalized for failing to keep the appointment;
(b) MCEs shall implement written procedures and a monitoring system for timely follow-up with members when a participating provider has notified the MCE that the member failed to keep scheduled appointments. The procedures shall address:
(A) Timely rescheduling of missed appointments, as deemed medically appropriate;
(B) Documentation in the clinical record or non-clinical record of missed appointments;
(C) Recall or notification efforts; and
(D) Method of member follow up.
(c) If failure to keep a scheduled appointment is a symptom of the member’s diagnosis or disability or is due to lack of transportation to the MCE’s participating provider office or clinic, MCEs shall provide outreach services as medically appropriate;
(d) Recognition of whether NEMT services were the cause of the member’s missed appointment.
(17) CCOs must contract with the following specific provider types:
(a) Providers of residential chemical dependency treatment services;
(b) Any oral care organizations necessary to provide adequate access to oral services in the area where members reside.
(18) CCOs shall assess the needs of their membership and make available supported employment and assertive community treatment services when members are referred and eligible:
(a) CCOs shall report the number of individuals who receive supported employment and assertive community treatment services, at a frequency to be determined by OHA. When no appropriate provider is available, the MCE shall consult with the Authority and develop an approved plan to make supported employment and assertive community treatment services available;
(b) If 10 or more members in a CCO region have been referred, are eligible, and are appropriate for assertive community treatment, and have been on a waitlist to receive assertive community treatment for more than 30 days, CCOs shall take action to reduce the waitlist and serve those individuals by:
(A) Increasing team capacity to a size that is still consistent with fidelity standards; or
(B) Adding additional Assertive Community Treatment teams; or
(C) When no appropriate Assertive Community Treatment provider is available, the CCO shall consult with the Authority and develop an approved plan to increase capacity and add additional teams.

Source: Rule 410-141-3515 — Network Adequacy, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-141-3515.

410–141–3500
Definitions 410–141–3501
Administration of Oregon Integrated and Coordinated Health Care Delivery System Regulation 410–141–3505
Use of Subcontractors 410–141–3510
Provider Contracting and Credentialing 410–141–3515
Network Adequacy 410–141–3520
Record Keeping and Use of Health Information Technology 410–141–3525
Outcome and Quality Measures 410–141–3530
Sanctions 410–141–3540
Member Protections 410–141–3545
Coordinated Care Organization Behavioral Health Provider, Treatment and Facility Certification and Licensure 410–141–3550
Resolving Disputes between MCEs and the Authority 410–141–3555
Resolving Disputes between Health Care Entities and CCOs that Concern CCO Contact Award 410–141–3560
Resolving Contract Disputes Between Health Care Entities and CCOs 410–141–3565
Managed Care Entity Billing 410–141–3566
Telehealth Service and Reimbursement Requirements 410–141–3570
Managed Care Entity Encounter Claims Data Reporting 410–141–3575
MCE Member Relations: Marketing 410–141–3580
MCE Member Relations: Potential Member Information 410–141–3585
MCE Member Relations: Education and Information 410–141–3590
MCE Member Relations: Member Rights and Responsibilities 410–141–3600
MCE Assessment: Definitions 410–141–3601
MCE Assessment: General Administration 410–141–3605
MCE Assessment: Disclosure of Information 410–141–3610
MCE Assessment: Calculation, Report, Due Date, Verification 410–141–3615
MCE Assessment: Filing an Amended Report 410–141–3620
MCE Assessment: Determining the Date Filed 410–141–3625
MCE Assessment: Authority to Audit Records 410–141–3630
MCE Assessment: Determining Assessment Liability on Failure to File 410–141–3635
MCE Assessment: Financial Penalty for Failure to File a Report or Failure to Pay Assessment When Due 410–141–3640
MCE Assessment: Notice of Proposed Action 410–141–3645
MCE Assessment: Hearing Process 410–141–3650
MCE Assessment: Final Order of Payment 410–141–3655
Assessment: Remedies Available after Final Order of Payment 410–141–3700
CCO Application and Contracting Procedures 410–141–3705
Criteria for CCOs 410–141–3710
Contract Termination and Close-Out Requirements 410–141–3715
CCO Governance 410–141–3720
Service Area Change for Existing CCOs 410–141–3725
CCO Contract Renewal Notification 410–141–3730
Community Health Assessment and Community Health Improvement Plans 410–141–3735
Social Determinants of Health and Equity 410–141–3740
Traditional Health Workers 410–141–3800
CCO Enrollment for Children Receiving Health Services 410–141–3805
Mandatory MCE Enrollment Exceptions 410–141–3810
Disenrollment from MCEs 410–141–3815
CCO Enrollment for Temporary Out-of-Area Behavioral Health Treatment Services 410–141–3820
Covered Services 410–141–3825
Excluded Services and Limitations 410–141–3830
Prioritized List of Health Services 410–141–3835
MCE Service Authorization 410–141–3840
Emergency and Urgent Care Services 410–141–3845
Health-Related Services 410–141–3850
Transition of Care 410–141–3855
Pharmaceutical Services 410–141–3860
Integration and Coordination of Care 410–141–3865
Care Coordination Requirements 410–141–3870
Intensive Care Coordination 410–141–3875
MCE Grievances & Appeals: Definitions and General Requirements 410–141–3880
Grievances & Appeals: Grievance Process Requirements 410–141–3885
Grievances & Appeals: Notice of Action/Adverse Benefit Determination 410–141–3890
Grievances & Appeals: Appeal Process 410–141–3895
Grievances & Appeals: Expedited Appeal 410–141–3900
Grievances & Appeals: Contested Case Hearings 410–141–3905
Grievances & Appeals: Expedited Contested Case Hearings 410–141–3910
Grievances & Appeals: Continuation of Benefits 410–141–3915
Grievances & Appeals: System Recordkeeping 410–141–3920
Transportation: NEMT General Requirements 410–141–3925
Transportation: Vehicle Equipment and Driver Standards 410–141–3930
Transportation: Out-of-Service Area and Out-of-State Transportation 410–141–3935
Transportation: Attendants for Child and Special Needs Transports 410–141–3940
Transportation: Secured Transports 410–141–3945
Transportation: Ground and Air Ambulance Transports 410–141–3955
Transportation: Member Service Modifications and Rights 410–141–3960
Transportation: Member Reimbursed Mileage, Meals, and Lodging 410–141–3965
Reports and Documentation 410–141–5000
FINANCIAL SOLVENCY REGULATION: Definitions 410–141–5005
FINANCIAL SOLVENCY REGULATION: CCO Financial Solvency Requirements 410–141–5010
FINANCIAL SOLVENCY REGULATION: Procedure for General Financial Reporting and for Determining Financial Solvency Matters 410–141–5015
FINANCIAL SOLVENCY REGULATION: Financial Statement Reporting 410–141–5020
FINANCIAL SOLVENCY REGULATION: Annual Audited Financial Statements and Auditor’s Report 410–141–5025
FINANCIAL SOLVENCY REGULATION: Qualifications of Independent Certified Public Accountant 410–141–5030
FINANCIAL SOLVENCY REGULATION: Notification of Adverse Financial Condition 410–141–5035
FINANCIAL SOLVENCY REGULATION: Accountant’s Letter of Qualifications 410–141–5040
FINANCIAL SOLVENCY REGULATION: Independent Certified Public Accountants Workpapers 410–141–5045
FINANCIAL SOLVENCY REGULATION: Corporate Governance Annual Disclosure Filing 410–141–5050
FINANCIAL SOLVENCY REGULATION: Requirements for Reinsurance 410–141–5055
FINANCIAL SOLVENCY REGULATION: Requirements for Obtaining Credit for Reinsurance 410–141–5060
FINANCIAL SOLVENCY REGULATION: Qualified Trust Agreements 410–141–5065
FINANCIAL SOLVENCY REGULATION: Letters of Credit 410–141–5070
FINANCIAL SOLVENCY REGULATION: Assets, Liabilities, Reserves 410–141–5075
FINANCIAL SOLVENCY REGULATION: Disallowance of Certain Reinsurance Transactions 410–141–5080
FINANCIAL SOLVENCY REGULATION: Transparency 410–141–5085
ASSET VALUATION AND PERMITTED INVESTMENTS: Definitions 410–141–5090
ASSET VALUATION AND PERMITTED INVESTMENTS: Calculation of Value 410–141–5095
ASSET VALUATION AND PERMITTED INVESTMENTS: Assets Other Than Securities 410–141–5100
ASSET VALUATION AND PERMITTED INVESTMENTS: Investments Used to Provide Compensating Balances 410–141–5105
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Required Capitalization 410–141–5110
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Mortgage Loans 410–141–5115
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Real Property 410–141–5120
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment in Corporate Stocks 410–141–5125
ASSET VALUATION AND PERMITTED INVESTMENTS: Loans 410–141–5130
ASSET VALUATION AND PERMITTED INVESTMENTS: Investments 410–141–5135
ASSET VALUATION AND PERMITTED INVESTMENTS: Personal Property 410–141–5140
ASSET VALUATION AND PERMITTED INVESTMENTS: “Prudent Investor” Standard 410–141–5145
ASSET VALUATION AND PERMITTED INVESTMENTS: Prohibited Conduct by Directors, Trustees, Officers, Agents or Employees 410–141–5150
ASSET VALUATION AND PERMITTED INVESTMENTS: Investment of Funds in Obligations That Are Not Investment Quality 410–141–5155
ASSET VALUATION AND PERMITTED INVESTMENTS: Approval by Board 410–141–5160
ASSET VALUATION AND PERMITTED INVESTMENTS: Record of Investments 410–141–5165
ASSET VALUATION AND PERMITTED INVESTMENTS: Prohibited Investments 410–141–5170
CAPITALIZATION: Capital and Surplus 410–141–5175
CAPITALIZATION: Impaired Capital and Surplus 410–141–5180
CAPITALIZATION: Dividend and Distribution Restrictions 410–141–5185
CAPITALIZATION: Restricted Reserve Account 410–141–5190
CAPITALIZATION: Surplus Notes 410–141–5195
CAPITALIZATION: Risk-based Capital (RBC) Definitions 410–141–5200
CAPITALIZATION: RBC Reports 410–141–5205
CAPITALIZATION: Company Action Level Event 410–141–5210
CAPITALIZATION: Regulatory Action Level Event 410–141–5215
CAPITALIZATION: Authorized Control Level Event 410–141–5220
CAPITALIZATION: Mandatory Control Level Event 410–141–5225
REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Extraordinary Dividends and Other Distributions 410–141–5230
REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Reports of Material Acquisitions And Dispositions Of Assets, and Changes to Ceded Reinsurance Agreements 410–141–5235
REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Reports of Material Materiality and Reporting Standards for Asset Acquisitions and Dispositions 410–141–5240
REPORTING AND APPROVAL OF CERTAIN TRANSACTIONS: Materiality and Reporting Standards for Changes in Ceded Reinsurance Agreements 410–141–5245
EXAMINATIONS: CCO Production of Books and Records 410–141–5250
EXAMINATIONS: Authority Examinations of CCOs 410–141–5255
CCO ACQUISITIONS AND MERGERS: Purpose 410–141–5260
CCO ACQUISITIONS AND MERGERS: Activities Prohibited Unless Certain Provisions Satisfied 410–141–5265
CCO ACQUISITIONS AND MERGERS: Procedure For Acquiring Controlling Interest 410–141–5270
CCO ACQUISITIONS AND MERGERS: Information to Be Included in Form A 410–141–5275
CCO ACQUISITIONS AND MERGERS: Hearing, Request, Notice 410–141–5280
CCO ACQUISITIONS AND MERGERS: Determination Concerning Proposed Activity, Time For Decision, Grounds For Refusal 410–141–5285
CCO HOLDING COMPANY REGULATION: Definitions 410–141–5290
CCO HOLDING COMPANY REGULATION: Members of Holding Company Systems 410–141–5295
CCO HOLDING COMPANY REGULATION: Form and Contents of Registration Statement 410–141–5300
CCO HOLDING COMPANY REGULATION: Registration Statement Filing 410–141–5305
CCO HOLDING COMPANY REGULATION: Information Required to Be Disclosed 410–141–5310
CCO HOLDING COMPANY REGULATION: Presumption of Control 410–141–5315
CCO HOLDING COMPANY REGULATION: Disclaimer of Affiliation 410–141–5320
CCO HOLDING COMPANY REGULATION: Transactions Within Holding Company 410–141–5325
CCO HOLDING COMPANY REGULATION: Director and Officer Liability 410–141–5330
CCO HOLDING COMPANY REGULATION: Annual Enterprise Risk Report 410–141–5335
CCO HOLDING COMPANY REGULATION: Disclaimers and Termination of Registration 410–141–5340
CCO HOLDING COMPANY REGULATION: Forms 410–141–5345
CCO HOLDING COMPANY REGULATION: Forms 410–141–5350
CCO HOLDING COMPANY REGULATION: Forms 410–141–5355
CCO HOLDING COMPANY REGULATION: Forms 410–141–5360
CCO INSOLVENCY AND DISSOLUTION: Access to Funds and Transition of Members and Records 410–141–5365
CCO INSOLVENCY AND DISSOLUTION: Hazardous Operations 410–141–5370
CCO INSOLVENCY AND DISSOLUTION: Recovery From Parent Corporation Or Holding Company In The Event Of Liquidation Or Rehabilitation 410–141–5375
CCO INSOLVENCY AND DISSOLUTION: Voluntary Dissolution 410–141–5380
CIVIL PENALTIES
Last Updated

Jun. 8, 2021

Rule 410-141-3515’s source at or​.us