OAR 410-141-3585
MCE Member Relations: Education and Information

(1) MCEs may engage in activities for existing members related to outreach, health promotion, and health education. MCE must obtain approval of the Authority prior to distribution of any written communication by the MCE or its subcontractors and providers that:
(a) Is intended solely for members; and
(b) Pertains to requirements for obtaining coordinated care services at service area sites or benefits.
(2) MCEs may communicate with providers, caseworkers, community agencies, and other interested parties for informational purposes or to enable care coordination and address social determinants of health or community health. The intent of these communications should be informational only for building community linkages to impact social determinants of health or member care coordination and not to entice or solicit membership. Communication methodologies may include but are not limited to brochures, pamphlets, newsletters, posters, fliers, websites, health fairs, or sponsorship of health-related events. MCEs shall address health literacy issues by preparing these documents at a low-literacy reading level, incorporating graphics and utilizing alternate formats.
(3) MCEs shall have a mechanism to help members understand the requirements and benefits of the MCE’s integrated and coordinated care plan. The mechanisms developed shall be culturally and linguistically appropriate. Written materials, including provider directories, member handbooks, appeal and grievance notices, and all denial and termination notices are made available in the prevalent non-English languages in its particular service area and be available in formats noted in section (5) of this rule for members with disabilities. MCEs shall accommodate requests made by other sources such as members, family members, or caregivers for language accommodation, translating to the member’s language needs as requested.
(4) MCEs shall have written procedures, criteria, and an ongoing process of member education and information sharing that includes member orientation, member handbook, and health education. MCEs shall update their educational material as they add coordinated services. Member education shall:
(a) Include information about the coordinated care approach and how to navigate the coordinated health care system, including how to access intensive care coordination (ICC) Services, and where applicable for full benefit dual eligible (FBDE) members, the process for coordinating Medicaid and Medicare benefits;
(b) Clearly explain how members may receive assistance from certified and qualified health care interpreters and Traditional Health Workers as defined in OAR 410-180-0305and include information to members that interpreter services in any language required by the member, including American Sign Language, auxiliary aids and alternative format materials at provider offices are free to MCE members as stated in 42 CFR 438.10;
(c) Inform all members of the availability of Ombudsperson services.
(5) Written member education materials shall comply with the following language and access requirements:
(a) Materials shall be translated or include taglines in the prevalent non-English languages in the state as well as large print (font size 18) explaining the availability of written translation or oral interpretation to understand the information provided, as well as alternate formats, and the toll-free and TTY/TDY telephone number of the MCE’s member/customer service unit;
(b) Materials shall be made available in alternative formats upon request of the member at no cost. Auxiliary aids and services must also be made available upon request of the member at no cost. The MCE’s process for providing alternative formats and auxiliary aids to members may not in effect deny or limit access to covered services, grievance, appeals, or hearings;
(c) Electronic versions of member materials shall be made available on MCE website, including provider directories, formularies, and handbooks in a form that can be electronically retained and printed, available in a machine-readable file and format, and Readily Accessible, e.g., a PDF document posted on the plan website that meets language requirements of this section. For any required member education materials on the MCE website, the member is informed that the information is available in paper form without charge upon request to Members and Member representatives, and the MCE shall provide it upon request within five business days.
(6) MCE provider directories shall include:
(a) The provider’s name as well as any group affiliation;
(b) Street address(es);
(c) Telephone number(s);
(d) Website URL, as appropriate;
(e) Provider Specialty, as appropriate;
(f) Whether the provider will accept new members;

(g)

Whether the provider offers both telehealth and in-person appointments;

(h)

Information about the provider’s race and ethnicity, cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or an OHA-approved qualified and, as applicable, certified health care interpreter(s) at no cost to members at the provider’s office;
(i) Availability of auxiliary aids and services for all members with disabilities upon request and at no cost;
(j) Whether the provider has completed cultural competence training as required by ORS 413.450 (Continuing education in cultural competency) and in accordance to CCO Health Equity Plan Training and Education plan described in 410-141-3735 (Social Determinants of Health and Equity; Health Equity) whether providers have verifiable language fluency in non-English (i.e., such as clinical training in a foreign country or clinical language testing);
(k) Whether the provider’s office or facility is accessible and has accommodations for people with physical disabilities, including but not limited to information on accessibility of providers’ offices, exam rooms, restrooms, and equipment.
(L) The information for each of the following provider types covered under the contract, as applicable to the MCE contract:
(A) Physicians, including specialists;
(B) Hospitals;
(C) Pharmacies;
(D) Behavioral health providers; including specifying substance use treatment providers;
(E) Dental providers.
(m) Information included in the provider directory must be updated at least monthly, and electronic provider directories must be updated no later than 30 days after the MCE receives updated provider information. Updated materials shall be available on the MCE website in a readily accessible and machine-readable file, e.g., a PDF document posted on the plan website, per form upon request and another alternative format.
(7) Each MCE shall make available in electronic or paper form the following information about its formulary:
(a) Which medications are covered both generic and name brand;
(b) What tier each medication is on.
(8) Within 14 days of an MCE’s receiving notice of a member’s enrollment, MCEs shall mail a welcome packet to new members and to members returning to the MCE 12 months or more after previous enrollment. The packet shall include, at a minimum, a welcome letter, a member handbook, and information on how to access a provider directory, including a list of any in-network retail and mail-order pharmacies.
(9) For existing MCE members, an MCE shall notify members annually of the availability of a member handbook and provider directory and how to access those materials. MCEs shall send hard copies upon request within five days.
(10) MCEs must notify enrollees:
(a) That oral interpretation is available free of charge for any language, including American Sign Language, and written information is available in prevalent non-English languages and alternate formats that include but are not limited to audio recording, close-captioned videos, large type (18 font), and braille; and
(b) The process for requesting and accessing interpreters or auxiliary aids and alternative formats, including where appropriate how to contact specific providers responsible through sub-contracts to ensure provision of language and disability access;
(c) Language access services also applies to member representatives, family members and caregivers with hearing impairments or limited English proficiency who need to understand the member’s condition and care.
(11) An MCE shall electronically provide to the Authority for approval each version of the printed welcome packet that includes a welcome letter, member handbook, and information on how to access a provider directory. At a minimum, the member handbook shall contain the following:
(a) Revision date;
(b) Tag lines in English and other prevalent non-English languages, as defined in this rule, spoken by populations of members. The tag lines shall be located at the beginning of the document for the ease of the member and describe how members may access free sign and oral interpreters, as well as translations and materials in alternate formats;
(c) MCE’s office location, mailing address, web address, office hours, and telephone numbers including TTY;
(d) Availability and access to coordinated care services through a patient-centered primary care home or other primary care team with the member as a partner in care management. Explain how to choose a PCP, how to make an appointment, and how to change PCPs, and the MCE’s policy on changing PCPs;
(e) How to access information on contracted providers currently accepting new members and any restrictions on the member’s freedom of choice among participating providers;
(f) Which participating or non-participating provider services the member may self-refer;
(g) Policies on referrals for specialty care, including prior authorization requirements and how to request a referral;
(h) Explanation of ICC services and how eligible members may access those services;
(i) Information about the coordinated care approach, how to navigate the coordinated care health care system as applicable to dual-eligible individuals, the process for coordinating Medicaid and Medicare benefits;
(j) How and where members are to access urgent care services and advice, including how to access these services and advice when away from home;
(k) How and when members are to use emergency services, both locally and when away from home, including examples of emergencies;
(L) Information on contracted hospitals in the member’s service area;
(m) Information on post-stabilization care after a member is stabilized in order to maintain, improve, or resolve the member’s condition;
(n) Information on the MCE’s grievance and appeals processes and the Authority’s contested case hearing procedures, including:
(A) Information about assistance in filling out forms and completing the grievance process available from the MCE to the member as outlined in OAR 410-141-3875 (MCE Grievances & Appeals: Definitions and General Requirements);
(B) Information about the member’s right to continued benefits during the grievance process as provided in OAR 410-141-3885 (Grievances & Appeals: Notice of Action/Adverse Benefit Determination).
(o) Information on the member’s rights and responsibilities, including the availability of the OHP Ombudsperson;
(p) Information on charges for non-covered services, and the member’s possible responsibility for charges if they go outside of the MCE network for non-emergent care; including information specific to deductibles, copays and coinsurance for dually-enrolled qualified Medicare beneficiaries;
(q) Information about when providers may bill clients for services and what to do if they receive a bill, including information specific to payment responsibilities for dually-enrolled qualified Medicare beneficiaries;
(r) The transitional procedures for new members to obtain prescriptions, supplies, and other necessary items and services in the first month of enrollment if they are unable to meet with a PCP or PCD, other prescribing provider, or obtain new orders during that period; including specific communications for members who are becoming new Medicare enrollees;
(s) Information on advance directive policies including:
(A) Member rights under federal and Oregon law to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives;
(B) The MCE’s policies for implementation of those rights, including a statement of any limitation regarding the implementation of advanced directives as a matter of conscience.
(t) Whether or not the MCE uses provider contracts including alternative payment methodologies or incentives;
(u) The member’s right to request and obtain copies of their clinical records, whether they may be charged a reasonable copying fee, and that they may request the record be amended or corrected;
(v) How and when members are to obtain ambulance services;
(w) Resources for help with transportation to appointments with providers and scheduling process for use of non-emergency medical transportation (NEMT) services;
(x) Explanation of the covered and non-covered coordinated care services in sufficient detail to ensure that members understand the benefits to which they are entitled;
(y) How to access in-network retail and mail-order pharmacies;
(z) How members are to obtain prescriptions including information on the process for obtaining non-formulary and over-the-counter drugs;
(aa) The MCE’s confidentiality policy;
(bb) How and where members may access any benefits that are available under OHP but are not covered under the MCE’s contract, including any cost sharing;
(cc) When and how members may voluntarily and involuntarily disenroll from MCEs and change MCEs;
(dd) MCEs shall, at a minimum, annually review their member handbook for accuracy and update it with new and corrected information to reflect OHP program changes and the MCE’s internal changes. If changes affect the member’s ability to use services or benefits, the MCE shall offer the updated member handbook to all members;
(ee) The “Oregon Health Plan Client Handbook” is in addition to the MCE’s member handbook, and an MCE may not use it to substitute for any component of the MCE’s member handbook.
(12) Member health education shall include:
(a) Information on specific health care procedures, instruction in self-management of health care, promotion and maintenance of optimal health care status, patient self-care, and disease and accident prevention. MCE providers or other individuals or programs approved by the MCE may provide health education. MCEs shall make every effort to provide health education in a culturally sensitive and linguistically appropriate manner in order to communicate most effectively with individuals from non-dominant cultures;
(b) Information specifying that MCEs may not prohibit or otherwise restrict a provider acting within the lawful scope of practice from advising or advocating on behalf of a member who is their patient for the following:
(A) The member’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered;
(B) Any information the member needs to decide among all relevant treatment options;
(C) The risks, benefits, and consequences of treatment or non-treatment.
(c) MCEs shall ensure development and maintenance of an individualized health educational plan for members whom their provider has identified as requiring specific educational intervention. The Authority may assist in developing materials that address specifically identified health education problems to the population in need;
(d) An explanation of ICC services and how eligible members may access those services. MCEs should ensure that ICC-related education reaches potentially eligible members, including those with special health care needs including those who are aged, blind, or disabled, or who have complex medical needs or high health care needs, multiple chronic conditions, mental illness, chemical dependency, or who receive additional Medicaid-funded LTSS;
(e) The appropriate use of the delivery system, including proactive and effective education of members on how to access emergency services and urgent care services appropriately;
(f) MCEs shall provide written notice to affected members of any significant changes in provider(s), program, or service sites that affect the member’s ability to access care or services from MCE’s participating providers. The MCE shall provide, translated as appropriate, the notice at least 30 days before the effective date of that change, or as soon as possible if the participating provider has not given the MCE sufficient notification to meet the 30-day notice requirement. The Authority shall review and approve the materials within two working days.
(13) MCEs shall provide an identification card to members, unless waived by the Authority, that contains simple, readable, and usable information on how to access care in an urgent or emergency situation. The cards are solely for the convenience of the MCE, members, and providers.

Source: Rule 410-141-3585 — MCE Member Relations: Education and Information, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-141-3585.

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 410-141-3585’s source at or​.us