OAR 410-141-3710
Contract Termination and Close-Out Requirements

(1) This rule applies to any termination of an MCE contract, including but not limited to non-renewal under OAR 410-141-3725 (CCO Contract Renewal Notification), expiration of the contract at the end of its term, or termination during the term of the contract initiated by either party. Consistent with OAR 410-141-3725 (CCO Contract Renewal Notification), MCEs shall abide by all requirements in this rule regardless of whether termination notice is provided by the Authority or the MCE.
(2) The party initiating the termination shall render written notice of termination to the other party by certified mail, return receipt requested, or in person with proof of delivery and a contemporaneous copy emailed to the other party’s contract administrator.
(3) The notice of termination shall specify the circumstances giving rise to termination and the date on which such termination shall become effective.
(4) After receipt of an MCE’s notification of intent not to renew or notice of termination, the Authority shall issue written notice to the MCE specifying:
(a) The effective date of termination;
(b) The MCE’s operational and reporting requirements; and
(c) Timelines for submission of deliverables.
(5) Upon notification of termination or non-renewal, an MCE shall submit to the Authority a transition plan detailing how it fulfills its continuing obligations for the duration of the contract. The transition plan shall include:
(a) How each of the MCE’s members and contracted providers are notified of the termination of the contract;
(b) A plan to transition its members to other MCEs; and
(c) A plan for closing out its MCE business, including but not limited to the operational and reporting requirements and timelines for submission of deliverables, as specified by the Authority, and the requirements specified in this rule.
(6) Transition plans are subject to approval by the Authority:
(a) The MCE must revise the transition plan as necessary to obtain approval by the Authority;
(b) Failure to submit a transition plan and obtain written approval of the termination plan by the Authority may result in the Authority’s withholding of 20 percent of the MCE’s monthly capitation payment until the Authority has approved the transition plan;
(c) If the Authority’s approval of the transition plan occurs less than 90 days before the effective date of termination, then the Authority may require the MCE to extend the contract to a later effective date of termination, including as necessary the MCE’s acceptance of amendments to the contract generally applicable to MCE contracts through the extended effective date.
(7) The MCE shall designate an individual as the contract transition coordinator.
(8) The contract transition coordinator shall be the Authority’s contact for ensuring the MCE’s completion of the MCE’s contractual obligations, performance, operations, and member transitions including the transition plan.
(9) MCEs must submit reports to the Authority every 30 calendar days detailing the MCE’s progress in executing its transition plan. In the event of the MCE’s substantial failure to execute timely its transition plan, the Authority may withhold 20 percent of any payments due to the MCE from the Authority until such failure is corrected.
(10) MCEs shall submit a final report to the Authority describing how it fulfilled all transition and close-out activities described in the transition plan. The final report is subject to the Authority approval before issuance of any final payment.
(11) MCEs shall continue to perform all financial, management, and administrative services obligations identified in contract throughout the closeout period, including at minimum:
(a) Restricted reserves and insurance coverage for a period of 18 months following the notice of termination, or until the state provides the MCE with written release agreeing that all continuing obligations are fulfilled, whichever is earlier;
(b) Maintaining adequate staffing to perform all required functions as specified in contract;
(c) Supplying all information necessary to the Authority or its designee upon request for reimbursement of any outstanding claims at the time of termination;
(d) Assisting the Authority to ensure an orderly transition of member services after notice of termination consistent with the Authority’s Transition of Care Policy; and
(e) To make available all signed provider agreements or subcontracts to the Authority upon request.
(12) The MCE must arrange for the orderly transfer of all OHP members assigned to the MCE to coverage under any new arrangement authorized by the Authority, including any actions required by the Authority to complete the transition of members and the termination of the MCE contract. These actions include:
(a) Forwarding of all medical or financial records related to the contractually obligated activities;
(b) High needs care coordination;
(c) Facilitation and scheduling of medically necessary appointments for care and services;
(d) Identification of chronically ill high risk, hospitalized, and pregnant members in their last four weeks of pregnancy.
(13) If a change of providers may be harmful to the member, the MCE must continue to provide services until that treatment is concluded or appropriate transfer of care is arranged.
(14) The MCE shall make available and require its providers and subcontractors to make available to the Authority copies of medical, behavioral, oral and managed long-term services and supports records, patient files, and any other pertinent information necessary for efficient care management of enrollees, as determined by the Director of the Authority:
(a) Records shall be in a usable form and shall be provided at no expense to the Authority, using a file format and dates for transfer specified by the Authority;
(b) Under no circumstances shall a Medicaid member be billed for this service;
(c) Information that shall be required includes:
(A) Numbers and status of grievances in process;
(B) Numbers and status of hospital authorizations in process, listed by hospital;
(C) Daily hospital logs;
(D) Prior authorizations approved, pending, or denied;
(E) Program exceptions approved;
(F) Medical cost ratio data;
(G) Information on outstanding payments for medical care rendered to members;
(H) All encounter data required under the terminated agreement;
(I) Identification of members whose treatment or treatment plans require continuity of care consideration;
(J) Any other information or records deemed necessary by the Authority to facilitate the transition of care.
(15) Following expiration of the contract and the completion of closeout period obligations, the MCE shall:
(a) Maintain claims processing functions as necessary for a minimum of 18 months after the date of termination. If additional claims are outstanding, the MCE shall maintain the claims processing system as long as necessary to complete final adjudication of all claims;
(b) Remain liable and retain financial responsibility for all claims with dates of service prior to the date of termination;
(c) Maintain financial responsibility for patients who are hospitalized prior to the termination date through the date of discharge or for patients receiving post hospital extended care benefits after termination to the extent the MCE is responsible under the contract;
(d) Maintain financial responsibility for services rendered prior to the termination date, for which payment is denied by the MCE and subsequently approved upon appeal by the provider; and
(e) Assist the Authority with grievances and appeals for dates of service prior to the termination date.
(16) Runout activities shall consist of the processing, payment, and reconciliations necessary regarding all enrollees, claims for payment from providers, appeals by both providers and members, and financial reporting deemed necessary by the Authority, including:
(a) Monthly claims aging report including IBNR amounts;
(b) Quarterly financial statements and annual audited financial statements in conformity with the specification in the contract up to the date specified by the Authority;
(c) Certified encounter reporting until all services rendered prior to contract expiration or termination have reached adjudicated status and the Authority data validation of the information is complete;
(d) Arranging for the retention, preservation, and availability of all records, including those records related to member grievance and appeals, litigation, base data, Medical Loss Ratio (MLR) reports, claims settlement, and those records covered under HIPAA as required by contract and state and federal law;
(e) Details of any existing third-party liability (TPL) or personal injury lien (PIL) cases and making any necessary arrangements to transfer the cases to the Authority’s TPL and PIL units; and
(f) Final reports that identify all expenditures for any period in which the MCE continued to pay claims for services provided during the contract period.
(17) The Authority may require status reports or updates to the data reporting requirements in section (16) upon request.
(18) MCEs shall submit to the Authority a written request for release certifying that all obligations have been satisfied. The Authority shall provide an official written release upon satisfaction of activities associated with the contract expiration or termination plan. The request must be signed, expressly under penalty of False Claims Act liability, by the president and the chief financial officer of the MCE and must attest that, except as expressly described in a writing attached to the attestation:
(a) All payments are received by the MCE under the contract, and all the MCE’s liabilities under the contract are extinguished;
(b) All reports, reconciliations, member matters, and provider matters are resolved and finalized; and
(c) The MCE complied with all contractual and legal requirements, including completion of the activities described in the transition plan.
(19) To the extent that the request for release under section (18) attaches any exception, the request for release must include a plan describing how each exception is resolved. Any payments due under the terms of the contract for services between the Authority and the MCE, including the distribution of restricted reserve funds or any withheld capitation amount, may be withheld until the Authority receives all written and properly executed documents from the MCE. The MCE is subject to all obligations under the contract, associated rules, and the transition plan until a final written release is issued by the Director of the Authority. Such release:
(a) Shall apply only to the extent of the MCE’s responsibilities under the MCE contract, associated rules, and the transition plan;
(b) Shall apply only to the extent the MCE’s submissions to the Authority are true, complete, and accurate;
(c) Shall apply only between the Authority and the MCE;
(d) May not bind third parties;
(e) May not preclude the Authority’s assertion of indemnity, contribution, or other obligations based on third-party claims;
(f) May not preclude the Authority’s assertion of false claims liability, Medicaid fraud, common-law fraud, or other claims, false statements, or fraud; and
(g) May not affect any post-termination obligations of the MCE under the contract for preservation of records or for auditors’ access.

Source: Rule 410-141-3710 — Contract Termination and Close-Out Requirements, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-141-3710.

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 410-141-3710’s source at or​.us