OAR 410-141-3865
Care Coordination Requirements

(1) CCOs will ensure continuous care management for all members.

(2)

For the purpose of OARs 410-141-3860 (Integration and Coordination of Care) – 410-141-3870 (Intensive Care Coordination), the following meanings apply:

(a)

“Health Risk Screening” means:

(A)

A systematic collaborative approach by the CCO and provider to collecting information from a Member about key areas of their health for the purpose of:
(i)
Assessing the Member’s health,
(ii)
Evaluating the Member’s level of health risk, and
(iii)
Providing the Member with individualized feedback about the results of the screening and evaluation with the goal of motivating behavioral changes to reduce health risks, maintain health, and prevent disease.

(B)

Results of the Health Risk Screening shall be documented in the member’s care plan.

(C)

Health Risk Screenings are usually administered through a survey or questionnaire. Suggested areas of information to collect include questions, depending on the Member’s age, regarding:
(i)
Demographics, such as age, gender, relationship status;
(ii)
Lifestyle behaviors, such as exercise, eating habits, alcohol and tobacco use, activities of daily living;
(iii)
Living Conditions such as access to food, housing and related living conditions;
(iv)
Behavioral/emotional health, such as stress, mood, life events, abuse;
(v)
Physical health, such as weight, height, blood pressure; and
(vi)
Personal and family health history.

(b)

“Intensive Care Coordination (ICC) Assessment” means the utilization of standardized tools, instruments, or processes for the purpose of identifying, and creating individual, personalized treatment and service plans to address the specific physical, behavioral, oral, and social needs of Priority Population Members, as well as other Members who have been identified, as a result of their Health Risk Screenings, as potentially in need of ICC Services, or having experienced a triggering event as set forth in OAR 410-141-3870 (Intensive Care Coordination)(9).
(3) CCOs shall conduct a health risk screening, which shall include a screening for behavior health issues, for each new member in accordance with OAR 410-141-3870 (Intensive Care Coordination). This screening is distinct from the assessment of special health care needs:
(a) CCOs must use a screening process to evaluate all members for critical risk factors that trigger the need for intensive care coordination for members with special health care needs;
(b) Members shall be screened upon initial enrollment with their CCO. This screening shall be completed as follows:
(A) Within 90 days of the effective date of initial enrollment;
(B) Within 30 days of the effective date of initial enrollment when the member is:
(i) Referred; or
(ii) Receiving Medicaid-funded long-term care, services and supports (LTSS); or
(iii) Is a member of a priority population as such term is defined in OAR 410-141-3870 (Intensive Care Coordination)(2); or
(C) Sooner than required under (A) or (B) if required by the member’s health condition.
(c) CCOs shall rescreen members annually or sooner if there is a change in health status indicating need for an updated assessment. Members shall be rescreened in accordance with this section (c) even if they have previously declined care coordination or ICC services;
(d) If a member’s health risk screening indicates that they meet criteria for ICC services, the CCO shall conduct, in accordance with OAR 410-141-3870 (Intensive Care Coordination), an ICC assessment within 30 days of completing the health risk screening;
(e) All Screenings and assessments shall be trauma-informed, culturally responsive and linguistically appropriate and person-centered.
(4) CCOs shall document all screenings and assessments in the member’s case file:
(a) If a CCO requires additional information from the member to complete a screening or assessment, the CCO shall document all attempts to reach the member by telephone and mail;
(b) CCOs shall maintain all screening and assessment documentation in accordance with OAR 410-141-3520 (Record Keeping and Use of Health Information Technology);
(c) CCOs shall share the results of member assessments and screenings consistent with ORS 414.679 and all other applicable state and federal privacy laws with the following:
(A) Participating medical providers serving the member, who are encouraged to integrate the resulting care plan into the individual’s medical record;
(B) The state or other MCEs serving the member;
(C) Members receiving LTSS and, if approved by the member, their case manager and their LTSS provider, if approved by the member; and
(D) With Medicare Advantage or DSNP plans serving dual eligible members.
(5) CCOs shall have processes to ensure review of a member’s potential need for long-term services and supports (LTSS) and for identifying those members requiring referral to the Department for LTSS.
(6) CCOs shall require their care coordinators to develop, and CCOs shall require their provider network to use, individualized care plans to the extent feasible to address the supportive and therapeutic needs of each member, particularly those with ICC needs, including those with serious and persistent mental illness receiving home and community-based services covered under the state’s 1915(i) State Plan Amendment and those receiving LTSS.
(7) A member’s care plan must at a minimum:
(a) Incorporate information from treatment plans from providers involved in the member’s care, and, if appropriate and with consent of the member, information provided by community partners;
(b) Contain a list of care team members, including contact information and role, compiled in cooperation with the member;
(c) Make provision for authorization of services in accordance with OAR 410-141-3835 (MCE Service Authorization);
(d) For members enrolled in ICC or a condition-specific program, intensive care coordination plans (ICCP) must be developed within 10 days of enrollment in the ICC program and updated every 90 days, or sooner if health care needs change.
(8) Care plans must reflect the member’s preferences and goals, and if appropriate, family or caregiver preferences and goals:
(a) Care plans shall be trauma-informed, culturally responsive and linguistically appropriate and person-centered;
(b) To ensure engagement and satisfaction with care plans, care coordinators shall:
(A) Actively engage members in the creation of care plans;
(B) Ensure members understand their care plans; and
(C) Ensure members understand their role and responsibilities outlined in their care plans.
(c) Care coordinators shall actively engage caregivers in the creation of member care plans and shall ensure that they understand their role as outlined in the care plan and that they feel equipped to fulfill their responsibilities;
(d) If participation in creating a member’s care plan would 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. 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 ameliorate the risk(s). This decision must be reviewed prior to each plan update, and the decision to continue the exclusion shall be documented as above;
(e) Members shall be provided a copy of their care plan at the time it is created, and after any updates or changes to the plan. However, if providing the member with a copy of their care plan would be significantly detrimental to their care or health, the care plan may be withheld from the member. CCOs must document the reasons for withholding the care plan, including a specific description of the risk or potential harm to the member, and describe what attempts were made to ameliorate the risk(s). This decision must be reviewed prior to each plan update, and the decision to continue withholding the care plan shall be documented as above.
(9) A member may decline care coordination and ICC. CCOs shall explicitly notify members that participation in care coordination or ICC is voluntary, and that treatment or services cannot be denied as a result of declining care coordination.
(10) Care coordinators shall perform their care coordination tasks in accordance with the following principles:
(a) Use trauma informed, culturally responsive and linguistically appropriate care, motivational interviewing, and other patient-centered tools to actively engage members in managing their health and well-being;
(b) Work with members to set agreed-upon goals with continued CCO network support for self-management goals;
(c) Promote utilization of preventive, early identification and intervention, and chronic disease management services;
(d) Focus on prevention, and when prevention is not possible, manage exacerbations and unanticipated events impacting progress toward the desired outcomes of treatment;
(e) Provide evidence-based condition management and a whole person approach to single or multiple chronic conditions based on goals and needs identified by the individual;
(f) Promote medication management, intensive community-based services and supports and, for ICC members, peer-delivered services and supports; and
(g) Have contact with, if the member is participating in a condition-specific program, the active condition-specific care team at least twice per month, or sooner if clinically necessary for the member’s care.
(11) Care coordinators shall promote continuity of care and recovery management through:
(a) Episodes of care, regardless of the member’s location;
(b) Monitoring of conditions and ongoing recovery and stabilization;
(c) Adoption of condition management and a whole person approach to single or multiple chronic conditions based on the goals and needs identified by the individual, including avoidance and minimization of acute events and chronic condition exacerbations; and
(d) Engaging members, and their family and caregivers as appropriate.
(e) For FBDE members, engagement of member Medicare providers and, when applicable, member Medicare Advantage or DSNP care coordination team, in order to reduce duplication, share assessments, coordinate NEMT, address member language or disability access needs, coordinate referrals, and ensure effective transitions of care.
(12) CCOs must facilitate transition planning for members. In addition to the requirements of 410-141-3860 (Integration and Coordination of Care), care coordinators shall facilitate transitions and ensure applicable services and appropriate settings continue after discharge by taking the steps set forth below.
(a) Taking an active role in discharge planning from a condition-specific facility including, without limitation, acute care or behavior rehabilitation services facilities.
(b) For discharges from the State Hospital and residential care, the care coordinator shall do all of the following:
(A) Have contact with the member no less than two times per month prior to discharge and two times within the week of discharge;
(B) Assist in the facilitation of a warm handoff to relevant care providers during transition of care and discharge planning; and
(C) Engage with the member, face to face, within two days post discharge.
(c) For discharges from an acute care admission, the care coordinator shall have contact with the member on a face-to-face basis whenever possible, as follows:
(A) Within one business day of admission;
(B) Two times per week while the member is in acute care; and
(C) No less than two times per week within the week of discharge.
(d) Prior to discharge from any residential, inpatient, long-term care, or other similarly licensed care facility, care coordinators shall conduct a transition meeting to facilitate development of a transition plan for both applicable services and appropriate settings. This meeting must be held 30 days prior to the member’s return to the CCO’s service area or, if applicable, to another facility or program or as soon as possible if the CCO is notified of impending discharge or transition with less than 30 days’ advance notice. The discharge plan must include a description of how treatment and supports for the member will continue;
(e) In the event a member has a lapse in Medicaid coverage while admitted to a hospital, residential, inpatient, long-term care, or other similarly licensed in-patient facility, CCOs must also, in addition to providing the services set forth in subsections (a)-(d) of this section (12) of this rule, oversee management of the member’s care, work to establish services that may be needed but currently are not available in their service areas, and if eligible, assist in the reinstatement of Medicaid coverage. The CCO’s obligation to provide such services shall continue for the period of 60 days from the date the member lost Medicaid coverage or until the member’s discharge, whichever occurs sooner.
(13) CCOs shall ensure care coordinators are providing the required and appropriate behavioral, oral, and physical health care services and supports to members. The individual(s) tasked with responsibility for supervising care coordinators, whether employed by a CCO or employed by a Subcontractor providing care coordination services, shall be a licensed master’s-level mental health professional. CCOs shall not subcontract or otherwise delegate the responsibility for ensuring any subcontracted care coordination services and activities meet the requirements set forth in this rule, OARs 410-141-3860 (Integration and Coordination of Care), 410-141-3870 (Intensive Care Coordination), and any other applicable care coordination requirements.

Source: Rule 410-141-3865 — Care Coordination Requirements, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-141-3865.

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 410-141-3865’s source at or​.us