OAR 410-141-3870
Intensive Care Coordination

(1)

CCOs are responsible for Intensive Care Coordination (ICC) services. The requirements described in this rule are in addition to the general care coordination requirements and health risk screenings described in OAR 410-141-3860 (Integration and Coordination of Care) and 410-141-3865 (Care Coordination Requirements).

(2) “Prioritized Populations” means individuals who:

(a) Are older adults, individuals who are hard of hearing, deaf, blind, or have other disabilities;

(b) Have complex or high health care needs, or multiple or chronic conditions, or SPMI, or are receiving Medicaid-funded long-term care services and supports (LTSS);

(c) Are children ages 0-5:

(A) Showing early signs of social/emotional or behavioral problems, or

(B) Have a Serious Emotional Disorder (SED) diagnosis;

(d) Are in medication assisted treatment for SUD;

(e) Are women who have been diagnosed with a high-risk pregnancy;

(f) Are children with neonatal abstinence syndrome;

(g) Children in Child Welfare;

(h) Are IV drug users;

(i) People with SUD in need of withdrawal management;

(j) Have HIV/AIDS or have tuberculosis;

(k) Are veterans and their families; and

(L) Are at risk of first episode psychosis, and individuals within the Intellectual and developmental disability (IDD) populations.

(3) “Intensive Care Coordinator” (ICC Care Coordinator) means a person coordinating ICC services as defined in this rule.

(4) “Intensive Care Coordination Plan” (ICC Plan) means a collaborative, comprehensive, integrated and interdisciplinary-focused written document that includes details of the supports, desired outcomes, activities, and resources required for an individual receiving ICC Services to achieve and maintain personal goals, health, and safety. It identifies explicit assignments for the functions of specific care team members, and addresses interrelated medical, social, cultural, developmental, behavioral, educational, spiritual and financial needs in order to achieve optimal health and wellness outcomes.

(5) All members of prioritized populations shall be automatically assessed for ICC services within 10 calendar days of completion of the health risk screening, or sooner if required by their health condition. Children who are members of a prioritized population shall be provided behavioral health services according to presenting needs.

(6) CCOs shall also conduct an ICC assessment of other members, including children age 18 and under, upon referral or after an initial-health risk screening as set forth below in this section (6). All referrals for ICC assessments shall be responded to by the CCO within one business day of receipt of the referral and the ICC assessment shall be completed within 30 days after receipt of referral or completion of an initial health-risk screening. ICC assessments shall be conducted when:

(a) A health risk screening conducted under, and in accordance with, OAR 410-141-3865 (Care Coordination Requirements) indicates a member has special health care needs or other needs or conditions that may indicate a need for ICC services;

(b) A member refers themselves;

(c) A member’s representative or provider, including a home and community- based services provider, refers the member; or

(d) Upon referral of any medical personnel serving as a member’s LTCSS case manager.

(7) CCOs shall have policies and procedures in place that enable early identification of members who may have ICC needs. CCOs shall have established process for responding to all requests for ICC assessments or services, which shall include, without limitation, the requirement to respond to all requests or referrals for ICC assessments or services within one business day.

(8) ICC assessments shall identify the physical, behavioral, oral and social needs of a member.

(9) For those members not receiving ICC services, and upon the occurrence of any of the reassessment triggering events listed below in subsections (c)(A) through (S) of this section (9), CCOs shall conduct new health risk screenings, and, as applicable, reassess members for ICC eligibility revise care plans, and ensure care coordination efforts are undertaken in accordance with OAR 410-141-3865 (Care Coordination Requirements). Contact shall be made with the member by the care coordinator within seven calendar days of receipt of notice of the reassessment triggering event:

(a) For those members receiving ICC services and upon the occurrence of any of the triggering events listed below in subsections (b)(A) through (S) of this section (9), ICC care coordinators shall, if in the ICC care coordinator’s professional opinion it is necessary to reassess the members for ICC services, update the members’ ICC plan, and ensure care coordination efforts are undertaken in accordance with OAR 410-141-3865 (Care Coordination Requirements) and this rule. Contact shall be made with the member by the ICC care coordinator within three calendar days of receipt of notice of a reassessment triggering event;

(b) Reassessment triggering events include all of the following events:

(A) New hospital visit (ER or admission);

(B) New high-risk pregnancy diagnosis;

(C) New chronic disease diagnosis (includes behavioral health);

(D) New behavioral health diagnosis;

(E) Opioid drug use;

(F) IV drug use;

(G) Suicide attempt, ideation, or planning (identification may be through the member’s care team, through diagnoses, or from the member or member’s supports);

(H) New I/DD diagnosis;

(I) Events placing the member at risk for adverse child experiences, such as DHS involvement or new reports of abuse or neglect to Child Welfare Services or Adult Protective Services;

(J) Recent homelessness;

(K) Two or more billable primary Z code diagnoses within one month;

(L) Two or more caregiver placements within past six months;

(M) An exclusionary practice, such as being asked not to return to day care, for children aged 0-6, or suspension, expulsion, seclusion, or in-school suspension, for school-aged children;

(N) Discovery of new or ongoing behavioral health needs;

(O) Discharge from a residential setting or long-term care back to the community;

(P) Severe high level of self-reported or detected alcohol or benzodiazepine usage while enrolled in a program of medication assisted treatment;

(Q) Two or more readmissions to an acute care psychiatric hospital in a 6-month period;

(R) Two or more readmissions to an emergency department for a psychiatric reason in a 6-month period; and

(S) Exit from condition-specific program.

(c) Members shall be reassessed for ICC services and care plans or, if applicable, ICC plans shall be revised annually;

(d) Reassessment for ICC services and care plans, or if applicable, ICC plans, revised if necessary, must be performed upon member request.

(10) Members eligible for ICC shall be assigned an ICC care coordinator:

(a) ICC Care coordinator assignments must be made within three business days of determining a member is eligible for ICC services;

(b) If a member is in a condition-specific program at the time they are determined eligible for ICC services, or enters a condition-specific program while receiving ICC services, then the CCO will appoint the care coordinator of the condition-specific program as the ICC care coordinator for the member while the member is in the condition-specific program. After a member transitions from a condition-specific program, the CCO must reassess the member for ICC services within seven calendar days of the transition and assign a new ICC care coordinator within three business days of the completion of the ICC reassessment;

(c) CCOs shall notify members of their ICC status by at least two means of communication within five business days following the completion of the ICC assessment. Notifications shall include details about the ICC program and the name and contact information of their assigned ICC care coordinator.

(11) CCOs shall implement procedures to share the results of ICC assessment including, without limitation, identifications made as a result of the assessment and intensive care coordination plan (ICCP) created for ICC services. CCOs shall share the results with participating providers serving the member, other parties identified in OAR 410-141-3865 (Care Coordination Requirements) and, for members receiving LTCSS, the results should be shared with the local offices for aging and adults with physical disabilities (APD) and the Office of Developmental Disability Services. Information sharing shall be consistent with ORS 414.679 and applicable state and federal privacy laws and meet timely access standards set forth in in 410-141-3515 (Network Adequacy).

(12) ICC services shall include, without limitation:

(a) Assistance to ensure timely access to and management of medical providers, capitated services, and preventive, physical health, behavioral health, oral health, remedial, and supportive care and services;

(b) Coordination with medical and LTCSS providers to ensure consideration is given to unique needs in treatment planning;

(c) Assistance to medical providers with coordination of capitated services and discharge planning; and

(d) Aid with coordinating necessary and appropriate linkage of community support and social service systems with medical care systems.

(13) ICC Care coordinators must provide the following services:

(a) Meet face to face with the member, or make multiple documented attempts to do so, for the initial and exiting appointments. Thereafter, ICC care coordinators must have face-to-face contact with the member individually at least once every three months and make other kinds of contact (face to face when possible) three times a month or more frequently if indicated. If an ICC care coordinator is unable to comply with the member contact requirements, the CCO must document attempts made, barriers, and remediation efforts taken to overcome the barriers to the member contact requirements;

(b) Contact the member no more than three calendar days after receiving notification of a reassessment trigger described in section (9) of this rule. If an ICC care coordinator is unable to make contact with the member within three calendar days of a reassessment trigger, the ICC care coordinator must document in the member’s case file all efforts made to contact the member. ICC care coordinators must continue brief contacts with members who have experienced a reassessment trigger as long as deemed necessary by the care team before they revert back to the routine contact requirements under subsection (a) of this section (13);

(c) Contact the member’s Primary Care Provider (PCP) within one week of ICC assignment, no less than once a month thereafter, or more often if required by the member’s circumstances, to ensure integration of care;

(d) Facilitate communication between and among behavioral and physical health service providers regarding member progress and health status, test results, lab reports, medications, and other health care information when necessary to promote optimal outcomes and reduce risks, duplication of services, or errors. This communication shall provide an interdisciplinary, integrative and holistic care update, including a description of clinical interventions being utilized and member’s progress towards goals;

(e) Convene and facilitate interdisciplinary team meetings monthly, or more frequently, based on need. Interdisciplinary team meetings must include the member unless the member declines or the member’s participation is determined to be significantly detrimental to the member’s health, in accordance with OAR 410-141-3865 (Care Coordination Requirements)(7)(d). The ICC care coordinator is responsible for arranging for the PCP or PCP staff to bring material to the meeting. The meetings shall provide a forum to:

(A) Describe the clinical interventions recommended to the treatment team;

(B) Create a space for the member to provide feedback on their care, self-reported progress towards their ICC plan goals and their strengths exhibited in between current and prior meeting;

(C) Identify coordination gaps and strategies to improve care coordination with the member’s service providers;

(D) Develop strategies to monitor referrals and follow-up for specialty care and routine health care services, including medication monitoring; and

(E) Align with the member’s individual ICC plan.

(f) Convening a post-transition meeting of the interdisciplinary team within 14 days of a transition between levels, settings or episodes of care.

(14) If a member is enrolled in other programs, including condition-specific programs, where there is a care manager, the ICC care coordinator remains responsible for the overall care of the member, while the program-specific care manager shall be responsible for supporting specific needs based on their specialty within the interdisciplinary team.

(15) CCOs shall implement processes for documenting all of the ICC services provided and attempted to be provided to members and for creating and implementing ICC plans for members requiring ICC services. CCOs shall produce ICC plans for each member requiring ICC services. Each ICC plan shall:

(a) Be developed in a person-centered process with providers caring for the member, including any community-based support services and LTSS providers and the member’s participation;

(b) Include consultations with any specialist(s) caring for the member and Medicaid funded long-term services and supports providers and case managers or for full benefit dual eligible (FBDE) members, Medicare providers or MCE aligned Medicare Advantage or Dual Special Needs Plan care coordinators;

(c) Be approved by the CCO in a timely manner if CCO approval is required;

(d) In alignment with rules outlined in OAR 410-141-3835 (MCE Service Authorization) CCO Service Authorization; and

(e) In accordance with any applicable quality assurance and utilization review standards.

(16) CCOs shall periodically inform all participating providers of the availability of ICC and other support services available for members. CCOs shall also periodically provide training for patient-centered primary care homes and other primary care provider staff.

(17) CCO staff providing or managing ICC care coordination services shall be required to:

(a) Be available for training, regional OHP meetings, and case conferences involving OHP clients (or their representatives) in the CCO’s service areas who are identified as being of a prioritized population;

(b) If a Member is unable to receive services during normal business hours, the CCO shall provide alternative availability options for the member;

(c) Be trained for, and exhibit skills in, person-centered care planning and trauma informed care; and communication with and sensitivity to the special health care needs of priority populations. CCOs shall have a written position description for its staff responsible for managing ICC services and for staff who provide ICC services;

(d) CCOs shall have written policies that outline how the level of staffing dedicated to ICC is determined. The ICC policies must include, without limitation, care coordination staffing standards such that the complexity, scope, and intensity of the needs of members receiving ICC services can be met.

(18) Consistent with the requirements under this rule, CCOs shall make Integration and Care Coordination services available during normal business hours, Monday through Friday. Information on ICC services shall be made available when necessary to a member’s representative during normal business hours, Monday through Friday. If a Member is unable to receive services outside of normal business hours, the CCO shall provide alternative availability options for member.

(19) CCOs shall have a process to provide members with special health care needs who are receiving ICC services or are receiving Medicaid-funded LTSS with direct access to a specialist, e.g., a standing referral or an approved number of visits, as appropriate for the member’s condition and identified needs. CCOs shall have processes in place to ensure it reviews member needs for LTSS and mechanisms to identify and refer to the Department of human services, inclusive of its area agency on aging, office of developmental disabilities services, and aging and people with disability programs, or, as may be applicable to a 1915(i) provider for LTSS assessment and services.

Source: Rule 410-141-3870 — Intensive Care Coordination, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-141-3870.

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 410-141-3870’s source at or​.us