Coverage Responsibility of an MCO
(1)The director will designate an MCO’s initial geographic service area (GSA). GSAs are established by postal zip code (See http://wcd.oregon.gov/Bulletins/bul_248.pdf). The MCO may only provide contract services in those GSAs approved by the director. Workers are not subject to an MCO contract unless the director has approved the GSA.
(2) Any expansion of an MCO’s service area must be approved by the director. The request for expansion must identify the new GSA and include evidence that the MCO has an adequate provider panel which meets the minimum requirements under OAR 436-015-0030 (Applying for Certification). The director may approve the MCO’s new GSA without the minimum categories of medical service providers when the MCO establishes that there are not an adequate number of providers in a given category able or willing to become members of the MCO. For categories where the MCO has fewer than three providers, the MCO must allow workers to seek treatment outside the MCO from providers in those categories. Treatment provided to workers must be consistent with the MCO’s treatment and utilization standards. Such providers, unlike come-along providers, cannot be required to comply with the terms and conditions regarding services performed by members of the MCO. However, while such providers are not themselves bound by the MCO’s treatment and utilization standards, workers are subject to those standards.
Rule 436-015-0035 — Coverage Responsibility of an MCO,