Or. Admin. Code § 410-120-1865 - Denial, Reduction, or Termination of Services
(1) The purpose of this rule is to describe
the requirements governing the denial, reduction, or termination of medical
assistance and access to the Authority administrative hearings process for
clients requesting or receiving medical assistance services paid for by the
Authority on a fee-for-service basis. Grievance, complaint, and appeal
procedures for clients receiving services from an MCE shall be governed
exclusively by the procedures in OAR
410-141-3260 and where
applicable OAR 410-141-3475.
(2) When the Authority authorizes a course of
treatment or covered service, but subsequently acts (as defined in
42 CFR
431.201) to terminate, suspend, or reduce the
course of treatment or a covered service, the Authority or its designee shall
mail a written notice to the client at least ten days before the date of the
termination or reduction of the covered service unless there is documentation
that the client had previously agreed to the change as part of the course of
treatment or as otherwise provided in
42 CFR
431.213.
(3) The written client notice must inform the
client of the action the Authority has taken or intends to take and reasons for
the action; a reference to the particular sections of the statutes and rules
involved for each reason identified in the notice; the client's right to
request an administrative hearing; an explanation of the circumstances under
which benefits may continue pending resolution of the hearing; and how to
contact the Authority for additional information. The Authority is not required
to grant a hearing if the sole issue is a federal or state law requiring an
automatic change adversely affecting some or all recipients.
(4) The Authority shall have the following
responsibilities in relation to continuation or reinstatement of benefit under
this rule:
(a) If the client requests an
administrative hearing by the tenth day following the date of the client
notice, or before the effective date of the action proposed in the notice, if
applicable, and requests that the services be continued, the Authority shall
continue the services. The service shall be continued until whichever of the
following occurs first, but may not exceed ninety days from the date of the
client's request for an administrative hearing):
(A) The current authorization expires;
or
(B) A decision is rendered about
the case that is the subject of the administrative hearing; or
(C) The client is no longer eligible for
medical assistance benefits or the health service, supply, or item that is the
subject of the administrative hearing is no longer a covered benefit in the
client's medical assistance benefit package; or
(D) The sole issue is one of federal or state
law or policy, and the Authority promptly informs the client in writing that
services are to be terminated or reduced pending the hearing
decision.
(b) The
Division shall notify the client in writing that it is continuing the service.
The notice shall inform the client that if the hearing is resolved against the
client, the cost of any services continued after the effective date of the
client notice may be recovered from the client pursuant to
42 CFR
431.230(b);
(c) The Authority shall reinstate services
if:
(A) The Authority takes an action without
providing the required notice and the client requests a hearing;
(B) The Authority does not provide the notice
in the time required under section (2) of this rule and the client requests a
hearing within 10 days of the mailing of the notice of action; or
(C) The post office returns mail directed to
the client, but the client's whereabouts become known during the time the
client is still eligible for services;
(D) The reinstated services must be continued
until a hearing decision, unless at the hearing it is determined that the sole
issue is one of federal or state law or policy.
(d) The Authority shall promptly correct the
action taken up to the limit of the original authorization, retroactive to the
date the action was taken, if the hearing decision is favorable to the client,
or the Authority decides in the client's favor before the hearing.
Notes
Statutory/Other Authority: 413.042
Statutes/Other Implemented: 411.408, 414.025 & 414.065
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