Or. Admin. Code § 410-120-2015 - [Effective 6/29/2025] HRSN Eligibility Screening

(1) The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering, determining eligibility, and delivering Health Related Social Needs (HRSN) Services when a Member initiates a request for HRSN Service. The Authority finds that:

(a) HRSN Services are foundational health promoting services that foster engagement in health care services as well as improve health outcomes; and

(b) HRSN Self-Attestation ("Self-Attestation") allows a Member to provide a statement that the MCE or the Authority may rely upon to assess eligibility for HRSN Services when Members have not established or sustained engagement in health care services.

(2) After receipt of a complete HRSN Request, an MCE and, as applicable, the Authority, shall offer to screen the Member for whom the HRSN Request was made. If the Member consents to the screening, the MCE or, as applicable, the Authority shall conduct an HRSN Eligibility Screening in accordance with OAR 410-120-0000 and this rule to determine whether to authorize the HRSN Service requested.

(3) If the HRSN Connector does not include all the information in the HRSN Request that is necessary for determining whether the Member is eligible to receive an HRSN Service, the MCE or, as applicable, the Authority, shall obtain all the information necessary in order to conduct the HRSN Eligibility screening. The MCE or Authority may refer the Member to an HRSN Service Provider who can support the Member to gather required documentation, or may work directly with the Member to obtain the necessary information.

(a) If an MCE determines the individual is enrolled in OHP but is enrolled in a different MCE or is enrolled in FFS, the MCE shall forward the HRSN Request to, as applicable, the MCE in which the Member is enrolled or the Authority;

(b) If the Authority determines the individual is enrolled in OHP but is enrolled in an MCE, the Authority shall forward the HRSN Request to the MCE in which the Member is enrolled.

(4) All Self-Attestations submitted by a Member through an HRSN Request must include the following information identified below in this Subsection (a) of this Section (4) and must be accepted by MCEs and the Authority as set out below in this Section (4).

(a) Members who submit Self-Attestations for HRSN Services must include in their HRSN Self-Attestation, at minimum, the following statements:

(A) The condition that fulfills eligibility criteria for the requested HRSN Service; and

(B) The information they have provided is true.

(b) MCEs and the Authority may accept Self-Attestations that are made orally by a Member so long as the MCE or, as applicable, the Authority documents the oral Self-Attestation and the Member signs or otherwise acknowledges the documentation.

(c) MCEs and the Authority must not require a Self-Attestation to be submitted in a specific format so long as the Self-Attestation includes the required elements listed in subsection (a) of this Section (4).

(5) Except as set forth in section (6) of this rule, the MCE, or as applicable the Authority, must conduct an HRSN Eligibility Screening based on the statements made in the Self-Attestation as follows:

(a) If the Self-Attestation does not include all the information necessary to complete the HRSN Eligibility Screening, the MCE, or as applicable the Authority, shall use good faith efforts to obtain all information necessary to complete the HRSN Eligibility Screening.

(b) The MCE, or as applicable the Authority, must verify or attempt to verify the information included in a Member's Self-Attestation with existing, supporting documentation as follows:

(A) Enrollment in OHP Plus (BMH Benefit Package Identifier) and the Member's OHP number must be verified;

(B) The following HRSN Covered Populations must be verified:

(i) Individuals Transitioning to Dual Medicaid and Medicare Status;

(ii) Individuals identified as Young Adults with Special Health Care Needs.

(C) HRSN Social Risk Factors for HRSN Nutrition-Related Supports must be verified by determining whether the Member qualifies as Low Food Security or Very Low Food Security as measured by the U.S. Household Food Security Survey Module: Six Item Short Form from the U.S. Department of Agriculture published in May 2024, available here: https://ers.usda.gov/sites/default/files/_laserfiche/DataFiles/50764/short2024.pdf?v=81104

(D) HRSN Clinical Risk Factors for Medically Tailored Meals must be verified.

(E) Good faith efforts must be made to verify:

(i) HRSN Covered Populations not identified in (B) of this subsection (b);

(ii) Social Risk Factors not identified in (C) of this subsection (b); and

(iii) All Clinical Risk Factors, except for Medically Tailored Meals.

(c) All good faith efforts to verify information and collect documentation that could be used to verify a Member's Self-Attestation must be documented by MCEs and, as applicable, the Authority.

(A) The absence of documentation is not alone a basis to conclude that the Self-Attestation it is not truthful.

(B) If the information included in the Member's Self-Attestation that is identified in OAR 410-120-2015(5)(b)(E) cannot, using good faith efforts, be verified within a reasonable period of time the MCE, or as applicable the Authority, must make an eligibility determination as to whether, on its face, the information provided is likely truthful in light of the totality of the circumstances.

(6) HRSN Service requests that have been accepted and subject to screening based on Self-Attestation must be authorized or denied by MCEs or, as applicable the Authority, as follows:

(a) The requested or identified HRSN Services must be authorized if there is a reasonable basis to conclude that the Self-Attestation is likely truthful in light of the totality of the circumstances of the Member's Self-Attestation and:

(A) The requested or identified HRSN Services are not duplicative of services the Member is already receiving; and

(B) In the case of HRSN Housing-Related Supports, all documentation required prior to authorization as identified in Table 4 of OAR 410-120-2005 have been obtained.

(b) The requested HRSN Service must be denied if:

(A) The identified HRSN Service request is for the HRSN Medically Tailored Meals Service within Nutrition-Related Supports and the Clinical Risk Factor cannot be verified by existing documentation to be medically necessary and appropriate by a registered dietician nutritionist licensed in the state of Oregon, or by a primary care physician or the Member's physician specialist such as a cardiologist, oncologist or other similar physician specialist.

(B) The identified HRSN Service request is for HRSN Housing Related Supports, and all documentation that is identified as required in Table 4 of OAR 410-120-2005 has not been obtained.

(C) The identified HRSN Service request is duplicative of a service the member is receiving and there is no gap in service need.

(D) Good faith efforts reveal that the Self-Attestation is not likely truthful in light of the totality of the circumstances.

(7) In the event there is no documented evidence that verifies a self-attested health condition, it may be reasonable for MCEs or, as applicable, the Authority to deny an identified HRSN Service. In undertaking the good faith verification process and in making a determination about authorization or denial, MCEs or, as applicable, the Authority, must take into consideration that some conditions may be less likely to have existing, supporting documentation due to their nature, their symptoms, safety concerns, stigma, and barriers to care. In keeping with the forgoing considerations, MCEs and, as applicable, the Authority may deny an identified HRSN Service request based on self-attested clinical risk factors if:

(a) It would be objectively reasonable that the attested health condition would require some type of health care service because of the nature of the condition or its symptoms; and

(b) The member has been enrolled in the same CCO for a period of time that has been long enough that it would be reasonable to expect that at least some claims or medical records data for the self-attested health condition should have been submitted in MMIS that could have been reviewed.

(8) All MCEs and the Authority shall document the results of each HRSN Eligibility Screening, which must include at minimum, all of the following:

(a) Confirmation the individual is enrolled in the OHP Plus benefit package, including the Member's OHP number;

(b) The HRSN Service requested, and whether the source of the HRSN Request was, Member self-referral, Member Representative, HRSN Connector (other than an HRSN Service Provider), HRSN Service Provider, or direct outreach from an MCE or the Authority;

(c) The HRSN Covered Population to which the Member belongs, based on existing documentation or Member Self-Attestation;

(d) The Member's HRSN Clinical Risk Factor(s) applicable to the requested HRSN Service as set forth in the Tables 1 and 2 included in OAR 410-120-2005, based on existing documentation or Member Self-Attestation;

(e) The Member's HRSN Social Risk Factors, as applicable to the requested HRSN Service as set forth in the tables included in OAR 410-120-2005, based on existing documentation or Member Self-Attestation;

(f) All other eligibility criteria that may be applicable to the requested HRSN Service as set forth in the tables included in OAR 410-120-2005;

(g) All required documentation that may be applicable to the requested HRSN Service as set forth in the tables included in OAR 410-120-2005;

(h) Confirmation or a determination that the Member is not receiving the same service as the requested HRSN Services from a local, state, or federally funded program, based on existing documentation or Member Self-Attestation. If the Member is receiving a similar service as the HRSN Service requested, the HRSN Service may be provided to an HRSN Authorized Member to fill gaps or otherwise supplement current program, but in no event shall a Member be authorized to receive duplicate existing services;

(i) Whether the Member's HRSN Services are authorized (or denied).

(9) HRSN Eligibility Screenings must be completed within sufficient time to meet the deadline for authorizing or denying the HRSN Service within fourteen (14) days of receipt of the complete HRSN Request, in accordance with OAR 410-141-3835 and OAR 410-120-2020.

(10) If the individual requesting an HRSN Service is not enrolled in OHP or is enrolled in OHP but is not enrolled in OHP Plus, the MCE or the Authority shall connect individuals to resources to determine OHP Eligibility as requested or consented to by the Member.

Notes

Or. Admin. Code § 410-120-2015

DMAP 130-2024, adopt filed 10/24/2024, effective 11/1/2024; DMAP 144-2024, temporary amend filed 12/29/2024, effective 1/1/2025 through 6/29/2025; DMAP 42-2025, amend filed 04/29/2025, effective 5/1/2025

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632