Or. Admin. Code § 410-141-3590 - MCE Member Relations: Member Rights and Responsibilities

(1) MCEs shall:

(a) Have written policies and procedures that ensure that members have the rights and responsibilities included in this rule;

(b) Communicate these policies and procedures to participating providers;

(c) Monitor compliance with these policies and procedures, take corrective action as needed, and report findings to the Quality Improvement Committee defined under OAR 410-141-3525.

(2) MCE members shall have the following rights and are entitled to:

(a) Be treated with dignity and respect;

(b) Be treated by participating providers the same as other people seeking health care benefits to which they are entitled and to be encouraged to work with the member's care team, including providers and community resources appropriate to the member's needs;

(c) Choose a Primary Care Provider (PCP) or service site and to change those choices as permitted in the MCE's administrative policies;

(d) Refer oneself directly to behavioral health or family planning services without getting a referral from a PCP or other participating provider;

(e) Have a friend, family member, member representative, or advocate present during appointments and other times as needed within clinical guidelines;

(f) Be actively involved in the development of their treatment plan;

(g) Be given information about their condition and covered and non-covered services to allow an informed decision about proposed treatments;

(h) Consent to treatment or refuse services and be told the consequences of that decision, except for court ordered services;

(i) Receive written materials describing rights, responsibilities, benefits available, how to access services, and what to do in an emergency;

(j) Have written materials explained in a manner that is understandable to the member and be educated about the coordinated care approach being used in the community and how to navigate the coordinated health care system;

(k) Receive communications of individually identifiable health information from the MCE by alternative means or at alternative locations per 45 CFR 164.522 if the member provides a written statement that includes:

(A) A valid alternative address or other method of contact suitable for enabling the member to receive communications from the MCE (e.g., valid cell phone number, verifiable e-mail address); and

(B) If required by the MCE, a clearly stated disclosure that all or part of the protected health information could put the member in danger.

(l) Receive culturally and linguistically appropriate services and supports in locations as geographically close to where members reside or seek services as possible and choice of providers within the delivery system network that are, if available, offered in non-traditional settings that are accessible to families, diverse communities, and underserved populations;

(m) Receive oversight, care coordination and transition and planning management from their MCE within the targeted population to ensure culturally and linguistically appropriate community-based care is provided in a way that serves them in as natural and integrated an environment as possible and that minimizes the use of institutional care;

(n) Receive necessary and reasonable services to diagnose the presenting condition;

(o) Receive integrated person-centered care and services designed to provide choice, independence and dignity and that meet generally accepted standards of practice and are medically appropriate;

(p) Have a consistent and stable relationship with a care team that is responsible for comprehensive care management;

(q) Receive assistance in navigating the health care delivery system and in accessing community and social support services and statewide resources including but not limited to the use of certified or qualified health care interpreters, certified traditional health workers including community health workers, peer wellness specialists, peer support specialists, doulas, and personal health navigators who are part of the member's care team to provide cultural and linguistic assistance appropriate to the member's need to access appropriate services and participate in processes affecting the member's care and services;

(r) Obtain covered preventive services;

(s) Have access to urgent and emergency services 24 hours a day, seven days a week without prior authorization;

(t) Receive a referral to specialty providers for medically appropriate covered coordinated care services in the manner provided in the MCE's referral policy;

(u) Have a clinical record maintained that documents conditions, services received, and referrals made;

(v) Have access to one's own clinical record, unless restricted by statute;

(w) Transfer of a copy of the clinical record to another provider;

(x) Execute a statement of wishes for treatment, including the right to accept or refuse medical, surgical, or behavioral health treatment and the right to execute directives and powers of attorney for health care established under ORS 127;

(y) Receive written notices before a denial of, or change in, a benefit or service level is made, unless a notice is not required by federal or state regulations;

(z) Be able to make a complaint or appeal with the MCE and receive a response;

(aa) Request a contested case hearing;

(bb) Receive certified or qualified health care interpreter services; and

(cc) Receive a notice of an appointment cancellation in a timely manner;

(dd) Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in other federal regulations on the use of restraints and seclusion.

(3) CCO members shall have the following responsibilities:

(a) Choose or help with assignment to a PCP or service site;

(b) Treat the MCE, provider, and clinic staff members with respect;

(c) Be on time for appointments made with providers and to call in advance to cancel if unable to keep the appointment or if expected to be late;

(d) Seek periodic health exams and preventive services from the PCP or clinic;

(e) Use the PCP or clinic for diagnostic and other care except in an emergency;

(f) Obtain a referral to a specialist from the PCP or clinic before seeking care from a specialist unless self-referral to the specialist is allowed;

(g) Use urgent and emergency services appropriately and notify the member's PCP or clinic within 72 hours of using emergency services in the manner provided in the MCE's referral policy;

(h) Give accurate information for inclusion in the clinical record;

(i) Help the provider or clinic obtain clinical records from other providers that may include signing an authorization for release of information;

(j) Ask questions about conditions, treatments, and other issues related to care that is not understood;

(k) Use information provided by MCE providers or care teams to make informed decisions about treatment before it is given;

(l) Help in the creation of a treatment plan with the provider;

(m) Follow prescribed agreed upon treatment plans and actively engage in their health care;

(n) Tell the provider that the member's health care is covered under the OHP before services are received and, if requested, show the provider the Division Medical Care Identification form;

(o) Tell the Department or Authority worker of a change of address or phone number;

(p) Tell the Department or Authority worker if the member becomes pregnant and notify the worker of the birth of the member's child;

(q) Tell the Department or Authority worker if any family members move in or out of the household;

(r) Tell the Department or Authority worker if there is any other insurance available;

(s) Pay for non-covered services under the provisions described in OAR 410-120-1200 and 410-120-1280;

(t) Pay the monthly OHP premium on time if so required;

(u) Assist the MCE in pursuing any third-party resources available and reimburse the MCE the amount of benefits it paid for an injury from any recovery received from that injury; and

(v) Bring issues or complaints or grievances to the attention of the MCE.

Notes

Or. Admin. Code § 410-141-3590

DMAP 55-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 143-2024, amend filed 12/29/2024, effective 1/1/2025

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635, 414.651 & CFR 164.522

Statutes/Other Implemented: ORS 414.610 - 414.685