Or. Admin. Code § 410-141-3826 - Responsibility for Particular Covered Services Based on Plan Type

(1) Coordinated Care Organization (CCO) responsibility for particular Covered Services, as that responsibility is described in the CCO contract, is determined by the member's plan type, as follows:

(a) Universally Offered Newborn Nurse Home Visiting Program, commonly known as Family Connects Oregon (FCO): FCO is governed by ORS 433.301 and described in OAR Chapter 333, Division 6;

(A) The CCO is responsible for care coordination for FCO services for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB);

(B) The Oregon Health Authority's (Authority) fee-for-service (FFS) program is responsible for FCO services for all other plan types that include physical health services.

(b) Out-of-Hospital Birth, commonly known as Planned Community Birth (PCB): PCB is described in OAR 410-141-3846;

(A) The CCO is responsible for the components of PCB specified in the CCO contract for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB);

(B) The Authority's FFS program is responsible for PCB for all other plan types that include physical health services. The FFS program is also responsible for the components of PCB not specified as the CCO's responsibility in the contract for members for whom the CCO is responsible for physical health services.

(c) Health-Related Social Needs (HRSN) Services: HRSN Services are authorized by the Oregon Health Plan 1115 Demonstration Project for 2022-2027, commonly known as the State 1115 Waiver, approved by the Centers for Medicare and Medicaid Services;

(A) The CCO is responsible for all HRSN Services for an eligible member if the CCO is responsible for the member's physical health services (plan types CCOA and CCOB), regardless of whether a particular HRSN Service is related to the member's physical health condition or needs;

(B) OHA's FFS program is responsible for all HRSN Services for an eligible member if the FFS program is responsible for the member's physical health services, regardless of whether a particular HRSN Service is related to the member's physical health condition or needs.

Notes

Or. Admin. Code § 410-141-3826

DMAP 36-2024, adopt filed 01/25/2024, effective 2/1/2024

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.591 & 414.631