Or. Admin. Code § 410-141-3850 - Transition of Care
(1) This
rule applies to care of a Medicaid member who is enrolled in a CCO (the
"receiving CCO") immediately after disenrollment from a "predecessor plan,"
which may be another CCO (including disenrollment resulting from termination of
the predecessor CCO's contract) or Medicaid fee-for-service (FFS). This rule
does not apply to a member who is ineligible for Medicaid or who has a gap in
coverage following disenrollment from the predecessor plan.
(2) For purposes of this rule, the following
additional definitions apply:
(a) "Continued
Access to Services" means making available to the member services,
prescriptions, and prescription drug coverage consistent with the access they
previously had including permitting the member to retain their current
provider, even if that provider is not in the CCO network;
(b) "Medically Fragile Children (MFC)" as
defined by OAR 411-300-0110 means children that
have a health impairment that requires long-term, intensive, specialized
services on a daily basis, who have been found eligible for MFC services by the
Department of Human Services (DHS);
(c) "Transition of Care Period" means the
period of time after the effective date of enrollment with the receiving CCO,
during which the receiving CCO must provide continued access to services. The
transition of care period lasts for:
(A)
Ninety (90) days for members who are dually eligible for Medicaid and Medicare;
or
(B) For other members, the
shorter of:
(i) Thirty (30) days for physical
and oral health and sixty (60) days for behavioral health; or
(ii) Until the enrollee's new PCP (oral or
behavioral health provider, as applicable to medical care or behavioral health
care services) reviews the member's treatment plan; or the minimum or
authorized prescribed course of treatment has been completed.
(3) CCOs shall
implement and maintain a transition of care policy that, at a minimum, meets
the requirements defined in this rule and
42 CFR §
438.62(b). A receiving CCO
must provide continued access to services to, at minimum, the following
members:
(a) Medically Fragile Children
(MFC);
(b) Breast and Cervical
Cancer Treatment program members;
(c) Members receiving CareAssist assistance
due to HIV/AIDS;
(d) Members
receiving services for end stage renal disease, prenatal or postpartum care,
transplant services (including pre-transplant and post-transplant services),
radiation, or chemotherapy services; and
(e) Any members who, in the absence of
continued access to services, may suffer serious detriment to their health or
be at risk of hospitalization or institutionalization.
(4) During the Transition of Care Period the
receiving CCO shall ensure that any member identified in section (3) of this
rule:
(a) Is provided with Continued Access
to Services and has support necessary to access those services such as
Non-Emergency Medical Transportation (NEMT);
(b) Is permitted to continue receiving
services from the member's previous provider, regardless of whether the
provider participates in the receiving CCO's network;
(c) Is referred to appropriate providers of
services that are in the network at the duration of the Transition of Care
period;
(d) Notwithstanding section
(4)(b) of this rule, the receiving CCO is responsible for continuing the entire
course of treatment with the recipient's previous provider as described in the
following service-specific transition of care period situations:
(A) Prenatal and postpartum care;
(B) Transplant services through the
first-year post-transplant;
(C)
Radiation or chemotherapy services for the current course of treatment;
or
(D) Prescriptions with a defined
minimum course of treatment that exceeds the transition of care
period.
(e) Where section
(4) of this rule allows the member to continue using the member's previous
provider, the receiving CCO shall reimburse non-participating providers
consistent with OAR 410-120-1295 at no less than
Medicaid fee-for-service rates;
(f)
The receiving CCO is not financially responsible for a continuous inpatient
hospitalization for which a predecessor CCO was responsible under its contract,
in accordance with OARs
410-141-3500,
410-141-3710, and
410-141-3805.
(5) After the Transition of Care
Period ends, the receiving CCO remains responsible for care coordination and
discharge planning activities as described in OAR
410-141-3860 and OAR
410-141-3870.
(6) The Predecessor Plan shall fully and
timely comply with request for historical utilization data and clinical records
within seven calendar days of the request from the receiving CCO.
(a) CCOs shall not delay the provision of
services if historical utilization data and clinical records is not available
in a timely manner;
(b) In such
instances, the CCO is required to approve claims for which it has received no
historical utilization data and clinical records during the transition of care
time period, as if the covered services were prior authorized. CCOs shall have
a process for the electronic exchange of, at a minimum, the data classes and
elements included in the content standard adopted at
45 CFR
170.213. Such information must be
incorporated into the CCO's records about the current member. With the approval
and at the direction of a current or former enrollee or the enrollee's personal
representative, the CCO must:
(A) Receive all
such data for a current member from any other payer that has provided coverage
to the enrollee within the preceding 5 years;
(B) At any time the member is currently
enrolled in CCO and up to 5 years after disenrollment, send all such data to
any other payer that currently covers the enrollee or a payer the enrollee or
the enrollee's personal representative specifically requests receive the data;
and
(C) Send data received from
another payer under this paragraph in the electronic form and format it was
received.
(7)
The receiving CCO shall follow all service authorization protocols outlined in
OAR 410-141-3835 and give the member
written notice of any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested or when reducing a previously authorized service authorization. The
notice shall meet the requirements of
42 CFR
§
438.404 and OAR
410-141-3885.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
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