Or. Admin. Code § 410-141-3860 - Care Coordination: Administration, Systems and Infrastructure
(1) Coordinated
Care Organizations (CCOs) must coordinate services for members in accordance
with 42 CFR §
438.208, OAR
410-141-3865, OAR
410-141-3870 and this rule. The
rules in this division relating to the CCO Care Coordination requirements take
precedence over any and all general Care Coordination rules set forth in Oregon
Administrative Rules Division 120. This coordination must encompass all
services accessed to address their member's physical, developmental,
behavioral, oral and social needs (including Health-Related Social Needs (HRSN)
and Social Determinants of Health and Equity (SDOH-E)). To meet these
requirements, CCO's must:
(a) Identify the
needs of their members on an initial and ongoing basis as described in OAR
410-141-3865;
(b) Ensure coordinated services are provided
to their members as described in OAR
410-141-3870; and
(c) Ensure their members are informed about
the availability of Care Coordination and how to access it initially and
ongoing.
(2) CCOs must
ensure the overall coordination of all services and supports to which their
members are entitled, regardless of who provides the service. CCOs are
responsible for coordinating with Medicaid Fee-For-Service (FFS), Medicare or
Medicare Advantage Plans, Community Mental Health Programs (CMHP), Oregon
Department of Human Services (ODHS), including Aging and People with
Disabilities (APD), Child Welfare (CW), and Developmental Disability Services
(DDS), Oregon Department of Education (ODE), Oregon Youth Authority (OYA),
Local Public and Mental Health Authorities and any other institutional,
community and social support organizations serving their members, to the extent
feasible.
(3) Primary
responsibility for Care Coordination is determined based on the Member's CCO
Plan Type.
(a) If a Member is enrolled in Plan
Type CCOA or CCOB the CCO is primarily responsible for Care Coordination and
must ensure the coordination of all services and supports furnished to the
Member by any other entity referenced in (2) of this rule.
(b) If a Member is enrolled in Plan Type
CCOE, CCOF or CCOG, the Oregon Health Authority's Medicaid Fee-For-Service
(FFS) program is primarily responsible for Care Coordination. The CCO must
proactively collaborate with FFS Care Coordination and other providers serving
the Member to maintain awareness of identified needs and any existing Care
Plans and to ensure the services covered by the CCO are coordinated.
(4) The entities in Section (2) of
this rule may all have some level of responsibility for a Member's care.
Therefore, the fundamental role the CCO must fill is to facilitate, collaborate
and oversee any relevant coordinating entities and lead when necessary, as
required in Section (3)(a) of this rule.
(5) When a Member is engaged in multiple
programs (e.g., Long Term Services and Supports, Intellectual and Developmental
Disabilities, Child Welfare, Youth Wraparound, Intensive In-home Behavioral
Health Treatment, etc.) where there are care teams or coordinators involved the
CCO's responsibility is to collaborate with those entities who are coordinating
services the Member is receiving in order to reduce duplication and identify
Care Coordination gaps.
(a) If the CCO is
collaborating with another program the CCO is required to be aware of and
document the coordinating entities activities to understand and identify
additional unmet needs the Member may have that require Care Coordination be
provided by the CCO.
(b) The CCO is
responsible for leading and facilitating Care Coordination for all needs
identified that are not addressed or coordinated by another program or
entity.
(6) Care
Coordination is intended to continuously:
(a)
Improve Member health outcomes;
(b)
Support and enable a Member's ability to manage, maintain and improve any
chronic conditions or disabilities;
(c) Improve Member satisfaction;
(d) Reduce health inequities; and
(e) Reduce barriers to accessing health
care.
(7) In all aspects
of its systems and practice, Care Coordination must be:
(a) Person-centered or person and
family-centered for minors under age 18 and for adults age 18 or older, who are
under the legal authority of a family member or guardian;
(b) Trauma-informed and responsive;
(c) Culturally, linguistically and
developmentally responsive and appropriate;
(d) Accessible to all members, including
those with disabilities and persons who experience Limited English Proficiency
and equitable access to services, consistent with
42 CFR §
435.905, ORS
413.550 and Title VI, §1557
(ACA 1557);
(e) Delivered with a
whole-person approach that encourages Member self-determination and
autonomy;
(f) Designed to account
for the unique contextual needs of various member populations in relation to
their families and communities, such as children, youth, young adults, and
older adults, so that every Member's needs are identified and addressed in a
way that is appropriate for their situation; and
(g) Focused on prevention, safety, early
identification, intervention, and ongoing management.
(8) CCOs must develop and continuously
improve the infrastructure (e.g., systems, technology solutions, processes,
relationships, and agreements) needed to support, enable, and uphold their
responsibility to coordinate services for their members. This infrastructure is
not limited to, but must address:
(a)
Management and implementation, including at minimum:
(A) Implementing and utilizing a care
management platform to track and monitor care coordination activities (e.g.,
document, track, and report care planning activities, goals and outcomes,
Members' care team, communication to/from care team, community resources,
completed assessments, identified needs, change in health-related
circumstances, communication with individual Members, and timeliness of
activities). To the maximum extent feasible, CCOs shall establish system
interfaces with community partners and providers.
(B) Implementing and utilizing member data to
develop a risk stratification model and mechanism to stratify members by the
following risk levels, at a minimum: no- or low-risk, moderate-risk, high-risk.
The Oregon Health Authority (Authority) must approve CCOs' risk stratification
mechanisms and algorithms before implementation.
(i) Data sources used to identify risks, risk
level and care gaps must include but are not limited to the following sources:
claims and utilization data, Health Risk Assessments, functional needs
assessments, referrals, event notifications, and other available resources to
inform physical, developmental, behavioral, oral and social needs (including
Health-Related Social Needs (HRSN) and Social Determinants of Health and Equity
(SDOH-E)); and
(ii) Risk scores
shall be utilized, in conjunction with the application of appropriate clinical
subjectivity by health care providers to further interpret objective and
subjective patient information to determine the Member's risk level and inform
the overall care planning process. That shall be documented in the Care Profile
and align the CCOs efforts and activities to the level of intensity and
intervention the Member requires; and
(iii) Continuous and ongoing data mining and
identification of additional care gaps shall inform updates to the Member's
risk level and interventions needed.
(C) Regularly monitoring population level
trends to determine and identify cohorts of the population requiring Care
Coordination due to a Rising Risk or emergent need;
(D) Developing monitoring mechanisms to
regularly track timeliness, adequacy, and effectiveness of Care Coordination
efforts and outreach by the CCO and providers, or subcontracted entity if Care
Coordination is delegated;
(E)
Tracking data required for reporting and ongoing improvement efforts;
(F) Maintaining policies, procedures,
workflows, and desk processes to support CCO staff or subcontractors in
managing Care Coordination activities;
(G) CCOs shall follow the grievance and
appeal system requirements outlined in OAR
410-141-3875, OAR
410-141-3880, OAR
410-141-3885, OAR
410-141-3890, OAR
410-141-3895, OAR
410-141-3900, OAR
410-141-3905, OAR
410-141-3910, and OAR
410-141-3915 for grievances and
appeals pertaining to Care Coordination.
(H) Abide by, or enter into as needed, any
agreements or Memoranda of Understanding (MOUs) governing coordination with
other entities described in (2) of this rule, including at minimum but not
limited to, Aging and People with Disabilities (APD) or Type B Area Agency on
Aging (AAA) for Long Term Services and Supports.
(I) Maintaining training and qualification
requirements for CCO staff and subcontracted entities;
(J) Using creative and innovative strategies
to develop and build member engagement;
(K) Maintaining and publishing a contact
point for use at any time by members, their representative or guardian,
providers or other entities.
(b) Record keeping, mutual exchange of
information, and privacy, including at minimum:
(A) Documentation and record keeping of
member information in accordance with OAR
410-141-3520;
(B) The systems and processes (e.g., data
sharing agreements, electronic health information exchange) needed for mutual
exchange of information between the CCO, providers and community
partners;
(C) Developing and
entering into agreements or Memoranda of Understanding (MOUs) with providers
and/or member serving systems or organizations not contracted with the CCO to
ensure mutual exchange of information of a Member's physical, developmental,
behavioral, oral, and social needs (including Health-Related Social Needs
(HRSN) and Social Determinants of Health and Equity (SDOH-E)) information
across all entities, providers, and systems involved in Care Coordination, to
the extent feasible;
(D) Requiring
Primary Care and other CCO contracted providers to communicate and coordinate
care with each other and with the CCO in a timely manner, using electronic
health information technology, as available, or through other mechanisms (e.g.
paper-based systems); and
(E) The
Member having access to, and the ability to share, protected health information
with others involved in their care as set forth in
45 CFR §
164.524. Privacy protections outlined in
Health Insurance Portability and Accountability Act and Privacy and Security
Rules, privacy administrative rules in Chapter 407, Division 014, ORS
192.553 to
192.581, and ORS
646A.600 to
646A.628.
(c) Access to Care, including at minimum:
(A) Establishing, maintaining and monitoring
a network of participating providers to ensure the provision of an ongoing
source of care appropriate to the needs of its members in accordance with OAR
410-141-3515;
(B) Contracting with Patient-Centered Primary
Care Homes (PCPCH) to provide members a consistent and stable relationship with
a care team, and supporting and collaborating with them in the overall
coordination of the Member's care;
(C) Developing and entering into agreements,
memoranda of understandings (MOUs) with providers and other entities not
contracted with the CCO, to ensure a Member's access to coordinated physical,
developmental, behavioral, oral, and social needs (including Health-Related
Social Needs (HRSN) and Social Determinants of Health and Equity (SDOH-E))
services across multiple providers;
(D) Using Value Based Payments to encourage
specialty and Primary Care Providers to coordinate care;
(E) Assignment to a Primary Care Provider if
the Member has not selected a Primary Care Provider by the 90th day after
enrollment in the CCO. The CCO shall provide notice of the assignment to the
Member and to the Primary Care Provider.
(i) A
Member may select a different Primary Care Provider at any time and/or request
assistance with selecting an appropriate provider.
(ii) Eligible Members who are American
Indian/Alaska Native may select as their Primary Care Provider:
(I) An Indian health care provider (IHCP) who
is a Primary Care Provider within the CCO's provider network; or
(II) An out-of-network IHCP from whom the
Member is otherwise eligible to receive such primary care services.
(F) Maintenance of a
policy and procedure that informs members, their Non-Emergency Medical
Transportation (NEMT) providers and call centers of the availability of NEMT
services for Care Coordination activities.
(d) Subcontractor and provider oversight,
including at minimum:
(A) Ongoing and regular
monitoring and reporting to ensure compliance, and appropriate support, for any
delegated Care Coordination activities, in accordance with
42 CFR §
438.208, OAR
410-141-3505, OAR
410-141-3865, OAR
410-141-3870, and this
rule;
(B) CCOs must take corrective
action to address any deficiencies identified through monitoring and
reporting.
(9) CCOs shall monitor and document their
Care Coordination activities and the effectiveness of those efforts in a Care
Coordination report submitted to the Authority under the timelines specified by
the Authority in CCO Contract.
(a) The
Authority shall provide tools and additional guidance specific to reporting
requirements on the CCO Contract Forms webpage
https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.
(b) The Authority may determine additional
deliverables are necessary to appropriately oversee CCOs' implementation of
Care Coordination requirements.
(10) If CCOs are not in compliance with these
rules OHA may impose sanctions as described in CCO contract and OAR
410-141-3530.
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065 & 414.727
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