Or. Admin. R. 410-141-3585 - MCE Member Relations: Education and Information

Current through Register Vol. 60, No. 12, December 1, 2021

(1) MCEs may engage in activities for existing members related to outreach, health promotion, and health education. MCE must obtain approval of the Authority prior to distribution of any written communication by the MCE or its subcontractors and providers that:
(a) Is intended solely for members; and
(b) Pertains to requirements for obtaining coordinated care services at service area sites or benefits.
(2) MCEs may communicate with providers, caseworkers, community agencies, and other interested parties for informational purposes or to enable care coordination and address social determinants of health or community health. The intent of these communications should be informational only for building community linkages to impact social determinants of health or member care coordination and not to entice or solicit membership. Communication methodologies may include but are not limited to brochures, pamphlets, newsletters, posters, fliers, websites, health fairs, or sponsorship of health-related events. MCEs shall address health literacy issues by preparing these documents at a low-literacy reading level, incorporating graphics and utilizing alternate formats.
(3) MCEs shall have a mechanism to help members understand the requirements and benefits of the MCE's integrated and coordinated care plan. The mechanisms developed shall be culturally and linguistically appropriate. Written materials, including provider directories, member handbooks, appeal and grievance notices, and all denial and termination notices are made available in the prevalent non-English languages as defined in OAR 410-141-3575 in its particular service area and be available in formats noted in section (5) of this rule for members with disabilities. MCEs shall accommodate requests made by other sources such as members, family members, or caregivers for language accommodation, translating to the member's language needs as requested.
(4) MCEs shall have written procedures, criteria, and an ongoing process of member education and information sharing that includes member orientation, member handbook, and health education. MCEs shall update their educational material as they add coordinated services. Member education shall:
(a) Include information about the coordinated care approach and how to navigate the coordinated health care system, including how to access intensive care coordination (ICC) Services, and where applicable for full benefit dual eligible (FBDE) members, the process for coordinating Medicaid and Medicare benefits;
(b) Clearly explain how members may receive assistance from certified and qualified health care interpreters and Traditional Health Workers as defined in OAR 410-180-0305 and include information to members that interpreter services in any language required by the member, including American Sign Language, auxiliary aids and alternative format materials at provider offices are free to MCE members as stated in 42 CFR 438.10;
(c) Inform all members of the availability of Ombudsperson services.
(5) Written member materials shall comply with the following language and access requirements:
(a) Materials shall be translated in the prevalent non-English languages as defined in OAR 410-141-3575 in the service area as well as include a tagline in large print (font size 18) explaining the availability of written translation or oral interpretation to understand the information provided, as well as alternate formats, and the toll-free and TTY/TDY telephone number of the MCE's member/customer service unit;
(b) Materials shall be made available in alternative formats upon request of the member at no cost. Auxiliary aids and services must also be made available upon request of the member at no cost. The MCE's process for providing alternative formats and auxiliary aids to members may not in effect deny or limit access to covered services, grievance, appeals, or hearings;
(c) Electronic versions of member materials shall be made available on MCE website, including provider directories, formularies, and handbooks in a form that can be electronically retained and printed, available in a machine-readable file and format, and Readily Accessible, e.g., a PDF document posted on the plan website that meets language requirements of this section. For any required member education materials on the MCE website, the member is informed that the information is available in paper form without charge upon request to Members and Member representatives, and the MCE shall provide it upon request within five business days.
(6) MCE provider directories shall include:
(a) The provider's name as well as any group affiliation;
(b) Street address(es);
(c) Telephone number(s);
(d) Website URL, as appropriate;
(e) Provider Specialty, as appropriate;
(f) Whether the provider will accept new members;
(g) Whether the provider offers both telehealth and in-person appointments;
(h) Information about the provider's race and ethnicity, cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or an OHA-approved qualified and, as applicable, certified health care interpreter(s) at no cost to members at the provider's office;
(i) Availability of auxiliary aids and services for all members with disabilities upon request and at no cost;
(j) Whether the provider has completed cultural competence training as required by ORS 413.450 and in accordance to CCO Health Equity Plan Training and Education plan described in OAR 410-141-3735 whether providers have verifiable language fluency in non-English (i.e., such as clinical training in a foreign country or clinical language testing);
(k) Whether the provider's office or facility is accessible and has accommodations for people with physical disabilities, including but not limited to information on accessibility of providers' offices, exam rooms, restrooms, and equipment.
(L) The information for each of the following provider types covered under the contract, as applicable to the MCE contract:
(A) Physicians, including specialists;
(B) Hospitals;
(C) Pharmacies;
(D) Behavioral health providers; including specifying substance use treatment providers;
(E) Dental providers.
(m) Information included in the provider directory must be updated at least monthly, and electronic provider directories must be updated no later than 30 days after the MCE receives updated provider information. Updated materials shall be available on the MCE website in a readily accessible and machine-readable file, e.g., a PDF document posted on the plan website, per form upon request and another alternative format.
(7) Each MCE shall make available in electronic or paper form the following information about its formulary:
(a) Which medications are covered both generic and name brand;
(b) What tier each medication is on.
(8) Within 14 days of an MCE's receiving notice of a member's enrollment, MCEs shall mail a welcome packet to new members and to members returning to the MCE 12 months or more after previous enrollment. The packet shall include, at a minimum, a welcome letter, a member handbook, and information on how to access a provider directory, including a list of any in-network retail and mail-order pharmacies.
(9) For existing MCE members, an MCE shall notify members annually of the availability of a member handbook and provider directory and how to access those materials. MCEs shall send hard copies upon request within five days.
(10) MCEs must notify enrollees:
(a) That oral interpretation is available free of charge for any language, including American Sign Language, and written information is available in prevalent non-English languages as defined in OAR 410-141-3575 and alternate formats that include but are not limited to audio recording, close-captioned videos, large type (18 font), and braille; and
(b) The process for requesting and accessing interpreters or auxiliary aids and alternative formats, including where appropriate how to contact specific providers responsible through sub-contracts to ensure provision of language and disability access;
(c) Language access services also applies to member representatives, family members and caregivers with hearing impairments or limited English proficiency who need to understand the member's condition and care.
(11) An MCE shall electronically provide to the Authority for approval each version of the printed welcome packet that includes a welcome letter, member handbook, and information on how to access a provider directory.
(12) The CCO member handbook shall be written in plain language using a font size no smaller than 12 point. At a minimum, the member handbook shall contain the following:
(a) Revision date including month, day, and year;
(b) Tag lines in English and other prevalent non-English languages, as defined in OAR 410-141-3575, spoken by populations of members. The tag lines shall be in large type (18 point font). The tag lines shall be located at the beginning of the document for the ease of the member and describe the following:
(A) How members may, at no cost to them, access sign language and oral interpreters, translations and materials in alternate formats, and auxiliary aids and services;
(B) The toll-free and TTY/TDY telephone numbers of the MCE's customer service unit.
(c) CCO's office location, mailing address, web address, office hours, and telephone numbers including TTY;
(d) Explanation of access and care standards consistent with the requirements set forth in 42 CFR § 438.206 and OARs 410-141-3515 and 410-141-3860;
(e) Availability and access to coordinated care services through a patient-centered primary care home or other primary care team with the member as a partner in care management. Explain how to choose a PCP, how to make an appointment, and how to change PCPs, and the CCO's policy on changing PCPs;
(f) Explanation of the health risk screening process;
(g) How to access information on contracted providers currently accepting new members and any restrictions on the member's freedom of choice among participating providers;
(h) Explanation that American Indian and Alaskan Native members of the CCO may receive care from a tribal wellness center, Indian Health Services clinic, or the Native American Rehabilitation Association of the Northwest (NARA);
(i) Explanation of which participating or non-participating provider services the member may self-refer;
(j) Policies on referrals for specialty care, including prior authorization requirements and how to request a referral;
(k) Information on how to obtain a second opinion;
(L) Explanation of ICC services, including persons eligible as priority populations served and requirements for Intensive Care Coordination care planning, and how eligible members may access those services;
(m) Information about the coordinated care approach, how to navigate the coordinated care health care system as applicable to dual-eligible individuals, the process for coordinating Medicaid and Medicare benefits;
(n) Explanation of care coordination services and how the member can request and access a care coordinator.
(o) Information about the benefits and availability of traditional health worker (THW) services as defined in OAR 410-180-0305, and how to contact the CCO's THW liaison.
(p) How and where members are to access urgent care services and advice, including how to access these services and advice when away from home;
(q) How and when members are to use emergency services, both locally and when away from home, including examples of emergencies and use of 911;
(r) Information on how to contact the CCO's in-house or subcontracted after-hours call-in system to triage Urgent Care and Emergency service calls from members or a member's long term care provider or facility.
(s) Information on contracted hospitals in the member's service area including hospital name, physical address, toll-free phone number, TTY, and webpage;
(t) Information on mobile crisis services and crisis hotline for members, including information that crisis response services are available 24 hours a day for members receiving Intensive In-Home Behavioral Health Treatment.
(u) Information on post-stabilization care after a member is stabilized in order to maintain, improve, or resolve the member's condition;
(v) Explanation of available telehealth services as described in OAR 410-141-3566 including, but not limited to, the information contained in sections (4) and (5) of 410-141-3566, how to access telehealth services, and information on supports available to the member to assist them in accessing telehealth services.
(w) A statement or narrative that articulates the CCO's commitment to preventing fraud, waste, and abuse and complying with all applicable laws including, but not limited to, the State's False Claims Act and the federal False Claims Act;
(x) Information on where and how to report fraud, waste, or abuse by a provider or a member and a member's right to report fraud, waste, and abuse anonymously and be protected under applicable Whistleblower laws;
(y) Information on the CCO's grievance and appeals processes and the Authority's contested case hearing procedures, including:
(A) Information about assistance in filling out forms and completing the grievance process available from the CCO to the member as outlined in OAR 410-141-3875;
(B) Information about the member's rights in the grievance, appeals, and hearings process, including the right to continued benefits as provided in OAR 410-141-3885;
(C) The requirements and timeframes related to the processes for grievances, appeals, and hearings.
(z) Information on the member's rights and responsibilities, including the rights of minors, and availability of the OHP Ombudsperson;
(z) Information on charges for non-covered services, and the member's possible responsibility for charges if they go outside of the CCO network for non-emergent care; including information specific to deductibles, copays and coinsurance for dually-enrolled qualified Medicare beneficiaries;
(aa) Information about when providers may bill clients for services and what to do if they receive a bill, including information specific to payment responsibilities for dually-enrolled qualified Medicare beneficiaries;
(bb) Information on coverage and billing for out of state services, including information how to access additional assistance from the CCO with a bill from an out of state provider and any appeal rights available to the member, if applicable;
(cc) Explanation of transitional procedures for new members to obtain prescriptions, supplies, and other necessary items and services in the first month of enrollment if they are unable to meet with a PCP or PCD, other prescribing provider, or obtain new orders during that period; including how to access such services and specific communications for members who are becoming new Medicare enrollees;
(dd) Information on advance directive policies including:
(A) Member rights under federal and Oregon law to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives;
(B) The CCO's policies for implementation of those rights, including a statement of any limitation regarding the implementation of advanced directives as a matter of conscience;
(C) Avenues for filing complaints concerning noncompliance with the Advance Directive requirements, including the grievance and hearings process or directly with OHA, and information on how to file such a complaint with OHA;
(ee) Whether or not the CCO uses provider contracts, including alternative payment methodologies or incentives, and how this will impact the member;
(ff) The member's right to request and obtain copies of their clinical records, whether they may be charged a reasonable copying fee, and that they may request the record be amended or corrected;
(gg) How and when members are to obtain ambulance services;
(hh) Resources for help with transportation to appointments with providers and scheduling process for use of non-emergency medical transportation (NEMT) services;
(ii) All NEMT policies and procedures as outlined in OAR 410-141-3920 through 410-141-3965 and the CCO Contract, unless the member is provided with a stand-alone document, referred to as a "NEMT Rider Guide";
(jj) Explanation of the covered and non-covered services in sufficient detail to ensure that members understand the benefits to which they are entitled, including but not limited to;
(A) A delineation of the non-covered services the CCO coordinates from the non-covered services the CCO does not coordinate;
(B) Contact information for the Authority contractor responsible for coordination of non-covered services the CCO is not obligated to coordinate;
(C) Explanation that the CCO is responsible to arrange transportation for non-covered services that are coordinated by the CCO.
(kk) Information regarding any service not covered, in accordance with law, due to the religious or moral objections of the CCO and how to contact Oregon Health Authority for information regarding accessing the service;
(LL) How to access in-network retail and mail-order pharmacies;
(mm) How members are to obtain prescriptions including information on the process for obtaining non-formulary and over-the-counter drugs;
(nn) The CCO's confidentiality policy;
(oo) Explanation of the CCO's nondiscrimination policy and how and where to file a grievance if a member feels they were treated unfairly;
(pp) How and where members may access any benefits that are available under OHP but are not covered under the CCO's contract, including any cost sharing;
(qq) When and how members may voluntarily and involuntarily disenroll from CCOs and change CCOs;
(rr) Explanation of care and services available to members during a transition of care as defined in OAR 410-141-3850 and 42 CFR § 438.62, including CCO contact information to request more information regarding continued access to care and services during a transition of care and instructions on accessing the CCO's written transition of care policy;
(ss) CCOs shall, at a minimum, annually review their member handbook for accuracy and update it with new and corrected information to reflect OHP program changes and the CCO's internal changes. If changes affect the member's ability to use services or benefits, the CCO shall offer the updated member handbook to all members;
(tt) The "Oregon Health Plan Client Handbook" is in addition to the CCO's member handbook, and an CCO may not use it to substitute for any component of the CCO's member handbook.
(13) The DCO member handbook shall be written in plain language using a font size no smaller than 12 point. The DCO member handbook is required for DCOs directly contracted by OHA. At a minimum, the member handbook shall contain the following:
(a) The revision date, including month, day, and year;
(b) Tag lines in English and other prevalent non-English languages, as defined in as defined in OAR 410-141-3575, spoken by populations of members. The tag lines shall be in large type (18-point font). The tag lines shall be located at the beginning of the document for the ease of the member and describe the following:
(A) How members may access free sign and oral interpreters, translations and materials in alternate formats, and auxiliary aids and services;
(B) The toll-free and TTY/TDY telephone numbers of the DCO's customer service unit.
(c) DCO's office location, mailing address, web address, office hours, and telephone numbers including TTY;
(d) The toll-free number for any partners providing services directly to members, including non-emergency medical transportation providers;
(e) The DCO's confidentiality policy;
(f) Information about the structure and operations of the DCO, including whether or not the DCO uses provider contracts, including alternative payment methodologies or incentives, and how this will impact the member;
(g) Explanation of oral health benefits and covered services available to members without charge in sufficient detail to ensure that members understand the benefits to which they are entitled;
(h) Explanation of care and services available to members during a transition of care as defined in OAR 410-141-3850 and 42 CFR § 438.62, including DCO contact information to request more information regarding continued access to care and services during a transition of care and instructions on accessing the DCO's written transition of care policy;
(i) Explanation of transitional procedures for new members to obtain prescriptions, supplies, and other necessary items and services in the first month of enrollment if they are unable to meet with a Primary Care Dentist (PCD), other prescribing provider, or obtain new orders during that period;
(j) Explanation of how to choose a PCD, how to make an appointment, how to change PCDs, and the DCO's policy on changing PCDs;
(k) Explanation that American Indian/Native Alaskan members may choose an Indian Health Care Provider (IHCP) as the member's PCD if:
(A) The IHCP is participating as a PCD within the provider network; and
(B) The member is otherwise eligible to receive services from such Indian Health Care Provider; and
(C) The IHCP has the capacity to provide the services to such members.
(L) Explanation that American Indian members may obtain covered services from non-participating providers and can be referred by an IHCP to a participating provider for covered services in accordance with 42 CFR § 438.14;
(m) Explanation of access and care standards consistent with the requirements set forth in 42 CFR § 438.206 and OARs 410-141-3515 and 410-141-3860;
(n) Explanation of available telehealth services as described in OAR 410-141-3566 including, but not limited to, the information contained in sections (4) and (5) of 410-141-3566, how to access telehealth services, and information on supports available to the member to assist them in accessing telehealth services.
(o) Explanation of the health risk screening process;
(p) Information about tobacco dependency and cessation services and how to access such services through the DCO;
(q) Explanation of non-emergency medical transportation (NEMT) services, including how the DCO coordinates NEMT services for members and how a member accesses NEMT services.
(r) Explanation of care coordination services and how the member can request and access a care coordinator, including information that the DCO must coordinate dental services furnished to the member with the services the member receives from other plans and/or from community and social support providers.
(s) Policies on referrals, prior authorization and pre-approval requirements and how to request a referral, including but not limited to the following:
(A) No prior authorization or referral is necessary for urgent or emergency dental services including dental post-stabilization services;
(B) Information on how to access specialty dental care furnished by the DCO;
(C) Information on how to access specialty care and other benefits that are not furnished by the DCO;
(t) Information on how to obtain a second opinion;
(u) How to access information on contracted providers currently accepting new members and any restrictions on the member's freedom of choice among participating providers;
(v) Information regarding any service not covered, in accordance with law, due to the religious or moral objections of the DCO and how to contact Oregon Health Authority for information regarding accessing the service;
(w) How and where members are to access urgent care services and advice, including how to access these services and advice when away from home;
(x) How and when members are to use emergency services, both locally and when away from home, including examples of dental emergencies and use of 911;
(y) Information on how to contact the DCO's after-hours call-in system to triage Urgent Care and Emergency service calls from members or a member's long-term care provider or facility;
(z) Explanation that members can access dental services while out of state in an urgent or emergency situation, including information on how to access additional assistance from the DCO with a bill from an out of state provider and any appeal rights available to the member, if applicable;
(aa) Information on when and how members may voluntarily and involuntarily disenroll from DCOs or change DCOs;
(bb) A statement or narrative that articulates the DCO's commitment to preventing fraud, waste, and abuse and complying with all applicable laws including, but not limited to, the State's False Claims Act and the federal False Claims Act;
(cc) Information on where and how to report fraud, waste, or abuse by a provider or a member and a member's right to report fraud, waste, and abuse anonymously and be protected under applicable Whistleblower laws;
(dd) Information on the DCO's grievance and appeals processes and the Authority's contested case hearing procedures, including:
(A) Information about assistance in filling out forms and completing the grievance process available from the DCO to the member as outlined in OAR 410-141-3875;
(B) Information about the member's rights in the grievance, appeals, and hearings process, including the right to continued benefits as provided in OAR 410-141-3885.
(C) The requirements and timeframes related to the processes for grievances, appeals, and hearings.
(ee) Information on the member's rights and responsibilities, including the rights of minors, and availability of the OHP Ombudsperson;
(ff) The member's right to request and obtain copies of their clinical records, whether they may be charged a reasonable copying fee, and that they may request the record be amended or corrected;
(gg) Explanation of the DCO's nondiscrimination policy and how and where to file a grievance if a member feels they were treated unfairly, including contact information for the DCO's Non-discrimination coordinator;
(hh) Information about the requirement to provide providers and subcontractors with third-party liability information;
(ii) Explanation that the DCO will provide written notice to affected members of any significant changes in provider, program, or service sites that affect the member's ability to access care or services from the DCO's participating providers. Such notice shall be translated as appropriate and provided to the member at least 30 days before the effective date of the change, or as soon as possible if the participating provider has not given the DCO sufficient notification to meet the 30-day notice requirement;
(jj) Information on advance directive policies including:
(A) Member rights under federal and Oregon law to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives;
(B) The DCO's policies for implementation of those rights, including a statement of any limitation regarding the implementation of advanced directives as a matter of conscience;
(C) Avenues for filing complaints concerning noncompliance with the Advance Directive requirements, including the grievance and hearings process or directly with OHA, and information on how to file such a complaint with OHA;
(kk) DCOs shall, at a minimum, annually review their member handbook for accuracy and update it with new and corrected information to reflect OHP program changes and the DCO's internal changes. If changes affect the member's ability to use services or benefits, the DCO shall offer the updated member handbook to all members;
(LL) The "Oregon Health Plan Client Handbook" is in addition to the DCO's member handbook, and an DCO may not use it to substitute for any component of the DCO's member handbook.
(14) Member health education shall include:
(a) Information on specific health care procedures, instruction in self-management of health care, promotion and maintenance of optimal health care status, patient self-care, and disease and accident prevention. MCE providers or other individuals or programs approved by the MCE may provide health education. MCEs shall make every effort to provide health education in a culturally sensitive and linguistically appropriate manner in order to communicate most effectively with individuals from non-dominant cultures;
(b) Information specifying that MCEs may not prohibit or otherwise restrict a provider acting within the lawful scope of practice from advising or advocating on behalf of a member who is their patient for the following:
(A) The member's health status, medical care, or treatment options, including any alternative treatment that may be self-administered;
(B) Any information the member needs to decide among all relevant treatment options;
(C) The risks, benefits, and consequences of treatment or non-treatment.
(c) MCEs shall ensure development and maintenance of an individualized health educational plan for members whom their provider has identified as requiring specific educational intervention. The Authority may assist in developing materials that address specifically identified health education problems to the population in need;
(d) An explanation of ICC services and how eligible members may access those services. MCEs should ensure that ICC-related education reaches potentially eligible members, including those with special health care needs including those who are aged, blind, or disabled, or who have complex medical needs or high health care needs, multiple chronic conditions, mental illness, chemical dependency, or who receive additional Medicaid-funded LTSS;
(e) The appropriate use of the delivery system, including proactive and effective education of members on how to access emergency services and urgent care services appropriately;
(f) MCEs shall provide written notice to affected members of any significant changes in provider(s), program, or service sites that affect the member's ability to access care or services from MCE's participating providers. The MCE shall provide, translated as appropriate, the notice at least 30 days before the effective date of that change, or as soon as possible if the participating provider has not given the MCE sufficient notification to meet the 30-day notice requirement. The Authority shall review and approve the materials within two working days.
(15) MCEs shall provide an identification card to members, unless waived by the Authority, that contains simple, readable, and usable information on how to access care in an urgent or emergency situation. The cards are solely for the convenience of the MCE, members, and providers.

Notes

Or. Admin. R. 410-141-3585
DMAP 55-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021; DMAP 28-2021, amend filed 06/28/2021, effective 7/1/2021

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065 & 414.727

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