Or. Admin. Code § 410-120-2000

Current through Register Vol. 63, No. 10, October 1, 2024

Section 410-120-2000 - HRSN SERVICES DELIVERY

The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering and delivering Health Related Social Needs (HRSN) Services.

(1) HRSN Services General Requirements; Notices of Availability. HRSN Services are similar to Covered Services (as such word is defined in OAR 410-120-0000); however, HRSN Services are not subject to the medically necessary and appropriate standard for coverage under Oregon Health Plan (OHP) but instead are included in and paid for under OHP in accordance with this rule.

(a) Similarities between HRSN Services and Covered Services include the right of Managed Care Entities (MCEs) to be compensated for the provision of HRSN Services (in accordance with the HRSN Services Fee Schedule) and when Members request HRSN Services eligibility and authorization, the MCE's obligation to provide Members with:

(A) Notices outlined in this rule as well as the same notices, in form and content, that are required for Covered Services such as, for example, notices of Adverse Benefit Determinations under 42 CFR 438.404, and that comply with accessibility requirements under OARs 410-141-3580 and 410-141-3585, and 42 CFR 438.10;

(B) Service Authorizations in accordance with OAR 410-141-3835 (7), (8), (9)(d), (10), (11);

(C) Grievance and Appeal rights under OARs 410-141-3875 through OAR 410-141-3915, OAR 410-120-1860, and 42 CFR Subpart F; and

(D) HRSN Services delivery that complies with the State 1115 Waiver, and in keeping with National Culturally and Linguistically Appropriate Services (CLAS) Standards at https://thinkculturalhealth.hhs.gov/clas/standards.

(b) MCEs shall notify all Members of the availability of HRSN Services, and the process by which they may obtain an HRSN Eligibility Screening, and the standards for authorization of HRSN Services.

(2) Identifying Members of HRSN Covered Populations. The MCE and the Authority shall ensure multiple pathways for Members to be identified as potentially eligible for HRSN Services.

(a) Pathways for identifying potentially eligible Members for HRSN Services must include:

(A) Proactively identifying Members who belong to an HRSN Covered Population and who have at least one HRSN Clinical Risk Factor for an HRSN Service through a review of the MCE or Authority's encounter and claims data.

(B) Contracting with HRSN Service Providers to conduct HRSN Outreach and Engagement Services to identify Members who belong to an HRSN Covered Population and who also have at least one HRSN Clinical Risk Factor for an HRSN Service and make HRSN Requests;

(C) Engaging with and receiving HRSN Requests from other entities and individuals; and

(D) Accepting the Members' Self-Attestations or referrals.

(b) The MCE and the Authority shall not require HRSN Connectors or HRSN Service Providers to use the MCE's or the Authority's HRSN Request Form template. Instead, the MCE and the Authority must accept the HRSN Request Form used by HRSN Connectors and HRSN Service Providers so long as the HRSN Request Form includes the information necessary for the MCE or, as applicable, the Authority to contact or otherwise determine whether the individual may like to receive HRSN Services and is interested in participating in an HRSN Eligibility Screening.

(3) Screening Members for HRSN Eligibility.

(a) The MCE and the Authority shall make good faith efforts to ensure that all Members who have been identified as potentially eligible for HRSN Services are offered an HRSN Eligibility Screening.

(b) When a Member is referred to an MCE or the Authority by an HRSN Service Provider or Connector that has submitted an HRSN Request Form, the MCE, or as applicable, the Authority, shall conduct HRSN Eligibility Screenings of Members who have been identified as potentially eligible for HRSN Services by collecting the information necessary to determine whether the Member:

(A) Is enrolled in OHP, except not receiving the BRG service package defined in OAR 410-135-0030,

(B) Shall like to receive HRSN Services,

(C) Belongs to an HRSN Covered Population,

(D) Meets Social Risk Factor criteria applicable to the HRSN Services for which they are being screened,

(E) Meets Clinical Risk Factor criteria applicable to the HRSN Services for which they are being screened, and

(F) Is not receiving the same or substantially similar service from another state, local, or federally funded program.

(c) For Members who provide the MCE or the Authority with a Self-Attestation, the MCE and the Authority shall rely on the Self-Attestation to complete the HRSN Eligibility Screening. If the Self-Attestation does not include all the information necessary to complete the HRSN Eligibility Screening the MCE and the Authority shall use good faith efforts to obtain and, as applicable, verify all information necessary to complete the HRSN Eligibility Screening by documenting the Member:

(A) Is enrolled in OHP, except not receiving the BRG service package defined in OAR 410-135-0030,

(B) Shall like to receive HRSN Services,

(C) Belongs to an HRSN Covered Population,

(D) Meets Social Risk Factor criteria applicable to the HRSN Services for which they are being screened,

(E) Meets Clinical Risk Factor criteria applicable to the HRSN Services for which they are being screened, and

(F) Is or is not receiving the same or substantially similar service from another state, local, or federally funded program.

(d) All efforts to collect information needed to determine HRSN Eligibility must be documented. If the information included in a Member's Self-Attestation cannot, using good faith efforts, be verified within a reasonable period of time the MCE and the Authority shall authorize the identified HRSN Services need(s) if the MCE or, as applicable, the Authority, has a reasonable basis for concluding the Self-Attestation is truthful.

(e) If the potentially eligible individual is not a Member of the OHP, the MCE or the Authority shall connect individuals to resources to determine OHP Eligibility as requested or consented to by the Member

(4) Authorization HRSN Services.

(a) An MCE shall authorize its own Members, and the Authority shall authorize its Fee-for-Service (FFS) Members, to receive HRSN Services if the MCE or, as appliable, the Authority has completed the HRSN Services Screening and determined and documented that the applicable Member:

(A) Is enrolled in OHP, except not receiving the BRG service package defined in OAR 410-135-0030,

(B) Shall like to receive HRSN Services,

(C) Belongs to an HRSN Covered Population,

(D) Has determined the HRSN Services are Clinically Appropriate,

(E) Meets HRSN Social Risk Factor, criteria and,

(F) Is not receiving the same or substantially similar service from another state, local, or federally funded program.

(b) The Authorization must identify service duration, as appropriate, not to exceed twelve (12) months for an initial authorization, as well as amount and scope in accordance with 42 CFR § 438.210.

(c) MCEs and the Authority shall use reasonable efforts to ensure they do not knowingly authorize an HRSN service that is duplicative of a state or federally funded service or other HRSN Service the Member is already receiving.

(d) Document the approval or denial of HRSN Services.

(A) MCEs shall ensure the HRSN Services are furnished to all OHP Members in an amount, duration, and scope that is no less than the amount, duration, and scope for the same HRSN Services furnished to all OHP Members under the Authority's FFS delivery system;

(B) The MCE or, as applicable, the Authority is required to notify the Member of the approval or denial of HRSN Services within fourteen (14) days of the completing the HRSN Services Eligibility Screening.

(C) HRSN Services must be denied if the individual does not meet all the HRSN Eligibility Criteria for the HRSN Services for which they are screened.

(D) All notices of Service Authorization and Denials must:

(i) State the basis for the approval along with any utilization limitations based on amount, duration, or scope;

(ii) State the basis for denial;

(iii) Comply with OAR 410-141-3835(7), (8), (10), (11); and

(iv) Inform the Member of their Grievance and Appeal rights under OARs 410-141-3875 through OAR 410-141-3915, OAR 410-120-1860, and 42 CFR Subpart F.

(E) The MCE, or as applicable, the Authority is required to notify the HRSN Connector who submitted the HRSN Request of the approval or denial of the HRSN Request through a Closed Loop Referral if the HRSN Connector shall be or may have been the HRSN Service Provider.

(e) If an HRSN Eligible Member is authorized for an HRSN Service (HRSN-Authorized Member), then, unless the HRSN-Authorized Member objects to the sharing of their personal information, the MCE or as applicable, the Authority must refer the HRSN-Authorized Member to an HRSN Service Provider that provides the Member's HRSN Service need. The referral must be made through a Closed Loop Referral. If the HRSN-Authorized Member objects to the sharing of their personal information with an HRSN Service Provider, then the HRSN-Authorized Member must be provided with a written referral that they may deliver to the HRSN Service Provider to which they have been referred. The MCE or, as applicable, the Authority must:

(A) To the extent capacity permits, support the HRSN-Authorized Member's choice of HRSN Service Provider;

(B) Identify and refer the HRSN-Authorized Member to alternative HRSN Service Providers if needed and available;

(C) Inform the HRSN-Authorized Member they have the right to direct the MCE or, as applicable, the Authority, to use a different means of communicating with HRSN Service Providers other than technology, like CIE, and still receive HRSN Services; and

(D) Ensure and document the Member's HRSN Service needs are being and have been met by the HRSN Service Provider in compliance with the Member's HRSN Person-Centered Service Plan.

(5) Confirmation of Climate-Related Supports Required. Prior to making a Closed Loop Referral, the MCE or, as applicable, the Authority must determine availability of the Climate-Related Supports (either devices or any necessary installation or other related service supports, or both) and notify the HRSN-Authorized Member of the anticipated date or time frame that the Climate-Related Supports shall be available. If for any reason there is limited availability of either devices or necessary installation or other related service supports, the MCE shall notify the State of the following information:

(a) There is a limitation of availability of the Climate-Related Supports,

(b) The reason for the limitation, and

(c) The MCE's plan to obtain additional equivalent devices or related service supports or both.

(6) No Subcontracting or Delegation of HRSN Service Authorization and Planning. The MCE shall not subcontract or otherwise Delegate the responsibility for HRSN Service authorization or service planning to an HRSN Service Provider or any other third-party that has involvement in, or responsibility for, denying or authorizing HRSN Services, or service planning for Members. However, for HRSN Climate-Related Support Services only, MCEs may conduct HRSN Eligibility Screening, HRSN Authorization, and HRSN Service planning and provision so long as the MCE has a documented policy and process for safeguarding against conflicts of interest in keeping with the standards set out in 42 CFR 441.730(b)(5)(A).

(7) Person-Centered Service Plan (PCSP). Upon authorization of HRSN Services, the MCE or, as applicable, the Authority and the Member shall update the HRSN-Authorized Member's Care Plan as outlined in OAR 410-141-3870 to include an HRSN PCSP for authorized the HRSN Service(s).

(a) The HRSN PCSP shall be in writing and developed with and agreed upon by the Member, the Member's guardian, or both, as applicable.

(b) The HRSN PCSP must include all of the following:

(A) The recommended HRSN Service(s),

(B) The authorized HRSN Service duration,

(C) The HRSN Service Provider, supporting member choice of provider and working to ensure a mutually agreeable option if choices are limited,

(D) The goals of the HRSN Service(s), identifying other HRSN Services and other OHP services the Member may need (if not already included in the Member's Care Plan), and

(E) The anticipated follow-up and transition plan.

(c) The MCE's, or as applicable, the Authority's is responsible for managing the member's HRSN services.

(d) The MCE or, as applicable, the Authority, shall, at a minimum, have as many meetings as may be necessary to develop the PCSP, but in no event less than one meeting with the Member (or the Member's guardian, or both, as applicable) during development of the PCSP. The meeting with the Member may be held in person, by telephone, or via videoconference. If efforts to have a meeting are unsuccessful, or if the Member declines participation, the MCE or, as applicable, the Authority shall document the attempts and barriers to having a meeting, and justification for continued provision of HRSN Service. At a minimum, MCE or, as applicable, the Authority, shall conduct a six (6) month check-in to evaluate or understand whether (a) the HRSN services are meeting the Member's needs, (b) additional/new services are needed if the service duration is longer than six (6) months, and (c) HRSN services are duplicating other services they are receiving.

(e) Regardless of whether the Member participates in the development of the PCSP, they are still entitled to receive the HRSN Services for which they have been authorized.

(f) A parent, guardian, or caregiver of a member may receive HRSN Service(s) on such member's behalf if the parent, guardian, or caregiver lives with the member and it is in the best interest of the member as determined through the PSCP.

(8) HRSN Service Provider Qualifications. MCEs and the Authority shall ensure that all contracted HRSN Service Providers meet the specific provider qualifications to provide HRSN Services to Members who are authorized by the MCEs or Authority to receive HRSN Services (HRSN-Authorized Members). Contracted HRSN Service Providers must:

(a) Maintain an active business registration with the Oregon Secretary of State.

(b) Be accessible to Members, including having the operating hours and the staff necessary to meet the Members' needs.

(c) Demonstrate their ability or experience to effectively serve at least one of OHA's Priority Populations, as defined in ORS 413.042.

(d) Demonstrate they employ or contract with administrative and service delivery staff, who are, as reasonably determined by the MCE or the Authority, qualified to perform and fulfill the responsibilities of their jobs.

(e) Demonstrate they provide culturally and linguistically appropriate, responsive and trauma-informed services, which includes the ability to:

(A) Supply (i) language interpretation and translation services to those Members who have limited English proficiency, and (ii) American Sign Language (ASL) services for to those Members who require ASL in order to communicate; and

(B) Respond to the cultural needs of the diverse populations they serve by performing services in accordance with National CLAS Standards.

(f) Documented demonstration of a history of responsible financial administration via recent annual financial reports, an externally conducted audit, or other similar documentation.

(g) Meet readiness standards defined by the Authority, including providing the MCE with an attestation of their agreement or ability (or both agreement and ability) to comply with all of the following:

(A) Reporting and oversight requirements established by the Authority or the MCE or, as applicable, both;

(B) All laws relating to information privacy and security applicable to their business;

(C) Compliance with the credentialing obligations under section (1)(c) of this rule;

(D) All obligations related to participating in the Closed Loop Referral process (documented acceptance and confirmation/incomplete services/reporting); and

(E) Invoicing for HRSN Services as agreed upon in their contract with the MCE or Authority to provide HRSN Services.

(h) Comply with oversight requirements established by the Authority, or the MCE, (or both as applicable), and all laws relating to privacy and security that are applicable to their business.

(i) Agree to be enrolled as a Medicaid HRSN Service Provider in MMIS, OHA's electronic system that processes Medicaid claims. The MCE may enroll their contracted HRSN Service Providers as "encounter only" providers in MMIS.

(j) Are not delegated any responsibility for HRSN Service authorization or Service Planning

(9) It is preferred that MCEs and the Authority contract with HRSN Service Providers providing Climate-Related Supports that are capable of both delivering and installing Climate-Related Devices. In the event an HRSN Service Provider does not provide installation services, MCEs and the Authority shall ensure installation services are also performed by a different qualified HRSN Services Provider or HRSN vendor(s).

(10) MCEs and the Authority shall, and shall ensure that HRSN Service Providers providing HRSN Outreach and Engagement Services, assign the responsibility for performing HRSN Outreach and Engagement Services to only those staff who have knowledge of principles and methods, as well as the experience and skills that enables them to effectively engage with individuals who are the intended beneficiaries of HRSN Services for the purpose of connecting them to the HRSN Services and other benefits and services that shall meet their needs.

Or. Admin. Code § 410-120-2000

DMAP 35-2024, adopt filed 01/22/2024, effective 1/22/2024; DMAP 118-2024, amend filed 08/26/2024, effective 8/26/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632