Or. Admin. Code § 410-120-2000

Current through Register Vol. 63, No. 12, December 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; Overview of Administration and Delivery of HRSN Services. HRSN Services (defined in OAR 410-120-0000) are similar to Covered Services, but approval for receiving HRSN Services is not subject to the Medically Necessary and Appropriate standard required for Covered Services. Instead, in order for a Member to receive HRSN Services, the HRSN Service must be determined to be Clinically Appropriate (defined in OAR 410-120-0000).

(2) HRSN Services are included in OHP Plus benefit package and are paid for on an encounter basis.

(3) MCEs and HRSN Service Providers shall be compensated for the provision of HRSN Services in accordance with the HRSN Services Fee Schedule. The state must review the HRSN Fee Schedule at least once (1) every calendar year to determine whether changes need to be made as determined by the Authority in its sole discretion. Subject to the Authority's reasonable discretion and applicable law, MCEs and HRSN Service Providers shall be compensated for HRSN Services on an encounter basis or incorporated into capitation rates.

(4) MCEs and, as applicable, the Authority must provide Members with the same notices required to be provided for all other Covered Services, including, without limitation, Service Authorizations in accordance with 42 CFR 435.917 and OAR 410-141-3835 and notices of Adverse Benefit Determination (ABD).

(a) MCEs shall notify all Members of the availability of HRSN Services, the process by which they may obtain an HRSN Eligibility Screening, and the standards for authorization of HRSN Services in their Member communications, in accordance with OAR 410-141-3585.

(b) All notices must comply with accessibility requirements as required by 42 CFR 438.10, and OARs 410-141-3580 and 410-141-3585.

(c) All notices of Adverse Benefit Determinations (ABDs) must comply with 42 CFR § 438.404, OAR 410-141-3885, 42 CFR § 435.917 and OAR 410-120-1860 and include information that tells Members about their Grievance and Appeal rights under 42 CFR Part 438, Subpart F, OARs 410-141-3875 through OAR 410-141-3915, OAR 410-120-1860, 42 CFR 435.917, and OAR 410-120-1860

(5) HRSN Services administration and delivery consists of a number of tasks and activities which are required to be delivered by the HRSN Service Provider and MCE, or Authority, in accordance with the following administrative rules:

(a) HRSN Eligibility and Outreach and Engagement of Members that complies with OAR 410-120-2005,

(b) Requests for HRSN Services that complies with OAR 410-120-2010,

(c) HRSN Screening, Service Authorization, and referral to HRSN Service Provider that complies with OAR 410-120-2015 and OAR 410-120-2020,

(d) Conducting an HRSN Person-Centered Service Plan that complies with OAR 410-120-2025, and

(e) Contracting with HRSN Service Providers that meet qualifications in compliance with OAR 410-120-2030.

(6) HRSN Services delivered by the MCE, the Authority, or an HRSN Service Provider, shall be culturally and linguistically appropriate, responsive, and trauma-informed in accordance with National CLAS Standards and Trauma-Informed Care principles.

(7) MCE and as applicable, the Authority, shall protect against conflicts of interest in the administration and delivery of HRSN Services.

(a) An MCE and, as applicable, the Authority shall not deliver any HRSN Service that it has authorized unless the MCE can demonstrate it is the only willing and qualified organization that is capable of providing the HRSN Service in the applicable Authorized Member's geographic region.

(b) The MCE and as applicable, the Authority must devise conflict of interest protections including separation of authorization and HRSN Service Provider functions within the MCE and as applicable, the Authority.

(c) The conflict of interest protections devised by the MCE must be documented in a form or format identified by the Authority, is subject to the approval of the Authority, and must be retained and provided if requested for Authority audit or other review.

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; DMAP 130-2024, amend filed 10/24/2024, effective 11/1/2024

Statutory/Other Authority: ORS 413.042

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