Or. Admin. Code § 410-141-3860

Current through Register Vol. 63, No. 12, December 1, 2024

Section 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. This coordination must encompass all services accessed to address the member's physical, developmental, behavioral, dental 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 or request it initially and ongoing.

(2) CCOs must ensure the overall coordination of all services and supports furnished to the member, 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 community and social support organizations.

(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 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) 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) Ensure a member's ability to live well with and manage 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 and for minors, person-and family-centered;

(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 and ORS 413.550;

(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 plan goals and outcomes, members' care team, communication to/from care team, community resources, completed assessments and identified needs, change in health-related circumstances), communication with individual members, and timeliness of activities. To the maximum extent feasible, CCOs may 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 categories, 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 risk level and care gaps must include but are not limited to the following sources: claims and utilization data, Health Risk Assessments, functional need assessments, social needs and risks, referrals, event notifications, and other available resources to inform physical, developmental, behavioral, and dental health needs;

(ii) Risk scores shall be utilized to inform the level of intensity and intervention required by the member and incorporated into the members care profile;

(iii) Continuous and ongoing data mining and identification of additional care gaps shall inform updates to the member's risk level and intervention needed.

(C) Regularly monitoring population level trends to determine and identify cohorts of the population requiring Care Coordination due to an 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 a contact point for the escalation of emergent or unmet Care Coordination needs 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, behavioral, dental, and social needs information across all entities, providers, and systems involved in Care Coordination;

(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.

(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, behavioral, dental, and social needs 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 410-141-3865, 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 Contracts 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.

Or. Admin. Code § 410-141-3860

DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020; DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021; DMAP 6-2021, temporary amend filed 02/10/2021, effective 2/10/2021 through 8/8/2021; DMAP 28-2021, amend filed 06/28/2021, effective 7/1/2021; DMAP 37-2024, amend filed 01/25/2024, effective 2/1/2024; DMAP 82-2024, minor correction filed 04/01/2024, effective 4/1/2024

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065 & 414.727