OAR 410-120-1215: Fee-for-Service Care Coordination: Administration

(1) The Authority or its designee shall provide Open Card Members with Care Coordination services. Care Coordination includes all physical, developmental, behavioral, oral health services accessed and as requested by the Open Card Member. Care Coordination also addresses Open Card Members’ Health-Related Social Needs (HRSN) in support of addressing barriers related to Social Determinants of Health and Equity (SDOH-E). Physical, developmental, behavioral, and oral health services together with services provided to address HRSN and SDOHE, are collectively called, “OHP Services.” The Authority’s desired goal for the sustained provision of Care Coordination over a substantial time-period is to: (a) Improve Open Card Member health outcomes; (b) Support and enable an Open Card Member’s ability to manage, maintain and improve any chronic conditions or disabilities; (c) Reduce health inequities experienced by Open Card Members by facilitating improved and timely access to care. (2) The Authority or its designee must provide Open Card Members with Care Coordination that: (a) Identifies the Open Card Member’s need for OHP Services on an initial and ongoing basis, as described in OARs 410-120-1220 and 410-120-1225; (b) Is provided or accessed promptly after enrollment in the fee-for-service (FFS) delivery system and on an ongoing basis while enrolled in the FFS delivery system. (3) The Authority or its designee must provide Care Coordination to Open Card Members regardless of which Provider provides the OHP Services. (4) When a Member transitions from one OHP delivery system to another (CCO or FFS), the predecessor entity shall ensure that all documentation in relation to the Member’s Care Coordination (Care Profile, Care Plan, HRA, etc.) is provided to the receiving entity in compliance with section (11) of this rule. (5) The Authority or its designee may provide Care Coordination for the following services, upon request of the Open Card Member, if the Open Card Member also receives: (a) Health care services covered by Medicare or Medicare Advantage Plans; or (b) Services from state, local, community, or social support agencies or organizations, including but not limited to, Community Mental Health Programs (CMHP), Oregon Department of Human Services (ODHS), including Aging and People with Disabilities (APD), Child Welfare (CW), and Office of Developmental Disability Services (ODDS), Oregon Department of Education (ODE), Oregon Youth Authority (OYA), Coordinated Care Organizations (CCO), local public and mental health authorities, or any other institutional, community, and social support organizations serving the Open Card Member. (6) If an Open Card Member receives all their OHP Services through the Authority’s FFS delivery system, the Authority or its designee must provide the Open Card Member with all Care Coordination services. (a) The Authority or its designee is primarily responsible for the Care Coordination for Members who are enrolled in plan type CCOE, CCOF or CCOG; (b) If an Member is enrolled in a CCO to receive some services (plan types CCOA or CCOB), the CCO is responsible for providing care coordination services except in certain circumstances when the Authority is responsible for paying for specific services, including but not limited to, Long-Term Services and Supports (LTSS), some Behavioral Health services, and other services carved-out in the CCO contract. In those circumstances the CCO shall: (A) Proactively collaborate with the Authority or its designee regarding the CCO’s respective Care Coordination obligations for the services that are paid for by the Authority; and (B) Provide the CCO Member’s care team with written notice that the Authority and other parties are involved in the CCO Member’s care, provide the care team with the contact information for all other involved parties and instruct the care team that they must communicate with all parties that make up the CCO Member’s care team regarding the CCO Member’s needs; and (C) Communicate with the Authority and other care team members about the CCO Member’s Care Plan(s) and ensure that all OHP Services accessed by the CCO Member, whether covered and paid for by the CCO or the Authority, are coordinated in collaboration with the Authority. (7) When Open Card Members are receiving OHP Services from multiple programs or delivery systems (e.g., Long Term Services and Supports, Intellectual and Developmental Disabilities, Child Welfare, Youth Wraparound, Intensive In-home Behavioral Health Treatment, etc.) and those programs also engage their own care teams or coordinators in providing their respective services, the Authority or its designee may collaborate with those additional programs that are coordinating the Open Card Member’s services in order to reduce duplication of services and identify and fill Care Coordination gaps. In those cases, the Authority or its designee must: (a) Document both the other programs’ coordinating activities and identify any other Care Coordination needs the Open Card Member may have; and (b) Provide Care Coordination to the Open Card Member for all needs identified that are not addressed or coordinated by another program. (8) The Authority or its designee must document, track, and monitor Care Coordination services of Open Card Members for purposes of care planning, setting health goals and outcomes; (a) Documentation must be stored and maintained in a single file for each Open Card Member that results in the creation of an Open Card Member Care Profile that complies with the requirements set out in OAR 410-120-1220; (b) Monitoring must utilize baseline data relating to the Open Card Member’s health and then be compared to data that is subsequently collected and analyzed. (9) Open Card Members are identified by the designated care coordinator as: no- or low-risk, moderate-risk, or high-risk. (a) The designated care coordinator must determine the risk level using the Authority’s then-current risk stratification mechanisms and algorithms. The data sources used must include, without limitation: (A) Claims and utilization data; (B) Health Risk Assessments performed and utilized in accordance with OAR 410-120-1220; (C) Functional needs assessments; (D) Referrals, event notifications, and other available resources that provide relevant information regarding the Open Card Member’s physical, developmental, behavioral, oral health care needs, the need for HRSN services, and the over-all impact SDOH-E in the Open Card Member’s health. (b) Data sources are used to identify risks, risk level, and care gaps. Continuous and ongoing data mining and identification of additional care gaps shall inform updates to the Open Card Member’s risk level, Care Profile, Care Plan, OHP Service needs, and interventions needed; (c) Risk scores are 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 Open Card Member’s risk level and inform the overall Care Coordination planning process. (10) Open Card Members have the right to exercise their Grievance, complaint and Appeal rights under OARs 410-120-1860 and 410-120-1865 for Grievances and Appeals pertaining to Care Coordination. (11) The Authority or its designee must provide Open Card Members requesting Care Coordination services with a designated care coordinator who has the training and experience necessary to meet OHA’s care coordinator qualifications (designated care coordinator). (a) The Authority or its designee may provide Open Card Members (or their authorized Representative) with: (A) The contact information for their designated care coordinator and for an alternate care coordinator when the designated care coordinator is unavailable; (B) Prompt access to their complete Care Profile, in accordance with 45 CFR §164.524, and all other records pertaining to provided services, up-to-date and complete per OAR 410-120-1360 (Requirements for Financial, Clinical and Oher Records); (C) Communications and information exchanged regarding the Care Coordination and other related services provided; (b) At the Open Card Member’s request, the Authority or its designee may provide the Care Profile to a third-party the Open Card Member has identified. (c) Exclusions and limitations to Open Card Member Care Coordination information sharing are included in OAR 410-120-1225. (12) The Authority or its designee must develop, maintain, disclose, or otherwise share all information and documentation regarding an Open Card Member’s Care Coordination services and all other information related to the provision and administration of the Open Card Member’s OHP Services in accordance with, as applicable, 45 CFR Parts 160 and 164 (HIPAA), 42 CFR Part 2, 42 CFR §431.300, as well as all applicable state privacy and information security laws, including without limitation ORS 192.553 through 192.581 and OAR Chapter 943, Division 014.