OAR 410-120-1221: Fee-for-Service Care Coordination: Identification of Open Card Member Needs

(1) The Authority or its designee must provide Open Card Members with Care Coordination services based on their level of need. To determine an Open Card Member’s level of need, a Health Risk Assessment (HRA) must be conducted, and a Care Profile must be created as described in this rule; (a) Based on the results of the HRA and other information that is collected and analyzed for the purpose of developing a Care Profile of an Open Card Member, the Member may, as described in this rule, have a Care Plan developed that will guide the Care Coordination services provided by the Authority or its designee. If the Open Card Member’s Care Profile does not require, as set out in this rule, a Care Plan, the Member may request that a Care Plan be developed and utilized by the Authority or its designee in providing Care Coordination services; (b) The Authority or its designee must provide Care Coordination services, as described in OAR 410-120-1225, to Open Card Members regardless of a Care Plan being developed. (2) The Authority or its designee must provide an initial HRA, within 90 days of enrollment, or sooner if the Open Card Member’s health status requires. The results of an HRA are utilized to determine, along with other relevant information, an Open Card Member’s health care needs and Health-Related Social Needs. That information is then used to create a Care Plan that identifies the appropriate OHP Services and the scope of the Care Coordination services an Open Card Member will be provided to support access to the identified OHP Service needs. Refusal or failure to complete an HRA by an Open Card Member shall not limit the Open Card Member’s access to other Care Coordination services and supports. (3) The HRA must be provided by the Open Card Member’s designated care coordinator using a standardized tool provided by or approved by the Authority and in the Member’s preferred method of communication and language. The designated care coordinator must: (a) Contact the Open Card Member to complete the HRA using the Member’s identified preferred method of contact and language in accordance with Section 1557 of the Affordable Care Act (ACA); (A) If the Open Card Member cannot be contacted on the first attempt, the care coordinator must make at least two (2) other attempts to provide additional information or support to the Member to complete the HRA. This must include attempts to reach the Member utilizing two (2) mixed modalities (e.g., paper, telephone, text (SMS), email or other methods that consider known or previously requested language access aids such as large print, video, braille), on different days and at different times; (B) The Open Card Member has the right to decline to participate in the HRA; (b) Make the results of the HRA available to the Open Card Member, their Representative or guardian in their preferred language and preferred method of communication whether orally or in writing, and either on paper or electronically or other methods in accordance with Section 1557 of the Affordable Care Act as large print, video, braille; (c) Review and document an Open Card Member’s HRA in their Care Profile in accordance with OAR 410-120-1215(7) or the Member’s general health care record; (d) Share the results of the HRA with other entities and Providers serving the Open Card Member for the purpose of reducing duplication of those activities; and (e) When the Open Card Member, their Representative or guardian has not returned or responded to the HRA: (A) Use other available data sources, including but not limited to those identified in OAR 410-120-1215(3) and section (3) of this rule, to identify sufficient information to assign a risk level to the Open Card Member; and (B) Ensure services are coordinated for Open Card Members regardless of their participation in, or completion of the HRA. (4) Each Open Card Member has the right to have a Care Profile developed, updated, and maintained by the Authority or the Authority’s designee. Each care profile may include, without limitation, the following information: (a) Personal information, including but not limited to: (A) Demographic information; (B) Communication preferences and needs (e.g. preferred language, method of contact (telephone, SMS, email), alternate formats, auxiliary aids and services); (C) Primary and preferred language; (D) Name and contact information for any authorized Representative; (E) Name and contact information for any legal guardian or authorized Representative, including parents; (b) Completed assessments, including the Health Risk Assessment developed in accordance with this rule; (c) Current and any past health risk scores and risk levels; (d) The names of the Open Card Members’ care team, including but not limited to: (A) Designated care coordinator; (B) Health care Providers (e.g. primary care provider, behavioral health provider, specialists, etc.); (C) Contact information; (D) Assigned care coordination responsibilities; (E) Provider entities such as those identified in 410-120-1215, with specific individuals named as the point of contact; (e) The Open Card Member’s identified needs; (f) An overview of the supports, services, activities and resources that have been or will be deployed to meet the Open Card Member’s needs; (g) The Open Card Member’s desire to participate in Care Coordination and assessments, care planning, etc.; (h) Current and any previously documented health-related circumstances; (i) Current Care Plan and any other open or closed Care Plan(s); (j) Communications to or from identified care team providers; (k) Communications with the Open Card Member; and (l) Other similar information. (5) The Authority or its designee must develop a Care Plan for Open Card Members who have been identified has having specific health-risk scores in accordance with OAR 410-120-1215; (a) The Authority or its designee must develop a care plan for Open Card Members in the moderate-risk and high-risk levels, or who require Long Term Service and Supports (LTSS); (b) The Authority or its designee must develop a care plan for Open Card Members in the no- or low-risk levels when the Member’s needs change resulting in a higher risk level or when the Member or their authorized representative or guardian requests it; (c) Development of a Care Plan is one part of the Care Coordination process and service. The Authority may provide Open Card Members, or their authorized Representatives or guardians (or all of them), with the opportunity to participate in the development of the Member’s Care Plan; (A) Care Plans developed with the participation of the Open Card Member, must be developed in keeping with the process identified in OAR 410-120-1225; and (B) Open Card Members identified as moderate or high-risk who decline participation in Care Plan development, may still have Care Plans developed for them by the designated care coordinator. Care Plans developed by the designated care coordinator must be documented, made part of the Open Card Member’s Care Profile, and utilize the relevant information and sources identified in OAR 410-120-1215(4). At a minimum, the designated care coordinator must include the following information: (i) The Open Card Member’s physical, developmental, behavioral, oral, and social needs (including Health Related Social Needs and Social Determinants of Health and Equity), when available; and (ii) Services and activities the designated care coordinator has or plans to deploy to focus on mitigation of the Open Card Member’s identified risks and level; and (iii) Outreach attempts and opportunities for engagement the designated care coordinator continues to provide to the Open Card Member; and (iv) The reason the Open Card Member (or their legal guardian or their authorized Representative) has declined or is otherwise unable to participate in the development of their Care Plan; (C) For Open Card Members receiving LTSS, the designated care coordinator must be provided with access to or integrate any service or Care Plans developed by entities listed in OAR 410-120-1215(4) into the Member’s Care Profile or Care Plan, or both; (d) The Authority or its designee may utilize the Care Plan to ensure continuity of an Open Card Member’s care according to their needs; (e) The Authority or its designee may utilize the Care Plan to determine the scope of Care Coordination services provided to the Open Card Member as described in OAR 410-120-1225. (6) The Authority or its designee must assess Open Card Members for the need for LTSS and Special Health Care Needs (SHCNs) as those terms are defined in OAR 410-120-0000; (a) The results of the Open Card Member’s HRA and other relevant assessments or documentation are used to identify the risk level and need for LTSS and SHCNs; (b) If at any time, an Open Card Member is identified as potentially eligible for, or requiring LTSS, or services necessary to address their SHCNs, the Authority or its designee shall promptly refer to the Oregon Department of Human Services (ODHS), including Aging and People with Disability (APD) programs, the Office of Developmental Disabilities Services (ODDS), local mental health authorities (LMHA) or other service programs where appropriate for completion of a comprehensive assessment and potential service planning. That assessment must occur as soon as the health condition arises, to determine whether the Open Card Member requires either a course of treatment or regular care monitoring to address those conditions.