OAR 410-120-1225: Fee-for Service Care Coordination: Service Coordination

(1) The Authority’s designee must provide Open Card Members Care Coordination services as described in this rule and in OARs 410-120-1215 and 410-120-1221. (2) Upon enrollment, the Authority’s designee must provide Open Card Members with prompt Care Coordination services that facilitate access to any Urgent Care Services or Emergency Services (as defined in OAR 410-120-0000) the Member may need, even if the Member has not yet selected a Primary Care Provider (PCP) or completed the Health Risk Assessment (HRA). (3) The Authority’s designee must provide Open Card Members Care Coordination services regardless of the location of eligible Provider(s). (a) If an Open Card Member experiences a care setting transition, the designated care coordinator must: (A) Transition the Open Card Member into the most appropriate independent and integrated community settings and provide follow-up services as Medically Necessary and Appropriate prior to discharge to facilitate successful handoff to community providers; (B) Provide Care Coordination and discharge planning in accordance with the discharge plan; (C) Provide Care Coordination and discharge planning services when the Open Card Member: (i) Is discharged for temporary placement in a residential facility (behavioral or physical health) outside the Open Card Member’s home or community; or (ii) Was enrolled in OHP upon entering the Oregon State Hospital and will return to their home or community upon discharge; (b) The designated care coordinator may coordinate and authorize care when it has been deemed Medically Necessary and Appropriate to receive services outside of the Open Card Member’s community due to the unavailability of the Medically Necessary services; (c) The designated care coordinator must coordinate the Open Card Member’s care when the Member is temporarily outside their community; (d) The Authority or its designee shall provide the Post-Hospital Extended Care (PHEC) benefit according to the criteria established by Medicare, as cited in the Medicare Coverage of Skilled Nursing Facility Care. (4) When an Open Card Member’s Care Profile identifies the Member as having moderate to high-risk health needs, the Authority’s designee must provide Care Coordination for OHP Services without request; (a) For Open Card Members who have low health-risk needs, the Authority’s designee may provide Care Coordination services when requested by the Open Card Member, the Member’s Representative or guardian, or by a Provider or entity involved in the Member’s care; (b) Open Card Members have the right to decline the provision of Care Coordination services at any time. (5) To provide Care Coordination services, a Care Plan may be developed and implemented by the designated care coordinator to address the needs, goals, preferences, and circumstances of the Open Card Member as described in OARs 410-120-1215 and 410-120-1221. (a) The Authority’s designee must review, update, or revise any applicable Care Plan(s) annually and as follows: (A) When requested by the Open Card Member, the Member’s Representative or guardian, or any Provider involved in or providing care to the Open Card Member; or (B) Upon a change in health-related circumstances as described in OAR 410-120-1221; (b) For Open Card Members who decline to participate in the development of their Care Plan, the Authority’s designee shall develop Care Plans in keeping with, at minimum, the requirements set forth in OAR 410-120-1221, and to the extent possible given due to the Open Card Members’ lack of participation, in keeping with the requirements set forth in subsection (5)(c) below of this rule; (c) For Open Card Members who participate in the development of their Care Plan, the Authority’s designee must develop and revise the Care Plan in alignment with all the following: (A) The Open Card Member’s identified needs and risk level; and (B) The Open Card Member’s identified goals and preferences, when available, to the extent the Member desires or can participate; and (C) By incorporating information from any relevant assessments, treatment and service plans from Providers or community partners involved in the Open Card Member’s care, to the maximum extent feasible; and (D) In consultation with any other Provider, case manager, or entity providing services to, or coordinating care for, the Open Card Member; and (E) In consultation with a clinician that has the appropriate clinical qualifications and expertise to review and revise the Care Plan considering the Open Card Member’s complex physical, developmental, behavioral or oral health care needs including clinical subjectivity; and (F) In accordance with an Open Card Member’s updated risk level as described in paragraph (5)(a)(B) of this rule; and (G) In accordance with state quality assurance and utilization review standards, as applicable; and (H) With the Open Card Member, their Representative or guardian’s participation (or all of them) to the extent they desire or can participate; (i) The Care Plan must be agreed to and approved by the Open Card Member, their Representative or guardian; (ii) The Open Card Member, their Representative or guardian, must understand the Care Plan, including the components that identify any roles and responsibilities the Member will perform themselves; (d) If the designated care coordinator determines that the participation of the Open Card Member, the Member’s authorized Representative, or family in the creation of their Care Plan may be detrimental to the Open Card Member’s care or health, those individuals may be excluded from the development of the Member’s Care Plan. In these situations: (A) The reasons for the exclusion must be documented in the Care Plan and include a specific description of the risk or potential harm that the Open Card Member would experience or would be at risk of experiencing if the Member, their authorized Representative, or family, were included in the development of the Care Plan. The documentation of the decision must also include a description of the attempts made to address the concern(s) without having to exclude the individuals from the process; and (B) The decision regarding exclusion from participation must be reviewed, reconsidered, and redetermined prior to each update of a Care Plan. If it is determined the exclusion is still required, that decision must be documented in the Open Card Member’s care plan in accordance with paragraph (5)(d)(A) above; (e) Except as permitted under paragraph (5)(e)(C) of this rule, the Authority or its designee must provide the Open Card Member, and if applicable, their authorized Representative or guardian, a copy of the Member’s Care Plan promptly after it has been completed. The designated care coordinator must also promptly provide the completed Care Plan to all Providers who will be rendering services to the Open Card Member in keeping with the Care Plan; (A) If the Care Plan is required to be approved, then approval must be made in a timely manner. Timeliness is determined by the Open Card Member’s health needs; (B) Once the Care Plan is completed, and if applicable, approved, the Authority or its designee must provide the Open Card Member, their Representative or guardian prompt electronic access to the Care Plan; (i) If the Open Card Member prefers a different method of communication, the Member may promptly receive a paper copy of their Care Plan; (ii) The Authority or its designee shall provide the Open Card Member’s Care Plan in the Member’s preferred language; (iii) In accordance with Section 1557 of the Affordable Care Act and OAR 410-120-1215, the Open Card Member has a right to receive or otherwise access their Care Plan through the use of auxiliary aids and services, in alternate formats, or other means, promptly upon request. For purposes of this subparagraph, “promptly” means within five (5) business days after the date of the Open Card Member’s request; (C) If it is determined by the Open Card Member’s care team that providing the Member with full or partial access to the Care Plan could be significantly detrimental to the Member’s care or health, the designated care coordinator may withhold from the Member only those parts of the Care Plan that have been determined to be detrimental. When a designated care coordinator withholds all or part of an Open Card Member’s Care Plan, the designate care coordinator must: (i) Document in the Open Card Member’s Care Plan the reasons for withholding the full or partial Care Plan, including a specific description of the risk or potential harm that was the basis for the determination. The documentation must also describe what attempts were made to address the concern(s) prior to determining that the Care Plan should be fully or partially withheld; and (ii) Review the decision to withhold the full or partial Care Plan prior to each Care Plan update and reevaluate the decision to withhold the Care Plan upon completion of the updated Care Plan prior to making any decision to continue fully or partially withholding the updated Care Plan. If, upon reevaluation, the decision is to continue to withhold all or part of the Care Plan, that decision must be documented in the Open Card Member’s Care Plan keeping with subparagraph (5)(e)(C)(i) of this rule; (f) An Open Card Member’s care plan must be closed when: (A) It is no longer warranted by the Member’s risk level or circumstances; or (B) Requested by the Member, their Representative or guardian; (g) An Open Card Member’s Care Plan may, but is not required to, be closed when the designated care coordinator has not been able to make contact with the Open Card Member, their Representative or guardian, after a minimum of three (3) attempts of outreach utilizing the Member’s preferred method of communication and language and using at least two (2) mixed modalities (e.g., paper, email, telephone, or text (SMS) ), over a 60 day period and with consultation and agreement of available care team members; (h) If an Open Card Member no longer wishes to participate in their Care Plan, and the Member continues to be identified as medium – or high-risk, or continues to receive LTSS, the designated care coordinator must transition the Open Card Member to a directed Care Plan as outlined in OAR 410-120-1221(4)(c)-(e); (i) The Authority or its designee shall keep an Open Card Member’s Care Profile up-to-date even if the Member declined to participate in the Care Plan or the Care Plan has been closed, regardless of the reason for the closure. (6) The Authority or its designee may provide Open Card Members with opportunities to meet with an interdisciplinary team: (a) The Authority or its designee must provide opportunities to meet with an interdisciplinary team to Open Card Members who receive LTSS or have been identified as having Special Health Care Needs, as defined in OAR 410-120-0000, and who have been assessed in accordance with OAR 410-120-1221(4) and require: (A) A course of treatment; or (B) Regular care monitoring; or (C) Identified as high-risk; (b) Interdisciplinary team meetings must occur within 14 days of the Open Card Member’s transition between levels of care, settings of care, or episodes of care or as otherwise required by the Member’s Care Plan. (c) Interdisciplinary team meetings may include the following individuals, Providers, entities, or organizations: (A) The Open Card Member and their authorized Representative or guardian, unless the Member declines or the Member’s participation, or their authorized representative or guardian’s participation, is determined to be significantly detrimental to the Member’s health, in accordance with (5)(b)(G) of this rule; (B) All of the available Open Card Member’s Providers; and (C) Other available organizations or entities that provide OHP and other services to the Open Card Member, including without limitation, those listed in OAR 410-120-1215(4). (D) In the event some of the above Providers, entities, or organizations are unable to attend the interdisciplinary meeting, the Authority or designated care coordinator will be responsible for obtaining the information and documentation from those Providers, entities, and organizations that is necessary to fulfill the purpose of the interdisciplinary team meeting as described in subsection (6)(d) of this rule; (d) Interdisciplinary team meetings are held for the purpose of providing an opportunity for: (A) The Open Card Member to provide an update and feedback on the care they have received, including the progress they have made toward their care plan goals, their strengths and challenges, and any change in those strengths and challenges since the last interdisciplinary team meeting was held; (B) Other attendees to describe the clinical interventions, services, and treatment provided to the Open Card Member and the progress made in treating or otherwise addressing the Member’s health condition; (C) All attendees to identify gaps in care and Care Coordination and strategies for filling or otherwise closing those gaps; (D) Developing strategies for identifying, addressing, monitoring, and following up on the needs of the Open Card Member identified during the interdisciplinary meeting, including, without limitation, referrals for specialty care, routine health care services (including medication monitoring), other community program resources or social services that can meet the needs of the Member; (E) Updating the Open Card Member’s Care Plan in keeping with the decisions made, information shared, and the Member’s needs identified during the interdisciplinary meeting; and (F) Identifying, prior to ending the interdisciplinary meeting, the subsequent dates or frequency the interdisciplinary team will meet to address the Open Card Member’s Care Plan needs; (e) The Care Plan, as updated during an interdisciplinary meeting, must be shared in accordance with subsections (4)(e)-(f) of this rule; (f) If required by the Open Card Member’s health condition and identified needs, as identified as in the updated Care Plan, the Member must be provided with direct access to specialists, which may include a standing referral or an approved number of visits.