OAR 410-141-3530: Sanctions

(1) The Authority may establish and impose sanctions on Managed Care Entities (MCEs), pursuant to 42 CFR § 438.700, if the Authority makes a determination specified in paragraph (3) of this rule. (2) The Authority may base its determinations on findings from onsite surveys, enrollee or other complaints, financial status, or any other source. (3) The Authority may impose sanctions if the Authority determines that an MCE acts or fails to act as follows: (a) Fails substantially to provide medically necessary services required under law or under its contract with the Authority to an enrollee covered under the contract; (b) Imposes on enrollee’s premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program; (c) Acts to discriminate among enrollees on the basis of their health status or need for health care services. This includes termination of enrollment or refusal to re-enroll a beneficiary, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by beneficiaries whose medical condition or history indicates probable need for substantial future medical services; (d) Misrepresents or falsifies information that it furnishes to the Centers for Medicare and Medicaid Services (CMS) or to the Authority; (e) Misrepresents or falsifies information that it furnishes to an enrollee, potential enrollee, health care provider, or HRSN Service Provider; (f) Fails to comply with the requirements for physician incentive plans, as set forth in 42 CFR §§ 422.208 and 422.210; (g) Distributes directly or indirectly through any agent or independent contractor marketing materials that are not approved by the Authority or that contain false or materially misleading information; (h) Violates any of the other applicable requirements of state or federal Medicaid law; or (i) Fails to comply with any legal or contractual requirements that, pursuant to the MCE contract, may form a basis for sanctions. (4) The Authority may impose a range of sanctions under this rule including the following: (a) Civil monetary penalties in the amounts specified in section (5) of this rule; (b) Appointment of temporary management for an MCE as permitted under 42 CFR 438.706; (c) Granting members the right to terminate enrollment without cause and notifying the affected members of their right to disenroll; (d) Suspension of all new enrollment, including default enrollment, after the date the Authority notifies the MCE of a determination of a violation of rule or contract requirements; (e) Suspension of payment for members enrolled after the effective date of the sanction and until the Authority is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur; (f) Additional sanctions available under Oregon Revised Statutes and Oregon Administrative Rules that address areas of noncompliance specified in section (3) of this rule or any additional areas of noncompliance. (5) If the Authority imposes civil monetary penalties: (a) The maximum civil monetary penalty the Authority may impose varies depending on the nature of the MCE’s action or failure to act, subject to the limits in 42 CFR § 438.704; (b) The Authority may issue penalties as specified on a per event, per member impacted, or per day basis for the duration of noncompliance. (6) Before imposing any sanctions, the Authority must give the affected MCE timely written notice that explains the following: (a) The basis and nature of the sanction; (b) Any appeal rights under this rule and any other appeal rights that the Authority elects to provide. (7) Administrative review, and if requested mediation: (a) Are available for review of sanction decisions in accordance with OAR 410-120-1580 and 410-141-3550; (b) If the Authority determines that there is continued egregious behavior, or that such action is necessary to ensure the health or safety of members, the Authority may impose the sanction before an administrative review opportunity is provided. (8) Before terminating an MCE’s contract for cause, the Authority must provide the MCE the opportunity for a pre-termination hearing. The Authority must do all of the following: (a) Give the MCE written notice of its intent to terminate, the reason for termination, and the time and place of the hearing; (b) After the hearing, give the MCE written notice of the decision affirming or reversing the proposed termination of the contract and for an affirming decision the effective date of termination; (c) For an affirming decision, give enrollees of the MCE notice of the termination and information on their options for receiving Medicaid services following the effective date of termination.