OAR 410-141-3585: CCO Member Relations: Education and Information

(1) CCOs may engage in activities for existing members related to outreach, health promotion, and health education. The CCO must obtain approval of the Authority prior to distribution of any written communication by the CCO or its subcontractors and providers that: (a) Is intended solely for members; and (b) Pertains to requirements for obtaining coordinated care services at service area sites or benefits. (2) CCOs may communicate with providers, caseworkers, community agencies, and other interested parties for informational purposes or to enable care coordination and address social determinants of health or community health. The intent of these communications should be informational only for building community linkages to impact social determinants of health or member care coordination and not to entice or solicit membership. Communication methodologies may include but are not limited to brochures, pamphlets, newsletters, posters, fliers, websites, health fairs, or sponsorship of health-related events. CCOs shall address health literacy issues by preparing these documents at a low literacy reading level, incorporating graphics and utilizing alternate formats. (3) CCOs shall have a mechanism to help members understand the requirements and benefits of the CCO’s coordinated care model. The mechanisms developed shall be culturally and linguistically appropriate. Written materials, including provider directories, member handbooks, appeal and grievance notices, and all denial and termination notices are made available in the prevalent non-English languages as defined in OAR 410-141-3575 in its particular service area and be available in formats noted in section (5) of this rule for members with disabilities. CCOs shall accommodate requests made by other sources such as members, family members, or caregivers for language accommodation, translating to the member’s language needs as requested. (4) CCOs shall have written procedures, criteria, and an ongoing process of member education and information sharing that includes member orientation, member handbook, and health education. CCOs shall update their educational material as they add coordinated services. Member education shall: (a) Be made available in the prevalent non-English languages in the CCOs service area and provided in alternate formats upon request and free of charge in compliance with 42 CFR 438.10. Auxiliary aids and services must also be made available upon request at no cost; (b) Include information about the care coordination approach and how to navigate the coordinated health care system and where applicable for Full Benefit Dual Eligible (FBDE) members, the process for coordinating Medicaid and Medicare benefits; (c) Clearly explain how members may receive assistance from certified and qualified health care interpreters and Traditional Health Workers as defined in OAR 950-060-0010; (d) Inform all members of the availability of Ombudsperson services. (5) Written member materials shall comply with the following language and access requirements: (a) Materials shall be translated in the prevalent non-English languages as defined in OAR 410-141-3575 in the service area as well as include taglines in large print (font size 18) explaining the availability of written translation or oral interpretation to understand the information provided, as well as alternate formats, and the toll-free and TTY/TDY telephone number of the CCO’s member/customer service unit; (b) Materials shall be made available in alternative formats upon request of the member at no cost. Auxiliary aids and services must also be made available upon request of the member at no cost. The CCO’s process for providing alternative formats and auxiliary aids to members must not in effect deny or limit access to covered services, grievance, appeals, or hearings; (c) Electronic versions of member materials shall be made available on the CCO website, including provider directories, formularies, and handbooks in a form that can be electronically retained and printed, available in a machine-readable file and format, is searchable and Readily Accessible. For any required member education materials on the CCO website, the member is informed that the information is available in paper form without charge upon request to Members and Member representatives, and the CCO shall provide it upon request within five business days. (6) CCO provider directories shall be a single, comprehensive resource that encompasses the CCO’s entire Provider Network, including any Providers contracted by Subcontractors that serve the CCO’s Members. CCOs must not utilize a Subcontractor’s separate or standalone provider directory to meet the Provider Directory requirement and shall include: (a) The provider’s name as well as any group affiliation; (b) Street address(es); (c) Telephone number(s); (d) Website URL, as appropriate; (e) Provider Specialty, as appropriate; (f) National Provider Identifier (NPI), as appropriate; (g) Whether the provider shall accept new members; (h) Whether the provider offers both telehealth and in-person appointments; (i) Information about the provider’s race and ethnicity, cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or an Authority-approved qualified and, as applicable, certified health care interpreter(s) at no cost to members at the provider’s office; (j) Availability of auxiliary aids and services for all members with disabilities upon request and at no cost; (k) Narrative space that is optional for providers to list biographical, cultural, linguistic, or other relevant information. (l) Whether the provider’s office or facility is accessible and has accommodations for people with physical disabilities, including but not limited to information on specific accessibility features of provider’s offices, exam rooms, and equipment (e.g., wide entries, wheelchair access, accessible exam tables and rooms, lifts, scales, restrooms, grab bars, or other equipment). (m) The information for each of the following provider types covered under the contract, as applicable to the CCO contract: (A) Physicians, including specialists, available to members on an outpatient basis and not solely available in a nursing facility or other institutional setting; (B) Hospitals; (C) Pharmacies; (D) Behavioral health providers; including specifying substance use treatment providers; (E) Dental providers; (F) HRSN Service Providers. (n) Information included in the provider directory shall be updated at least monthly, and electronic provider directories shall be updated no later than thirty (30) days after the CCO receives updated provider information. Updated materials shall be available on the CCO website in a readily accessible and machine-readable file per form upon request and another alternative format. (7) Each CCO shall make available in electronic or paper form the following information about its formulary: (a) Which medications are covered both generic and name brand; (b) What tier each medication is on. (8) Within fourteen (14) days of a CCO’s receiving notice of a member’s enrollment, CCOs shall mail a welcome packet to new members and to members returning to the CCO twelve (12) months or more after previous enrollment. The packet shall include, at a minimum, a welcome letter, an ID card, a Notice of Availability of Language Access, a Notice of Nondiscrimination, and information on how to access a member handbook and a provider directory, including a list of any in-network retail and mail-order pharmacies. (9) For existing CCO members, a CCO shall notify members annually of the availability of a member handbook and provider directory and how to access those materials. CCOs shall send hard copies upon request within five days. CCOs must also notify members of their nondiscrimination policies annually and as otherwise specified in 45 CFR 92.10. (10) CCOs must notify enrollees: (a) That interpreter services in any language required by the member, including American Sign Language, auxiliary aids and alternative format materials are available free of charge to CCO members in its health programs and activities as stated in 42 CFR 438.10. This notice must be provided in the manner specified in 45 CFR 92.11; (b) The process for requesting and accessing interpreters or auxiliary aids and alternative formats, including where appropriate how to contact specific providers responsible through sub-contracts to ensure provision of language and disability access; (c) Language access services also applies to member representatives, family members and caregivers with hearing impairments or limited English proficiency who need to understand the member’s condition and care. (11) A CCO shall electronically provide to the Authority for approval each version of the printed welcome packet that includes a welcome letter, an ID card, a Notice of Availability of Language Access, a Notice of Nondiscrimination, and information on how to access a member handbook and a provider directory. (12) CCOs shall adopt the language in the Authority’s Model Member Handbook. CCO Member Handbooks shall comply with the Authority’s formatting and readability standards. (13) Member health education shall include: (a) Information on specific health care procedures, instruction in self-management of health care, promotion and maintenance of optimal health care status, patient self-care, and disease and accident prevention. CCO providers or other individuals or programs approved by the CCO may provide health education. CCOs shall make every effort to provide health education in a culturally sensitive and linguistically appropriate manner in order to communicate most effectively with individuals from non-dominant cultures; (b) Information specifying that CCOs must not prohibit or otherwise restrict a provider acting within the lawful scope of practice from advising or advocating on behalf of a member who is their patient for the following: (A) The member’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered; (B) Any information the member needs to decide among all relevant treatment options; (C) The risks, benefits, and consequences of treatment or non-treatment. (c) CCOs shall ensure development and maintenance of an individualized health educational plan for members whom their provider has identified as requiring specific educational intervention. The Authority may assist in developing materials that address specifically identified health education problems to the population in need; (d) An explanation of care coordination and how members may participate in those services. CCOs shall ensure that care coordination related education is provided to members with special health care needs as defined in OAR 410-141-3500; (e) The appropriate use of the delivery system, including proactive and effective education of members on how to access emergency services and urgent care services appropriately; (f) CCOs shall provide written notice to affected members of any Material Changes to Delivery System as defined in OAR 410-141-3500 or any other significant changes in provider(s), program, or service sites that affect the member’s ability to access care or services from CCO’s participating providers. The CCO shall provide, translated as appropriate, the notice at least thirty (30) days before the effective date of that change, or within fifteen (15) calendar days after receipt or issuance of the termination notice if the participating provider has not given the CCO sufficient notification to meet the thirty (30) day notice requirement. The Authority shall review and approve the materials within two (2) working days. (14) CCOs shall provide an identification card to members, unless waived by the Authority, that contains simple, readable, and usable information on how to access care in an urgent or emergency situation. The cards are solely for the convenience of the CCO, members, and providers.