OAR 410-141-3720: Service Area Change for Existing CCOs

(1) For purposes of this rule, the following definitions apply: (a) “Applicant” means a coordinated care organization (CCO) as defined in ORS 414.572 with a CCO contract with the Authority that submits an application seeking a contract amendment for a new service area. The CCO is described for purposes of this rule as the applicant upon its submission of the CCO Letter of Intent to Apply; (b) “Document Review” means the review conducted by the Authority, occurring at the point after the receipt of the completed SAC packet and before the effective date of the contract amendment, to determine applicant’s ability to serve Medicaid beneficiaries in the requested service areas; (c) “Letter of intent to apply (LOIA)” means a letter from a CCO to the Authority stating the CCO’s intent to submit a SAC packet in response to a service area need. An LOIA may be binding or non-binding, as specified in the Authority’s announcement of the service area need; (d) “SAC packet” means the packet of application documents that the Authority provides to CCOs applying for a service area change (SAC); (e) “Service Area” has the meaning provided for in OAR 410-141-3500; (f) “Service Area Change Process” or “SAC Process” means the process the Authority uses to evaluate and approve CCO requests to expand into a new service area when a service area need exists. (2) A CCO that desires to withdraw from all or a portion of its service area shall provide the Authority with a form Letter of Intent to Withdraw from the service area at least 120 calendar days prior to the intended date of withdrawal. The template for this form can be found on the CCO Contract Forms page. Partial withdrawals (i.e., withdrawal from only part of the service area) shall be allowed to be effective only upon written approval by the Authority. The Authority shall work with the CCO and any other impacted CCO for a workable withdrawal transition. (3) Upon receiving written notice from a CCO of its desire to withdraw from all or part of a service area, the Authority shall acknowledge receipt and commence the withdrawal process defined in the applicable contract and in OAR 410-141-3710 (Contract Termination and Close-Out Requirements). (a) Within a period not to exceed five (5) business days after receipt of the withdrawal notice, the Authority shall notify all contracted CCOs of: (A) The identity of the withdrawing CCO; (B) The geographic boundaries of the affected service area(s); (C) The number of members impacted; (D) The anticipated effective date of the withdrawal; and (E) The opportunity for expansion by contracted CCOs. (b) With the notice of withdrawal to the contracted CCOs, the Authority shall open a fourteen (14) calendar day interest period during which contracted CCOs may submit written notice of interest in expanding into the vacated service area. OHA shall provide instructions for the form and method of submitting interest; (c) CCOs submitting a written notice of interest shall, at minimum: (A) Identify the geographic areas the CCO seeks to serve; (B) Describe how the CCO will meet network adequacy requirements consistent with OAR 410-141-3515; (C) Outline the CCO’s proposed timeline and activities to ensure continuity of care, member protections, and care coordination consistent with OAR 410-141-3860 through 410-141-3870; and (D) Identify any anticipated subcontracting necessary to serve the area, consistent with OAR 410-141-3505. (d) After the interest period closes, the Authority shall review all timely submitted notices of interest to determine the feasibility of service area expansion by one or more interested contracted CCOs. If no CCO submits a notice of interest, or the one or combination of more than one CCOs submitting a notice of interest fails to meet the Authority’s criteria for assuming the vacated service area, the Authority shall initiate a service area change (SAC) process. (4) The Authority shall determine if a service area need exists, or is anticipated to exist, when: (a) A service area, or a portion of a service area, is being served by one CCO and that CCO is withdrawing; (b) A CCO is withdrawing from a service area, or a portion of a service area, that has one or more additional contracted CCOs and the remaining CCO(s) are unable to meet the contractual requirements to serve the service area’s population when considering: (A) Access to care; (B) Service delivery; (C) Member rights and health equity; and (D) Financial performance. (5) A service area need will not exist if: (a) The remaining CCOs in the service area are determined to meet the contractual requirements to service the service area’s population; or (b) One or more CCOs serving a contiguous area indicate interest to the Authority upon the initial announcement of the withdrawing CCO and are determined to meet the contractual requirements to service the service area’s population. (6) If the Authority determines that a service area need exists: (a) The Authority shall notify all existing CCOs that the SAC process is being initiated and that the Authority will begin accepting LOIAs. The announcement shall specify when the LOIA is due; (b) CCOs that want to be considered for expansion into the service area shall submit their LOIAs by the deadline indicated in the Authority’s notice of the SAC process being initiated. CCOs shall designate a sole point of contact in their LOIA for this process. The Authority will not accept an LOIA or any subsequent SAC application materials from a CCO that has not submitted an LOIA by the deadline indicated in the Authority’s notice; (c) The Authority shall send a letter of acknowledgement to the CCO within five (5) calendar days of receipt of the LOIA. (7) Within 30 calendar days of the date specified by the Authority as the due date for submission of an LOIA, the CCO shall complete a SAC packet in its entirety and submit it to the contract administration unit at the address indicated in the SAC packet. CCOs can locate a SAC packet on the CCO Contract Forms page. (8) CCOs applying through the SAC process outlined in this rule must meet the requirements set forth in ORS 414.572 and submit documentation as it applies to the new service area indicated in the application. Documentation requirements, based on criteria set forth in OAR 410-141-3700 and 410-141-3705, shall be included in the acknowledgement letter sent by the Authority as described in section 6(c) of this rule, which shall include, but is not limited to, information related to the following: (a) Delivery system network and provider capacity reports highlighting any providers operating in the new service area or existing contracted providers expanding their services into the new service area; (b) Any updates to the most recently submitted quarterly financial report; (c) An updated subcontractor report; (d) Information related to how services in the new service area will impact existing operations, including updated policies and procedures, as applicable; (e) Information related to identifying regional, cultural, socioeconomic, and racial disparities in health care that exist among the enrollees in the new service area and establishing community support for those areas of need; and (f) Information related to coordination of care and transfer of new members, specifically high-risk members or members with special health care needs. (9) The Authority shall review SAC packets from all CCOs that have timely submitted an LOIA and SAC packet as required by this rule and that are considered responsive and completed as set forth in this rule. (a) During its review of the SAC packets, the Authority may request additional information from a CCO. If additional information is requested, the CCO shall submit the additional information to the Authority within 14 days of the request. (b) Within 30 calendar days from the date the initial SAC packets were due, the Authority shall complete its document review. This includes the final submission date for the SAC packet and receipt by the Authority of all additional requested information. (c) To be eligible for recertification in the new service area, the applicant must meet standards established by the Authority and this rule, and be in compliance with the contract between the CCO and the Authority. (10) The Authority shall determine which CCO(s) will be selected to serve the new service area under the procedures and criteria set forth in OAR 410-141-3700(4) and 410-141-3705. (11) The Authority shall prepare a contract amendment for document review and signature for each CCO that receives approval to expand into the new service area. The CCO shall have 30 calendar days to return an executed contract amendment for the service area change. (12) Applicants shall have the right to dispute any Authority actions or decisions pertaining to service area changes as set forth in OAR 410-141-3550.