OAR 410-141-3800: CCO Enrollment for Children Receiving Health Services

(1) Pursuant to OAR 410-141-3805, the Authority or Oregon Youth Authority (OYA) shall select CCOs for a child receiving services in an area where a CCO is available. (2) The Authority shall to the maximum extent possible ensure that all children are enrolled in CCOs at the next available enrollment date following eligibility determination, redetermination, or upon review by the Authority unless the Authority authorizes disenrollment from a CCO: (a) Except as provided in OAR 410-141-3805 (Coordinated Care Enrollment Requirements), 410-141-3810 (Disenrollment from Coordinated Care Health Plans), or ORS 414.631(2), children are not exempt from mandatory enrollment in a CCO on the basis of third-party resources (TPR) coverage consistent with OAR 410-141-3805; (b) The Authority shall review decisions to use fee-for-service (FFS) open card for a child if the child’s circumstances change and, at the time of redetermination, shall consider whether the Authority shall enroll the child in a CCO. (3) When a child is transferred from one CCO to another CCO or from FFS to a CCO, the CCO shall facilitate coordination of care consistent with OAR 410-141-3860: (a) CCOs shall work closely with the Authority to ensure continuous CCO enrollment for children; (b) If the Authority determines that it should disenroll a child from a CCO, the CCO shall continue to provide health services until the Authority’s established disenrollment date to provide for an adequate transition to the next CCO; (4) When a child experiences a change of placement that may be permanent or temporary, the Authority shall verify the address change information to determine whether the child no longer resides in the CCO’s service area: (a) A temporary absence as a result of a temporary placement out of the CCO’s service area does not represent a change of residence if the Authority determines that the child is reasonably likely to return to the CCO’s service area at the end of the temporary placement; (b) Children receiving children, adult, and family services from the Department who are eligible to be enrolled with the CCO serving the geographic area of placement: Department representatives may request a service area exception (SAE) to maintain CCO coverage on a placement they consider temporary; (c) Children in OYA custody who are eligible to be enrolled with the CCO serving the geographic area of placement: OYA representatives may request a service area exception (SAE) to maintain CCO coverage on a placement they consider temporary. (5) If the Authority enrolls the child in a CCO on the same day the child is admitted to psychiatric residential treatment services (PRTS), the CCO shall coordinate care and pay for covered health services during that placement even if the location of the facility is outside the CCO’s service area: (a) The child is presumed to continue to be enrolled in the CCO with which the child was most recently enrolled. The Authority considers an admission to a PRTS facility a temporary placement for purposes of CCO enrollment; (b) Any address change associated with the placement in the PRTS facility is not a change of residence for purposes of CCO enrollment and may not be a basis for disenrollment from the CCO unless the provisions in OAR chapter 410, division 141 apply; (c) If the Authority determines that a child was disenrolled for reasons not consistent with these rules, the Authority shall re-enroll the child with the appropriate CCO and assign an enrollment date that provides for continuous coverage with the appropriate CCO. If the child was enrolled in a different CCO in error, the Authority shall disenroll the child from that CCO and recoup the CCO payments. (6) Except for OAR 410-141-3805 and 410-141-3810, if a child is enrolled in a CCO after the first day of an admission to PRTS, the enrollment effective date shall be immediately upon discharge.