Or. Admin. Code § 410-120-0045

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-120-0045 - Applications for Medical Assistance at Provider Locations

(1) The Oregon Health Authority (Authority) allows Division enrolled providers the opportunity to assist patients applying for public and private health coverage offered through the Authority and the Oregon Health Insurance Exchange (OHIX, as defined in ORS 741.300(6)). To apply for this opportunity, providers fill out and submit form OHA 3128, Application Assistance by Provider Staff; this is an addendum to the provider's agreement to provide Medicaid reimbursed services. Once the provider is determined certified by the Authority to provide application assistance, providers shall receive an approval letter, requirements for assister certification, training requirements, and other information.

(2) For purposes of this rule, the provider's practice shall be referred to as a site. Sites can be, but are not limited to, the following:

(a) Hospitals;

(b) Federally qualified health centers/rural health clinics (FQHC/RHCs);

(c) County health departments;

(d) Substance Use Disorder adult and adolescent treatment and recovery centers;

(e) Tribal health clinics;

(f) Family Planning clinics;

(g) Other primary care clinics as approved by the Authority.

(3) The site may sign the Application Assistance by Provider Staff (OHA 3128) addendum indicating the site's willingness to provide on-site application assistance. The addendum outlines site and application assister standards as well as conflict of interest protections. The site shall require employees that are assisting to participate in mandatory training sessions for application assistance certification. Employees shall pass tests before initiating application assistance service. Sites shall ensure that individuals performing application assistance are recertified at appropriate times as set forth by the Authority. For purposes of this rule, certified staff shall be referred to as "application assisters."

(4) Application assisters shall utilize authorized methods to provide enrollment assistance. Regardless of which form of application is used, the application assister shall write the date the application was started and the assister's assigned assister identification number in the appropriate space on the application. Application assisters shall maintain copies of all eligibility verification documents and all records related to enrollment assistance, including the required, current OHA-provided Consent Form for six (6) years, whether in paper, electronic, or other forms in a secure and locked location. Application assisters support patients potentially eligible for public and private health coverage offered through the Authority and O. Sites are not under an obligation to provide application assistance to individuals other than those for whom they are providing service. Once written on the application, the date can never be changed, altered, or backdated.

(5) The application assister shall encourage applicants to provide accurate and truthful information, assist in completing the application and enrollment process, and shall assure that the information contained on the application is complete. The application assister may not attempt to pre-determine applicant eligibility or make any assurances regarding the eligibility for public or private health coverage offered through the Authority and OHIX.

(6) The application assister shall provide information to applicants about public medical programs and private insurance products so each applicant can make an informed choice when enrolling into a health insurance product. Language interpreters or interpreter services or referrals must be provided if requested by applicants including linguistically and culturally appropriate materials:

(a) The information given to the applicant shall, at a minimum, include an explanation of the significance of the date of request on the application and a review of public medical programs and private insurance products that are available, provide unbiased health coverage choices and information provided by the Authority or OHIX during the enrollment process, answer questions, and assist in filling out online or paper application forms. The information provided at these sessions may include, but is not limited to, the following:

(A) General eligibility criteria for public and private coverage accessible through the Authority and OHIX;

(B) Health plan choices, criteria, and how to enroll in public medical programs or OHIX private insurance product choices.

(b) The application assister shall make copies of the original eligibility verification documentation required to accompany the application, but not uploaded to ONE applicant portal.

(7) Providers, staff, contracted employees, and volunteers are subject to all applicable provisions under General Rules OAR Chapter 410, Division 120, and Application Assistance by Provider Staff addendum (OHP 3128):

(a) The application assister shall treat all information they obtain for public medical programs and private insurance as confidential and privileged communications. The application assister may not disclose such information without the written consent of the individual, their delegated authority, attorney, or responsible parent of a minor child or child's guardian. Nothing prohibits the disclosure of information in summaries, statistical or other form, that does not identify particular individuals;

(b) The Authority and sites shall share information as necessary to effectively serve public medical programs and OHIX eligible or potentially eligible individuals;

(c) Personally identifiable health information about applicants and recipients shall be subject to the transaction, security, and privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA) and the administrative rules there under. Sites shall cooperate with the Authority in the adoption of policies and procedures for maintaining the privacy and security of records and for conducting transactions pursuant to HIPAA requirements.

(8) The Authority shall be responsible for the following:

(a) The Authority shall provide training to application assisters on public medical programs and private insurance products, eligibility and enrollment, application procedures, and documentation requirements. The Authority shall set dates and times for these additional training classes as needed, following changes in policy or procedure;

(b) The Authority shall make available public medical programs application forms online and in hard copy (in English, translated languages, and alternative formats), health insurance coverage options, assister identification number instructions, reporting guidance, and other necessary forms;

(c) The Authority shall process all applications in accordance with Authority and OHIX standards;

(d) The Authority shall process completed applications that have satisfactory verification information within the time requirements set forth in the Authority and OHIX policy. In the event of a change in policy, the time for completion of processing shall be changed to the new time requirements.

(9) The Authority shall provide all necessary forms and applications as referenced above at no cost to the site. There are no monetary provisions in this rule for any payment for the performance of work by the site, except for those costs provided under OAR 410-147-0400 and 410-146-0460, because there is compensation for Out stationed Outreach Worker (OSOW) activities outlined in OAR 410-147-0400 for FQHCs and RHCs and OAR 410-146-0460 for Indian Health Care Providers (IHCPs). However, the parties acknowledge the exchange and receipt of other valuable considerations in the spirit of cooperation to the benefit of all by collaborating and authorizing the performance of the work. The Authority does not guarantee a particular volume of business under these rules.

(10) The provider may terminate enrollment at any time as outlined in OAR 410-120-1260(15).

Or. Admin. Code § 410-120-0045

DMAP 12-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 49-2012, f. 10-31-12, cert. ef. 11-1-12; DMAP 48-2013, f. & cert. ef. 9-12-13; DMAP 71-2013, f. & cert. ef. 12-27-13; DMAP 52-2016, f. 8-26-16, cert. ef. 9/1/2016; DMAP 17-2023, minor correction filed 03/31/2023, effective 3/31/2023; DMAP 93-2024, amend filed 05/24/2024, effective 5/24/2024; DMAP 131-2024, amend filed 10/30/2024, effective 11/10/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.041