Or. Admin. R. 410-120-2000

Current through Register Vol. 63, No. 6, June 1, 2024

Section 410-120-2000 - HRSN SERVICES DELIVERY

The purpose of this rule is to establish the processes, standards, and obligations required to be followed or met in administering and delivering Health Related Social Needs (HRSN) Services.

(1) HRSN Services General Requirements; Notices of Availability. HRSN Services are similar to Covered Services (as such word is defined in OAR 410-120-0000); however, HRSN Services are not subject to the medically necessary and appropriate standard for coverage under Oregon Health Plan (OHP) but instead are included in and paid for under OHP in accordance with this rule.

(a) Similarities between HRSN Services and Covered Services include the right of Managed Care Entity's (MCEs) to be compensated for the provision of HRSN Services (in accordance with the HRSN Services Fee Schedule) and when Members request HRSN Services eligibility and authorization, the MCE's obligation to provide Members with:

(A) Notices outlined in this rule as well as the same notices, in form and content, that are required for Covered Services such as, for example, notices of Adverse Benefit Determinations under 42 CFR 438.404, and that comply with accessibility requirements under OARs 410-141-3580 and 410-141-3585, and 42 CFR 438.10;

(B) Service Authorizations in accordance with OAR 410-141-3835 (7), (8), (9)(d), (10), (11);

(C) Grievance and Appeal rights under OARs 410-141-3875 through OAR 410-14103915, OAR 410-120-1860, and 42 CFR Subpart F; and

(D) HRSN Services delivery that complies with the State 1115 Waiver, and in keeping with National Culturally and Linguistically Appropriate Services (CLAS) Standards at https://thinkculturalhealth.hhs.gov/clas/standards.

(b) MCEs shall notify all Members of the availability of HRSN Services, and the process by which they may obtain an HRSN Eligibility Screening, and the standards for authorization of HRSN Services.

(2) Identifying Members of HRSN Covered Populations. The MCE and the Authority shall ensure multiple pathways for Members to be identified as potentially eligible for HRSN Services.

(a) Pathways for identifying potentially eligible Members for HRSN Services must include:

(A) Proactively identifying Members through a review of the MCE or Authority's encounter and claims data;

(B) Engaging HRSN Service Providers to conduct HRSN Outreach and Engagement to identify Members;

(C) Receiving HRSN Requests from other entities and individuals; and

(D) Accepting the Members' Self-Attestations or referrals.

(b) The MCE and the Authority shall not require HRSN Connectors or Service Providers to use the MCE's or the Authority's HRSN Request Form template. Instead, the MCE and the Authority must accept the HRSN Request Form used by HRSN Connectors and Service Providers so long as the HRSN Request Form includes the information necessary for the MCE or, as applicable, the Authority to contact or otherwise determine whether the individual would like to receive HRSN Services and is interested in participating in an HRSN Eligibility Screening.

(3) Screening Members for HRSN Eligibility.

(a) The MCE and the Authority shall make good faith efforts to ensure that all Members who have been identified as potentially eligible for HRSN Services are offered an HRSN Eligibility Screening.

(b) When a Member is referred to an MCE or the Authority by an HRSN Service Provider or Connector that has submitted an HRSN Request Form, the MCE, or as applicable, the Authority, shall conduct HRSN Eligibility Screenings of Members who have been identified as potentially eligible for HRSN Services by collecting the information necessary to determine whether the Member:

(A) Is enrolled in OHP,

(B) Would like to receive HRSN Services,

(C) Belongs to an HRSN Covered Population,

(D) Has at least one Social Risk Factor applicable to the HRSN Services for which they are being screened,

(E) Has at least one Clinical Risk Factor applicable to the HRSN Services for which they are being screened, and

(F) Is not receiving the same or substantially similar service from another state, local, or federally funded program.

(c) For Members who provide the MCE or the Authority with a Self-Attestation, the MCE and the Authority shall rely on the Self-Attestation to complete the HRSN Eligibility Screening. If the Self-Attestation does not include all the information necessary to complete the HRSN Eligibility Screening the MCE and the Authority shall use good faith efforts to obtain and, as applicable, verify all information necessary to complete the HRSN Eligibility Screening by documenting the Member:

(A) Is enrolled in OHP,

(B) Would like to receive HRSN Services,

(C) Belongs to an HRSN Covered Population,

(D) Has at least one Social Risk Factor applicable to the HRSN Services for which they are being screened,

(E) Has at least one Clinical Risk Factor applicable to the HRSN Services for which they are being screened, and

(F) Is or is not receiving the same or substantially similar service from another state, local, or federally funded program.

(d) All efforts to collect information needed to determine HRSN Eligibility must be documented. If the information included in a Member's Self-Attestation cannot, using good faith efforts, be verified within a reasonable period of time the MCE and the Authority shall authorize the identified HRSN Services need(s) if the MCE or, as applicable, the Authority, has a reasonable basis for concluding the Self-Attestation is truthful.

(e) If the potentially eligible individual is not a Member of the OHP, the MCE or the Authority shall connect individuals to resources to determine OHP Eligibility as requested or consented to by the Member.

(4) Authorization HRSN Services.

(a) An MCE shall authorize its own Members, and the Authority shall authorize its Fee-for-Service (FFS) Members, to receive HRSN Services if the MCE or, as appliable, the Authority has completed the HRSN Services Screening and determined the applicable Member:

(A) Is enrolled in OHP;

(B) Would like to receive HRSN Services;

(C) Belongs to an HRSN Covered Population;

(D) Has determined the HRSN Services are Clinically Appropriate, and

(E) Is not receiving the same or substantially similar service from another state, local, or federally funded program.

(b) The Authorization must identify service duration, as appropriate, not to exceed twelve (12) months for an initial authorization, as well as amount and scope in accordance with 42 CFR § 438.210.

(c) MCEs and the Authority shall use reasonable efforts to ensure they do not knowingly authorize an HRSN service that is duplicative of a state or federally funded service or other HRSN Service the Member is already receiving.

(d) Document the approval or denial of HRSN Services.

(A) MCEs shall ensure the HRSN Services are furnished to all OHP Members in an amount, duration, and scope that is no less than the amount, duration, and scope for the same HRSN Services furnished to all OHP Members under the Authority's FFS delivery system;

(B) The MCE or, as applicable, the Authority is required to notify the Member of the approval or denial of HRSN Services within fourteen (14) days of the completing the HRSN Services Eligibility Screening.

(C) HRSN Services must be denied if the individual does not meet all the HRSN Eligibility Criteria for the HRSN Services for which they are screened.

(D) All notices of Service Authorization and Denials must:

(i) State the basis for the approval along with any utilization limitations based on amount, duration, or scope;

(ii) State the basis for denial;

(iii) Comply with OAR 410-141-3835(7), (8), (10), (11); and

(iv) Inform the Member of their Grievance and Appeal rights under OARs 410-141-3875 through 410-14103915, 410-120-1860, and 42 CFR Subpart F.

(e) If an HRSN Eligible Member is authorized for an HRSN Service (HRSN-Authorized Member), then, unless the HRSN-Authorized Member objects to the sharing of their personal information, the MCE or as applicable, the Authority must refer the HRSN-Authorized Member to an HRSN Service Provider that provides the Member's HRSN Service need.

(A) The referral must be made through a Closed Loop Referral. If the HRSN-Authorized Member objects to the sharing of their personal information with an HRSN Service Provider, then the HRSN-Authorized Member must be provided with a written referral that they may deliver to the HRSN Service Provider to which they have been referred.

(B) The MCE or, as applicable, the Authority must:

(i) To the extent capacity permits, support the HRSN-Authorized Member's choice of HRSN Service Provider;

(ii) Identify and refer the HRSN-Authorized Member to alternative HRSN Service Providers if needed and available;[1]

(iii) Inform the HRSN-Authorized Member they have the right to direct the MCE or, as applicable, the Authority, to use a different means of communicating with HRSN Service Providers other than technology, like CIE, and still receive HRSN Services; and

(iv) Ensure and document the Member's HRSN Service needs are being and have been met by the HRSN Service Provider in compliance with the Member's HRSN Person-Centered Service Plan.

(5) Confirmation of Climate-Related Supports Required. Prior to making a Closed Loop Referral, the MCE or, as applicable, the Authority must determine availability of the Climate-Related Supports (either devices or any necessary installation or other related service supports, or both) and notify the HRSN-Authorized Member of the anticipated date or time frame that the Climate-Related Supports shall be available. If for any reason there is limited availability of either devices or necessary installation or other related service supports, the MCE shall notify the State of the following information:

(a) There is a limitation of availability of the Climate-Related Supports,

(b) The reason for the limitation, and

(c) The MCE's plan to obtain additional equivalent devices or related service supports or both.

(6) No Subcontracting or Delegation of HRSN Service Authorization and Planning. The MCE shall not subcontract or otherwise Delegate the responsibility for HRSN Service authorization or service planning to an HRSN Service Provider or any other third-party that has involvement in, or responsibility for, denying or authorizing HRSN Services, or service planning for Members. However, for HRSN Climate-Related Support Services only, MCEs may conduct HRSN Eligibility Screening, HRSN Authorization, and HRSN Service planning and provision so long as the MCE has a documented policy and process for safeguarding against conflicts of interest in keeping with the standards set out in 42 CFR 441.730(b)(5)(A).

(7) Person-Centered Service Plan (PCSP). Upon authorization of HRSN Services, the MCE or, as applicable, the Authority and the Member shall update the HRSN-Authorized Member's Care Plan as outlined in OAR 410-141-3870[2] to include an HRSN PCSP for authorized the HRSN Service(s).

(a) The HRSN PCSP shall be in writing and developed with and agreed upon by the Member, the Member's guardian, or both, as applicable. The HRSN PCSP must include all of the following:

(A) The recommended HRSN Service(s),

(B) The authorized HRSN Service duration,

(C) The HRSN Service Provider,

(D) The goals of the HRSN Service(s),

(E) The anticipated follow-up and transition plan.

(a) The MCE or, as applicable, the Authority, shall, at a minimum, have as many meetings as may be necessary to develop the PCSP, but in no event less than one meeting with the Member (or the Member's guardian, or both, as applicable) during development of the PCSP. The meeting with the Member may be held in person, by telephone, or via videoconference. If efforts to have a meeting are unsuccessful, or if the Member declines participation, the MCE or, as applicable, the Authority shall document the attempts and barriers to having a meeting, and justification for continued provision of HRSN Service.

(c) A parent, guardian, or caregiver of a child may receive HRSN Service(s) on their child's behalf if the parent, guardian, or caregiver lives with the child and it is in the best interest of the child as determined through the PSCP.

Or. Admin. R. 410-120-2000

DMAP 35-2024, adopt filed 01/22/2024, effective 1/22/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.572, 414.605, 414.665, 414.719 & 414.632