Or. Admin. Code § 410-120-2015

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-120-2015 - HRSN Eligibility Screening.

(1) After receipt of an HRSN Request, an MCE and, as applicable, the Authority, shall offer to screen the Member for whom the HRSN Request was made. If the Member consents to the screening, the MCE or, as applicable, the Authority shall conduct an HRSN Eligibility Screening in accordance with OAR 410-120-0000 and this rule to determine whether to authorize the HRSN Service requested.

(2) If the HRSN Connector does not include all the information in the HRSN Request that is necessary for determining whether the Member is eligible to receive an HRSN Service, the MCE or, as applicable, the Authority, shall obtain all the information necessary in order to conduct the HRSN Eligibility screening, including identifying the specific service the individual needs.

(a) If an MCE determines the individual is enrolled in OHP but is enrolled in a different MCE or is enrolled in FFS, the MCE shall forward the HRSN Request to, as applicable, the MCE in which the Member is enrolled or the Authority;

(b) If the Authority determines the individual is enrolled in OHP but is enrolled in an MCE, the Authority shall forward the HRSN Request to the MCE in which the Member is enrolled.

(3) For Members who provide an MCE or the Authority with a Self-Attestation, the MCE, or as applicable, 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, or as applicable, the Authority, shall use good faith efforts to obtain and verify all information necessary to complete the HRSN Eligibility Screening.

(4) All MCEs and the Authority shall document the results of each HRSN Eligibility Screening, which must include at minimum, all of the following:

(a) The individual is enrolled in OHP Plus, including the Member's OHP number;

(b) The HRSN Service requested, and whether the source of the HRSN Request was, (i) Member self-referral/attestation, (ii) Member Representative, (iii) HRSN Connector (other than an HRSN Service Provider), (iii) HRSN Service Provider, or (iv) direct outreach from an MCE or the Authority;

(c) The HRSN Covered Population to which the Member belongs;

(d) The Member's HRSN Clinical Risk Factor(s) applicable to the requested HRSN Service as set forth in the Tables 1 and 2 included in OAR 410-120-2005;

(e) The Member's HRSN Social Risk Factors, as applicable to the requested HRSN Service as set forth in the Tables included in OAR 410-120-2005;

(f) The Member's HRSN Services authorized (or denied);

(g) All other eligibility criteria that may be applicable to the requested HRSN Service as set forth in the Tables included in OAR 410-120-2005;

(h) All required documentation that may be applicable to the requested HRSN Service as set forth in the Tables included in OAR 410-120-2005;

(i) Confirmation or a determination that the Member is not receiving the same service as the requested HRSN Services from a local, state, or federally funded program, based on existing documentation or Member attestation.

(A) If the determination is made based on Member Self-Attestation without existing, supporting documentation, the determination must be reasonable in light of the existing documentation and circumstances.

(B) If the Member is receiving a similar service as the HRSN Service requested, the HRSN Service may be provided to an HRSN Authorized Member to fill gaps or otherwise supplement current program, but in no event shall a Member be authorized to receive duplicate existing services.

(5) MCEs and the Authority must document all efforts to collect information to determine HRSN Service Eligibility. 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, or, as applicable, the Authority, must 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.

(6) HRSN Eligibility Screenings must be completed within sufficient time to meet the deadline for authorizing or denying the HRSN Service within fourteen (14) days of receipt of the HRSN Request, in accordance with OAR 410-141-3835.

(7) If the potentially eligible individual is not enrolled in OHP or is enrolled in OHP but is not enrolled in OHP Plus, the MCE or the Authority shall connect individuals to resources to determine OHP Eligibility as requested or consented to by the Member.

Or. Admin. Code § 410-120-2015

DMAP 130-2024, adopt filed 10/24/2024, effective 11/1/2024

Statutory/Other Authority: ORS 413.042

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