Or. Admin. Code § 410-141-3515

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

Section 410-141-3515 - Network Adequacy

(1) Managed Care Entities (MCEs) shall maintain and monitor a network of participating providers that is sufficient in number, provider type, and geographic distribution to ensure adequate service capacity and availability to provide available and timely access to medically appropriate and culturally responsive covered services to both current members and those the MCE anticipate shall become enrolled as members.

(2) The MCE shall develop a provider network that enables members to access services within the standards defined in this rule.

(3) The MCE shall meet access-to-care standards that allow for appropriate choice for members. Services and supports shall be as close as possible to where members reside and, to the extent necessary, offered in nontraditional settings that are accessible to families, diverse communities, and underserved populations.

(4) MCEs shall meet quantitative network access standards defined in rule and contract.

(5) MCEs shall ensure access to integrated and coordinated care as outlined in OAR 410-141-3860, which includes access to a primary care provider or primary care team that is responsible for coordination of care and transitions.

(6) In developing its provider network, the MCEs shall anticipate access needs so that the members receive the right care at the right time and place, using a patient-centered, trauma informed approach. The provider network shall support members, especially those with behavioral health conditions, in the most appropriate and independent setting, including in their own home or independent supported living.

(7) In assessing the capacity and adequacy of its provider network, MCEs shall consider, in conjunction with the quantitative standards set forth in this rule, the variety of provider and facility types with the demonstrated ability and expertise to render specific medically or dentally appropriate covered services within the scope of applicable licensing and credentialling. This includes, but is not limited to, the prescribing of Medication-Assisted Treatment and more specialized oral health care services.

(8) All MCEs shall ensure 95 percent of members can access the following provider and facility types, further defined by the Authority in guidance made available on the CCO Contracts Forms webpage https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx, within acceptable travel time or distance standards set forth this rule:

(a) Tier one:

(A) Primary care providers serving adults and those serving pediatrics;

(B) Primary care dentists serving adults and those serving pediatrics;

(C) Mental health providers serving adults and those serving pediatrics;

(D) Substance use disorder providers serving adults and those serving pediatrics

(E) Pharmacy;

(F) Additional provider types when it promotes the objectives of the Authority or as required by legislation.

(b) Tier two:

(A) Obstetric and gynecological service providers;

(B) The following specialty providers, serving adults and those serving pediatrics;

(i) Cardiology;

(ii) Neurology;

(iii) Occupational Therapy;

(iv) Medical Oncology;

(v) Radiation Oncology;

(vi) Ophthalmology;

(vii) Optometry;

(viii) Physical Therapy;

(ix) Podiatry;

(x) Psychiatry;

(xi) Speech Language Pathology.

(C) Hospital;

(D) Durable medical equipment;

(E) Methadone Clinic;

(F) Additional provider types when it promotes the objectives of the Authority or as required by legislation.

(c) Tier three:

(A) The following specialty providers, serving adults and those serving pediatrics;

(i) Allergy & Immunology;

(ii) Dermatology;

(iii) Endocrinology;

(iv) Gastroenterology;

(v) Hematology;

(vi) Nephrology;

(vii) Otolaryngology;

(viii) Pulmonology;

(ix) Rheumatology;

(x) Urology.

(B) Post-hospital skilled nursing facilities;

(C) Additional provider types when it promotes the objectives of the Authority or as required by legislation.

(9) All MCE acceptable travel time and distance monitoring must assess the geographic distribution of providers relative to members and calculate driving time and distance from the member's physical address to the provider's location through the use of geocoding software or other mapping applications. The Authority shall provide tools and additional guidance specific to time and distance monitoring on the CCO Contracts Forms webpage https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

(a) A CCO service area may contain multiple geographic designations. When calculating travel time and distance, geographic designations shall not overlap and the following definitions of geographic designations shall apply:

(A) Large urban area: Conjoined urban areas with a total population of at least 1 million people or with a population density greater than 1,000 people per square mile.

(B) Urban area: An area with greater than 40,000 people within a 10 mile radius of a city center.

(C) Rural area: An area greater than 10 miles from the center of an urban area.

(D) County with extreme access considerations: County with a population density of 10 or fewer people per square mile.

(b) When calculating travel time and distance, MCEs shall use the following standards:

(A) Large Urban Area:

(i) Tier one: 10 minutes or 5 miles;

(ii) Tier two: 20 minutes or 10 miles;

(iii) Tier three: 30 minutes or 15 miles.

(B) Urban Area:

(i) Tier one: 25 minutes or 15 miles;

(ii) Tier two: 30 minutes or 20 miles;

(iii) Tier three: 45 minutes or 30 miles.

(C) Rural Area:

(i) Tier one: 30 minutes or 20 miles;

(ii) Tier two: 75 minutes or 60 miles;

(iii) Tier three: 110 minutes or 90 miles.

(D) County with Extreme Access Considerations:

(i) Tier one: 40 minutes or 30 miles;

(ii) Tier two: 95 minutes or 85 miles;

(iii) Tier three: 140 minutes or 125 miles.

(10) MCEs may request an exception to a standard set above. MCEs may request multiple exceptions.

(a) Exception requests must be submitted in a format provided by the Authority and made available on the CCO Contract Forms webpage https://www.oregon.gov/oha/HSD/OHP/Pages/CCO-Contract-Forms.aspx.

(b) The Authority shall review and approve or deny exception requests based on criteria made available on the CCO Contracts Forms webpage. Approved exceptions must be reviewed at least annually.

(11) MCEs shall have an access plan that establishes a protocol for monitoring and ensuring access, outlines how provider capacity is determined, and establishes procedures for monthly monitoring of capacity and access and for improving access and managing access in times of reduced participating provider capacity. The access plan and associated monitoring protocol shall address the following:

(a) Expected utilization of services based on anticipated member enrollment and health care needs of the member population;

(b) The number and types of providers required to furnish the contracted services based on the expected utilization of services referenced above and the number and types of providers actively providing services within the MCE's current provider network;

(c) How the MCE shall meet the accommodation and language needs of individuals with LEP as defined in OAR 410-141-3500 and people with disabilities in their service area in compliance with state and federal rules including but not limited to ORS 659A, Title VI of the Civil Rights Act of 1964, Section 1557 of the Affordable Care Act, the Americans with Disabilities Act, and Section 504 of the Rehabilitation Act of 1973;

(d) The availability of telemedicine within the MCE's contracted provider network.

(12) MCEs shall make the services it provides (including primary care, specialists, pharmacy, hospital, vision, ancillary, and behavioral health services or other services as necessary to achieve compliance with the requirements of 42 CFR 438, subpart K) as accessible to members for timeliness, amount, duration, and scope as those services are to other patients within the same service area. If the MCE is unable to provide those services locally by providers qualified and specialized to treat a member's condition, it must arrange for the member to access care from providers outside the service area.

(13) MCEs shall have policies and procedures and a monitoring system to ensure that members who are aged, blind, or disabled, or who have complex or high health care needs, multiple chronic conditions, or have behavioral health conditions, or who are children receiving Department or Oregon Youth Authority (OYA) services have access to primary care, oral care (when the MCE is responsible for oral care), behavioral health providers, and referral, and involve those members in accessing and managing appropriate preventive, health, remedial, and supportive care and services. MCEs shall monitor and have policies and procedures to ensure:

(a) Access to providers of pharmacy, hospital, vision, ancillary, and behavioral health services;

(b) Priority access for pregnant women and children ages birth through five (5) years to health services, developmental services, early intervention, targeted supportive services, oral and behavioral health treatment.

(14) MCEs shall have policies and procedures that ensure scheduling and rescheduling of member appointments are appropriate to the reasons for and urgency of the visit. The member shall be seen, treated, or referred within the following timeframes:

(a) Physical health:

(A) Emergency care: Immediately or referred to an emergency department depending on the member's condition;

(B) Urgent care: Within 72 hours or as indicated in initial screening and in accordance with OAR 410-141-3840;

(C) Well care: Within four (4) weeks, or as otherwise required by applicable care coordination rules, including OAR 410-141-3860 through 410-141-3870.

(b) Oral and Dental care for children and non-pregnant individuals:

(A) Dental Emergency services as defined in OAR 410-120-0000: Seen or treated within 24 hours;

(B) Urgent dental l care: Within two (2) weeks;

(C) Routine oral care: Within eight (8) weeks, unless there is a documented special clinical reason that makes a period of longer than eight (8) weeks appropriate.

(c) Oral and Dental care for pregnant individuals:

(A) Dental Emergency services. Seen or treated within 24 hours;

(B) Urgent dental care, within one (1) week;

(C) Routine oral care: Within four (4) weeks, unless there is a documented special clinical reason that must make access longer than four (4) weeks appropriate.

(d) Behavioral health:

(A) Urgent behavioral health care for all populations: Within 24 hours;

(B) Specialty behavioral health care for priority populations:

(i) In accordance with the timeframes listed in this rule for assessment and entry, terms are defined in OAR 309-019-0105, with access prioritized per OAR 309-019-0135. If a timeframe cannot be met due to lack of capacity, the member must be placed on a waitlist and provided interim services within 72 hours of being put on a waitlist. Interim services must be comparable to the original services requested based on the level of care and may include referrals, methadone maintenance, HIV/AIDS testing, outpatient services for substance use disorder, risk reduction, residential services for substance use disorder, withdrawal management, and assessments or other services described in OAR 309-019-0135;

(ii) Pregnant women, veterans and their families, women with children, unpaid caregivers, families, and children ages birth through five years, individuals with HIV/AIDS or tuberculosis, individuals at the risk of first episode psychosis and the I/DD population: Immediate assessment and entry. If interim services are necessary due to capacity restrictions, treatment at appropriate level of care must commence within 120 days from placement on a waitlist;

(iii) IV drug users including heroin: Immediate assessment and entry. Admission for treatment in a residential level of care is required within fourteen (14) days of request, or, if interim series are necessary due to capacity restrictions, admission must commence within 120 days from placement on a waitlist;

(iv) Opioid use disorder: Assessment and entry within 72 hours;

(v) Medication assisted treatment: As quickly as possible, not to exceed 72 hours for assessment and entry;

(vi) Children with serious emotional disturbance as defined in OAR 410-141-3500: Any limits that the Authority may specify in the contract or in sub regulatory guidance.

(C) Routine behavioral health care for non-priority populations: Assessment within seven days of the request, with a second appointment occurring as clinically appropriate.

(15) HRSN Services. All MCEs or, as applicable, the Authority, must make a referral to an HRSN Service Provider that is capable of delivering the authorized HRSN Service(s) as expeditiously as a Member's circumstances requires. The time period for delivery of the HRSN Service must not exceed four (4) weeks, which is the same time frame for scheduling appointments for Well Care as set forth in this OAR. The HRSN Service(s) is considered "delivered" once the Member receives the HRSN Service that was authorized.

(a) The timelines identified in this rule are not required to be met in circumstances of impossibility related to HRSN Service Vendor availability, as determined by the Authority in its sole discretion.

(b) The timelines identified in of this rule are not applicable to Members who are receiving HRSN Outreach and Engagement Services only. Instead, HRSN Outreach and Engagement Services must be delivered within a reasonable period of time in light of the Member's availability.

(c) For Members who have not authorized the sharing their information with an HRSN Service Provider, the four (4) week timeline identified in section (11) of this rule, shall commence when the HRSN-Authorized Member has delivered the referral to the referred HRSN Service Providers and the HRSN Service Provider has confirmed with the MCE or, as applicable, the Authority, receipt of the referral.

(d) MCEs and the Authority, are not responsible for preventing Imminent Eviction. MCEs and the Authority shall refer Members facing imminent eviction to local or state providers or programs that has the ability to address a Member's imminent eviction. MCEs and the Authority must still screen these Members for eligibility for other HRSN Services, including other HRSN Housing Supports, and if Authorized for the other HRSN Service, refer the HRSN Authorized Member to the applicable HRSN Service Providers.

(16) MCEs shall implement procedures for communicating with and providing care to members who have difficulty communicating due to a medical condition, who need accommodation due to a disability, or, as detailed in OAR chapter 950, division 050 for those who have Limited English Proficiency, prefer to communicate in a language other than English or who communicates in signed language.

(a) The policies and procedures shall ensure the provision of Oregon certified or Oregon qualified interpreter services by phone or in person anywhere the member is attempting to access care or communicate with the MCE or its representatives;

(b) MCEs shall ensure the provision of certified or qualified interpreter services for all covered services to interpret for members with hearing impairment or in the primary language of non-English-speaking members;

(c) All interpreters must be linguistically appropriate and capable of communicating in both English and the member's primary language and be able to translate clinical information effectively. Interpreter services must enable the provider to understand the member's complaint, make a diagnosis, respond to the member's questions and concerns, and communicate instructions to the member;

(d) MCEs shall ensure the provision of services that are culturally appropriate as described in National CLAS Standards, demonstrating both awareness for and sensitivity to cultural differences and similarities and the effect on the member's care. MCEs shall ensure the provision of Oregon certified or Oregon qualified interpreters.

(e) MCEs shall comply with requirements of the Americans with Disabilities Act of 1990, as amended via the ADA Amendments Act of 2008, in providing access to covered services for all members and shall arrange for services to be provided by non-participating providers when necessary;

(f) MCEs shall collect and actively monitor data on language accessibility to ensure compliance with these language access requirements;

(g) MCEs shall report to the Authority such language access data and other language access related analyses in the form and manner set forth in this rule and as may otherwise be required in the MCE contract. The Authority shall provide supplemental instructions about the use of any required forms:

(A) Using the interpreter services self-assessment reporting template provided by the Authority, MCEs shall conduct an annual language access self-assessment and submit the completed language access self-assessment to the Authority on or before the third Monday of each January;

(B) MCEs shall collect and report language access and interpreter services to the Authority quarterly using the report form provided by the Authority. The quarterly due date for each Report is the first day of each calendar quarter, reporting data for the twelve (12) months ending one quarter before the due date.

(C) MCEs shall complete and submit to the Authority any other language access reporting that may be required in the MCE contract.

(17) MCEs shall collect and actively monitor data on provider-to-enrollee ratios, interpretation utilization by the MCE and the MCE's provider network, travel time and distance to providers, percentage of contracted providers accepting new members, wait times to appointment (including specific data for behavioral health wait times), and hours of operation. MCEs shall also collect and actively monitor data on call center performance and accessibility for both member services and NEMT brokerage services call centers.

(18) MCEs must submit a Delivery System Network (DSN) report annually to the Authority that includes access data and other access-related analyses in the form and manner required by the Authority, including but not limited to capacity reports on:

(a) Behavioral health access;

(b) Interpreter utilization by the MCE's provider network;

(c) Behavioral health provider network.

(19) MCEs shall report the methodology for monitoring network adequacy to the Authority and the Authority-contracted External Quality Review Organization (EQRO).

(20) MCEs shall implement and require its providers to adhere to the following appointment and wait time requirements:

(a) A member may request to reschedule an appointment if the wait time for a scheduled appointment exceeds 30 minutes. If the member requests to reschedule, they shall not be penalized for failing to keep the appointment;

(b) MCEs shall implement written procedures and a monitoring system for timely follow-up with members when a participating provider has notified the MCE that the member failed to keep scheduled appointments. The procedures shall address:

(A) Timely rescheduling of missed appointments, as deemed medically appropriate;

(B) Documentation in the clinical record or non-clinical record of missed appointments;

(C) Recall or notification efforts; and

(D) Method of member follow-up.

(c) If failure to keep a scheduled appointment is a symptom of the member's diagnosis or disability or is due to lack of transportation to the MCE's participating provider office or clinic, or lack of interpreter services, MCEs shall provide outreach services and offer Care Coordination as medically appropriate to make a plan with the member to resolve barriers;

(d) Recognition of whether NEMT services were the cause of the member's missed appointment.

(21) MCEs shall assess the needs of their membership and make available supported employment and Assertive Community Treatment services when members are referred and eligible:

(a) MCEs shall report the number of individuals who receive supported employment and assertive community treatment services, at a frequency to be determined by the Authority. When no appropriate provider is available, the MCE shall consult with the Authority and develop an approved plan to make supported employment and Assertive Community Treatment (ACT) services available;

(b) If ten (10) or more members in a MCE region have been referred, are eligible, and are appropriate for assertive community treatment, and have been on a waitlist to receive ACT for more than thirty (30) days, MCEs shall take action to reduce the waitlist and serve those individuals by:

(A) Increasing team capacity to a size that is still consistent with fidelity standards; or

(B) Adding additional Assertive Community Treatment teams; or

(C) When no appropriate ACT provider is available, the MCE shall consult with the Authority and develop an approved plan to increase capacity and add additional teams.

(22) HRSN Service Provider Minimum Network Requirements.

(a) An MCE must offer HRSN Services in all service areas in which the MCE operates.

(b) The MCE must ensure that HRSN Services are delivered to Members within the timelines outlined in OAR 410-120-2000.

Or. Admin. Code § 410-141-3515

DMAP 55-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021; DMAP 56-2021, amend filed 12/30/2021, effective 1/1/2022; DMAP 60-2022, amend filed 06/24/2022, effective 7/1/2022; DMAP 89-2022, amend filed 12/16/2022, effective 1/1/2023; DMAP 86-2023, amend filed 12/13/2023, effective 1/1/2024; DMAP 35-2024, amend filed 01/22/2024, effective 1/22/2024; DMAP 130-2024, amend filed 10/24/2024, effective 11/1/2024

Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651

Statutes/Other Implemented: ORS 414.610 - 414.685, 414.572, 414.605, 414.665 & 414.719