Or. Admin. R. 410-141-3580

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

Section 410-141-3580 - MCE Member Relations: Potential Member Information

(1) In addition to the requirements below, information for potential members shall comply with the marketing requirements and prohibitions in 42 CFR § 438.104 and OAR 410-141-3575 and any requirements or guidelines adopted by the Authority there under.

(2) MCEs shall develop informational materials for potential members and provide such materials to the Authority. An MCE or the Authority may include informational materials in the application packet for potential members.

(3) MCEs' informational materials shall be sufficient for the potential member to make an informed decision about provider selection.

(4) The MCE shall make available to potential members, upon request, information on participating providers. MCE provider directories for potential members shall include all specified elements and be made readily accessible as defined in 42 CFR 438.10.

(5) MCEs' informational materials shall include the following information for potential members regarding the rights of American Indians and Alaskan Natives:

(a) MCEs' informational materials shall state that American Indians and Alaskan Natives enrolled in the MCEs may select an Indian health care provider (IHCP) that is participating as a primary care provider within the network of the MCE, insofar as the individual is otherwise eligible to receive primary care services from such IHCP and the IHCP has the capacity to provide primary care services to such American Indians and Alaskan Natives.

(b) MCEs shall clearly explain to potential members that American Indians and Alaskan Natives enrolled in an MCE shall also be permitted to obtain primary care services covered under the contract between the state and MCE from out-of-network IHCPs from whom the enrollee is otherwise eligible to receive primary care services. American Indians and Alaskan Natives may be referred by out-of-network IHCPs to a network provider without prior authorization or referral from a participating provider.

(6) MCEs' informational materials for potential members in their service area shall meet the following language requirements:

(a) Materials shall be culturally and linguistically appropriate and be sensitive to people with disabilities or reading limitations, including those whose primary language is not English;

(b) MCEs shall accommodate requests made by potential members, potential members' family members, or potential members' caregivers for language accommodation, translating to the potential member's language needs as requested. Alternate formats shall be provided and may include but are not limited to braille, large (18 point) print, audio narration, oral presentation, and electronic file along with other aids and services for other disabilities, including sign language interpretation and sighted guide.

(c) MCEs shall address health literacy issues by preparing informational materials at a 6th grade reading level, incorporating graphics and utilizing alternate format materials for potential members and using a minimum 12-point font or large print (18 point). MCEs shall make written informational materials available in alternative formats upon request of the potential member at no cost. Auxiliary aids and services and interpreter services must also be made available upon request of the potential member at no cost.

(7) MCEs shall ensure that all staff who have contact with potential members are:

(a) Fully informed of MCE and Authority rules applicable to enrollment, disenrollment, complaint and grievance policies and procedures, the availability of free qualified or certified health care interpreters in any language required by the member including American Sign Language, and the process for requesting auxiliary aids or alternative format materials;

(b) Able to assist members in determining which participating providers:

(A) Have capacity in languages other than English;

(B) Have offices/facilities that are accessible and have accommodations for people with physical disabilities, including but not limited to offices, exam rooms, restrooms and equipment; and

(C) Are accepting new members.

(c) Trained in cultural competency and trauma-informed care, as those terms are defined in OAR 309-035-0105 and in accordance with CCO Health Equity Plan Training and Education plan described in 410-141-3735.

(8) MCE staff shall be able to provide potential members with information on how to access the Authority Beneficiary Support System, including information for full benefit dual-eligible (FBDE) members on how to receive choice counseling on Medicaid and Medicare options as required in 42 CFR 438.71.

Or. Admin. R. 410-141-3580

DMAP 55-2019, adopt filed 12/17/2019, effective 1/1/2020

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

Statutes/Other Implemented: ORS 414.610 - 414.685