Or. Admin. Code § 410-120-2020 - Authorization of HRSN Services; Referral to HRSN Service Provider

(1) If, after completing the HRSN Eligibility Screening in accordance with OAR 410-120-2015, an MCE or, as applicable, the Authority, determines the Member meets all of the applicable HRSN Eligibility criteria, the MCE or the Authority shall authorize the identified HRSN Services and provide the Member notice as expeditiously as the circumstances require, which must not exceed fourteen (14) days following the receipt of the HRSN Request in accordance with OAR 410-141-3835.

(2) If, after completing the HRSN Eligibility Screening in accordance with OAR 410-120-2015, the MCE or, as applicable, the Authority, determines the Member does not meet all of the applicable HRSN Eligibility requirements, Contractor shall deny the HRSN Service request as expeditiously as possible, which must not exceed fourteen (14) days following the receipt of the HRSN Request, in accordance with OAR 410-141-3835. Contractor shall document the reason for the denial.

(3) The Authorization must identify service duration, as is Clinically Appropriate. The duration of an Authorized HRSN Service shall not exceed the allowable service duration detailed in the tables in OAR 410-120-2005. The duration may be less if required per the applicable tables in OAR 410-120-2005, as well as the amount and scope in accordance with 42 CFR 438.210.

(4) MCEs and the Authority must use reasonable efforts to ensure that HRSN Eligible Members who are receiving a similar service from a state, local, or federally funded organization or agency are only Authorized for any similar HRSN Services in accordance with OAR 410-120-2015.

(5) MCEs and the Authority must require clinical staff to review HRSN Service denials or reductions in scope, amount, or duration requested only when the following clinically-based eligibility circumstances exist:

(a) Specific to HRSN Climate-Related Supports: A decision by an MCE or the Authority to deny a Member's request for a climate-related device based on a determination that the Member does not meet the HRSN Climate Device Social Risk Factor must include review by clinical staff to ensure the climate-related device was not Clinically Appropriate as a component of health services treatment or prevention as set forth in Table 1 included in OAR 410-120-2005.

(b) Specific to HRSN Housing-Related Supports: A decision by an MCE or the Authority to deny a Member's request for a home modification or remediation service or reduce the scope, amount or duration of the home modification or remediation service due to a determination that the Member does not meet the HRSN Housing-Related Social Risk Factor of requiring a home modification or remediation service to treat, improve, stabilize, or prevent their HRSN Clinical Risk Factor, must include a review by clinical staff to ensure the denial or limitation was not Clinically Appropriate as set forth in OAR 410-120-0000.

(c) For all types of HRSN Services: Any decision by an MCE or the Authority to deny or reduce a Member's request for an HRSN Service based on a determination that the Member did not have the HRSN Clinical Risk Factor applicable to the HRSN Service for which they were screened, must include review by clinical staff to ensure such determination was made in accordance with applicable clinical standards.

(d) Clinicians who review decisions to deny or reduce the scope, amount or duration of an HRSN Service must have appropriate expertise in addressing the Member's HRSN needs.

(6) All MCEs and the Authority must document the approval, or denial, or reduction of HRSN Services.

(7) HRSN Services must be authorized before the expiration of HRSN Covered Populations eligible timeframes:

(a) For Adults and Youths Discharged from an HRSN Eligible Behavioral Health Facility and Adults and Youth Released from Incarceration, services must be authorized prior to the 366th day post-discharge.

(b) For Individuals Transitioning to Dual Status, services must be authorized within 90 days prior to the date Medicare coverage takes effect or prior to the 271st day after Medicare coverage takes effect.

(8) In accordance with 42 CFR 438.210, all MCEs must:

(a) Make available to their Members the same HRSN Services, in type, amount, duration and scope that the Authority offers to Fee-for-Service Members; and

(b) Screen and Authorize of HRSN Services for their HRSN Eligible Members in a manner that is no less restrictive than the Authority Screens and Authorizes HRSN Services for HRSN Eligible Fee-for-Service Members.

(9) All MCEs or, as applicable, the Authority, must notify HRSN Service Providers of an individual's HRSN Service authorization or denial if the HRSN Service Provider submitted the HRSN Request for the individual and:

(a) May be or may have been the HRSN Service Provider that would have provided the requested HRSN Service; or

(b) Provided HRSN O&E Services to the individual who was authorized or denied the HRSN Service.

(10) Members who have been screened and authorized to receive and have received HRSN Services, must not be rescreened for the same HRSN Services, except as set out in OAR 410-120-2005 and below. Members may be rescreened for a HRSN Housing-Related and Nutrition-Related Support Service authorization when:

(a) The Member was screened but not authorized for the HRSN Service but their circumstances have since changed;

(b) The Member was screened and authorized for the HRSN Service but they never received the approved HRSN Service.

(11) HRSN Authorized Members must be referred to an HRSN Service Provider that provides the HRSN Service that has been authorized. The referral must be made through a Closed Loop Referral unless the MCE or Authority is providing the HRSN Service in accordance with OAR 410-120-2000 (7)(a).

(a) The MCE or the Authority must inform the HRSN-Authorized Member they have the right to opt out of technology, like CIE, for Closed Loop Referrals and still receive HRSN Services;

(b) Before an HRSN-Authorized Member is referred to the applicable HRSN Service Provider, the MCE, or as applicable, the Authority, must, if the HRSN Service Provider is not already a Medicaid covered entity, obtain prior written authorization from the HRSN Authorized Member to share the information necessary to make the referral. The prior written authorization must comply with all applicable state and federal laws, which may include without limitation, HIPAA regulations such as 45 CFR 164.508;

(c) The provision of HRSN Services must not require an HRSN-Authorized Member to authorize the sharing of their personal information with the HRSN Service Provider;

(d) If the HRSN Authorized Member declines to authorize the sharing of their personal information in writing with an HRSN Service Provider, then the MCE or the Authority must provide the HRSN Authorized Member with a written referral that they may deliver to the HRSN Service Provider to which they have been referred.

(12) When referring HRSN-Authorized Members to HRSN Service Providers, MCEs and the Authority must:

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

(b) Identify and refer the HRSN Authorized Member to different HRSN Service Providers if the original provider is not able to provide the HRSN Service in a timely manner, and available in accordance with Care Coordination requirements outlined in OARs 410-141-3860, 410-141-3865, and 410-141-3870.

(13) 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 require. 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 OAR 410-141-3515. The four (4) week time period starts at the point of service authorization. The HRSN Service(s) is considered "delivered" once the Member receives at least one unit of the HRSN Service that was authorized. Some service authorizations will continue beyond one month, but at minimum, the first unit must be delivered within four (4) weeks.

(14) In the event the HRSN Service Provider is not able to provide the authorized service within the required timeline described in section (13) of this rule, the MCE may deliver the authorized HRSN Service provided conflicts of interest are guarded against as required and in keeping with OAR 410-120-2000(7)(a)-(c).

(15) The timeline identified in section (13) of this rule is not required to be met in circumstances of impossibility related to HRSN Service Vendor availability, as determined by the Authority in its sole discretion.

(16) The timeline identified in section (13) of this rule is 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.

(17) For Members who have not authorized the sharing of their information with an HRSN Service Provider, the four (4) week timeline identified in section (13) of this rule shall commence when the HRSN-Authorized Member has delivered the referral to the referred HRSN Service Provider and the HRSN Service Provider has confirmed with the MCE or, as applicable, the Authority, receipt of the referral.

(18) If a Member is facing Imminent Eviction as defined in OAR 410-120-0000 when the Member first requests an HRSN Housing Supports service, and the MCE or the Authority cannot provide the Member with the rent service category within the time frame necessary to keep the Member housed, MCEs and the Authority must, whenever possible, refer that Member to local or state providers or programs that may have the ability to address the Member's Imminent Eviction. If the MCE or Authority cannot provide the rent service requested in the needed time frame, the MCE or Authority may send a service denial.

(19) Even though the Authority and MCEs are not responsible for preventing Imminent Eviction in circumstances described in section (18), 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 Provider(s).

Notes

Or. Admin. Code § 410-120-2020

DMAP 130-2024, adopt filed 10/24/2024, effective 11/1/2024; DMAP 42-2025, amend filed 04/29/2025, effective 5/1/2025

Statutory/Other Authority: ORS 413.042

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