OFFICE OF THE SECRETARY OF STATE ARCHIVES DIVISION DENNIS RICHARDSON MARY BETH HERKERT SECRETARY OF STATE DIRECTOR LESLIE CUMMINGS 800 SUMMER STREET NE DEPUTY SECRETARY OF STATE SALEM, OR 97310 503-373-0701 TEMPORARY ADMINISTRATIVE ORDER FILED INCLUDING STATEMENT OF NEED & JUSTIFICATION 10/25/2018 4:39 PM ARCHIVES DIVISION SECRETARY OF STATE & LEGISLATIVE COUNSEL DMAP 94-2018 CHAPTER 410 OREGON HEALTH AUTHORITY HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS FILING CAPTION: Moving SRTF Admission Criteria from OAR 309-035-0163 to 410-172-0720(7) EFFECTIVE DATE: 10/28/2018 THROUGH 04/25/2019 AGENCY APPROVED DATE: 10/25/2018 CONTACT: Sandy Cafourek 500 Summer St. NE Filed By: 503-945-6430 Salem,OR 97301 Sandy Cafourek sandy.c.cafourek@dhsoha.state.or.us Rules Coordinator NEED FOR THE RULE(S): The Authority’s Health System Division needs to move SRTF Admission Criteria from OAR 309-035-0163 to 410-1720720(7), based on advice from the Department of Justice as being a more appropriate location. Using stakeholder feedback, adjusting admissions criteria for SRTF will result in ensuring individuals are residing in the most integrated setting appropriate to their needs in compliance with the Americans with Disabilities Act. JUSTIFICATION OF TEMPORARY FILING: The Authority finds that failure to act promptly will result in serious prejudice to the public interest, the Authority, and recipients of Medicaid benefits. These rules need to be adopted promptly so that the Authority may continue admissions of eligible individuals to secure residential treatment facilities. DOCUMENTS RELIED UPON, AND WHERE THEY ARE AVAILABLE: None AMEND: 410-172-0720 RULE TITLE: Prior Authorization and Re-Authorization for Residential Treatment RULE SUMMARY: The Authority’s Health System Division is moving SRTF Admission Criteria from OAR 309-035-0163 to 410-172-0720(7), based on advice from the Department of Justice as being a more appropriate location. Using stakeholder feedback, adjusting admissions criteria for SRTF will result in ensuring individuals are residing in the most integrated setting appropriate to their needs in compliance with the Americans with Disabilities Act. RULE TEXT: (1) The Authority does not consider a request for a fixed episode of care or standardized length of stay to be medically appropriate. Requested length of stay shall be based on an assessment of individual need and the medical appropriateness of the proposed time for treatment. (2) Residential treatment is intended as an outcome-based, transitional, and episodic period of care to provide service and supports in a structured environment that allows the individual to successfully reintegrate into an independent Page 1 of 3 community-based living arrangement. (3) Residential treatment is not intended to be used as a long-term substitute for lack of available supportive living environment in the community. (4) Authority licensed residential treatment programs are reimbursed for the provision of rehabilitation, substance use disorder, habilitation, or personal care services as defined in these rules. (5) The Division shall authorize admission and continued stay in residential programs based on the medical appropriateness of the request and supporting clinical documentation. (6) Prior authorization requests for admission and continued stay may be reviewed to determine: (a) The medical appropriateness of the admission for residential services provided; (b) The appropriateness of the recommended length of stay; (c) The appropriateness of the recommended plan of care; (d) The appropriateness of the licensed setting selected for service delivery; (e) A level of care determination was appropriately documented. (7) Prior authorization requests for admission and continued stay for a Secured Residential Training Facility (SRTF) shall also be reviewed to confirm that the individual meets all the following criteria: (a) The individual requires less than 24-hour hospital care and treatment; (b) The individual requires highly structured environmental supports and supervision seven days a week and 24 hours a day in order to participate successfully in a program of habilitative and rehabilitative activities; (c) Due to a mental illness and as evidenced by clinical documentation from the last 90 days or from an Authorityapproved and standardized risk assessment, the individual presents a risk in one of the following areas: (A) Clear intention or specific acts of bodily harm to others; (B) Suicidal ideation or self-injury requiring significant medical intervention; (C) Inability to care for basic needs that results in exacerbation or development of a significant health condition or the individual’s mental health symptoms impact judgment and awareness to the degree that the individual may place themselves at risk of imminent harm. (d) Due to the symptoms of a mental illness, there is significant risk that the individual will not remain in a place of service for the time needed to receive the services and supports necessary to resolve the symptoms of a mental illness that pose a threat to the individual’s safety and well-being. (8) If the Division determines that a residential service prior authorization request is not within coverage parameters, the provider shall be notified in writing and shall have ten business days to provide additional written documentation to support the medical appropriateness of the admission and procedures. (9) If the reconsidered decision is to uphold the denial, prior authorization shall be denied. (10) The provider may appeal any final decision through the Division administrative appeals process as described in OAR 410 120-1560 through1875. (11) Upon denial of a prior authorization request for continued stay, the Division shall authorize payment for up to 60 days of continued stay for the purposes of supporting transition management and planning for the recipient. (12) The Division shall determine re-authorization and authorization of continued stays based upon one of the following: (a) The recipient continues to meet all basic elements of medical appropriateness; (b) One of the following criteria shall be met: (A) Documentation that the treatment provided is resulting in measurable clinical outcomes but that the recipient is not sufficiently stabilized or yet developed the skills necessary to support transition to a less restrictive level of care; (B) The recipient develops new or worsening symptoms or behaviors that require continued stay in the current level of care. (13) Requests for continued stay based on these criteria shall include documentation of ongoing reassessment and necessary modification to the current treatment plan or residential plan of care. STATUTORY/OTHER AUTHORITY: ORS 413.042, 430.640 Page 2 of 3 STATUTES/OTHER IMPLEMENTED: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715 Page 3 of 3