Current through Register Vol. 63, No. 9, September 1, 2024
(1)
The ACT Program shall complete a Comprehensive Assessment that demonstrates
medical appropriateness prior to the provision of this service. If a
substantially equivalent assessment is available that reflects current level of
functioning and contains standards consistent with OAR
309-019-0135 to include
sufficient information and documentation to justify the presence of a diagnosis
that is the medically appropriate reason for services, the equivalent
assessment may be used to determine admission eligibility for the ACT
program.
(2) A referral for The ACT
Program is managed and coordinated by a designated SPOC, as defined in these
rules:
(a) The CCO, SPOC and or ACT Program
shall accept all referrals utilizing the Universal Referral Form provided by
the Division and verify the required documentation that supports ACT criteria.
The referral must include when an approximate, reasonable date of admission
and/or Intake for further evaluation for the ACT program is
anticipated.
(b) Based on the CCO
and ACT Program's published referral process and contractual language, the
deciding entity shall have 14 calendar days of receipt of a referral to
communicate to referring party and requested participant of final
determination. This determination shall reference applicable OAR's for
acceptance or denial. If there is insufficient information to process the
referral, the deciding entity will respond to referring party requesting the
additional information; which will be referred to as a pending
referral
(c) If a pending referral
is resubmitted, the deciding entity based on their published referral process,
will have an additional 14 calendar days after receipt of this resubmission. A
final determination must be made by the second resubmission timeframe based on
relevant Administrative Rules.
(3) The final determination must:
(a) Be a formal written response addressed to
the requested participant and referring party; only if HIPAA allows for care
coordination purposes or if legal status allows such communication.
(b) This decision must cite applicable
administrative rule and criteria to support the final determination.
(c) A referral can be reflective as "pending"
if there is more than 60 days until discharge from an acute care setting and
the ACT Team requests monitoring for progression. If this option is utilized,
the ACT program must document and site this OAR while also continuing to be
actively involved in care coordination and will provide a final determination
in good faith prior to discharge or end of jurisdiction date to ensure decision
does not interfere with discharge process.
(4) Referrals shall be accepted from mental
health outpatient programs, residential treatment facilities or homes, families
or individuals, and other community sources.
(5) Given the severity of mental illness and
functional impairment of individuals who qualify for ACT services, the final
decision to admit a referral can rest with the CCO based on contractual
language with said provider. Any referral to a provider shall include
supporting medical documentation attached to the Universal ACT Referral Form
provided by the Division and include an approximate date the referred
individual will be able to enroll in an ACT program.
(a) The individual's decision not to take
psychiatric medication is not a sufficient reason for denying admission to an
ACT program;
(b) ACT capacity in a
geographic regional service area is not a sufficient reason for not providing
ACT services to an ACT eligible individual. If an individual who is ACT
eligible cannot be served due to capacity, the SPOC and or CCO shall provide
the individual with the option of being added to a waiting list until such time
the ACT eligible individual may be admitted to a certified ACT program:
(A) The ACT eligible individual who is on the
waitlist due to capacity shall be offered alternative community-based
rehabilitative services as described in the Oregon Medicaid State Plan that
includes evidence-based practices to the extent possible;
(B) Alternative evidence-based services shall
be made available to the individual, until the individual is admitted into an
ACT Program.
(6) Individuals who meet admission criteria
and are not admitted to an ACT program due to program capacity shall be placed
on a waiting list. The Division shall monitor each regional waiting list until
sufficient ACT program capacity is developed to meet the needs of the ACT
eligible population.
(7) In
addition, if an individual is denied ACT services the individual or their
guardian may appeal the decision by filing a grievance in the manner set forth
in OAR 309-008-1500 or for an
Administrative Hearing which will be documented on The Division's form number
MSC 0443 by either the Program, CCO or The Division and submitted through
appropriate channels.
Statutory/Other Authority: ORS
161.390,
413.042,
430.256 &
430.640
Statutes/Other Implemented: ORS
161.390 -
161.400,
428.205 -
428.270,
430.010,
430.205-
430.210,
430.254 -
430.640,
430.850 -
430.955 &
743A.168
