Current through Register Vol. 63, No. 3, March 1, 2024
(1)
Under ORS
656.260,
the director may suspend or revoke an MCO's certification if:
(a) The director finds a serious danger to
the public health or safety;
(b)
The MCO is not providing services according to the terms of the certified MCO
plan;
(c) There is a change in
legal entity of the MCO that does not conform to the requirements of these
rules;
(d) The MCO fails to comply
with ORS chapter 656, OAR 436-009, 436-010, 436-015, or orders of the
director;
(e) The MCO or any of its
members commits any violation for which a civil penalty could be assessed under
ORS
656.254
or
656.745;
(f) Any false or misleading information is
submitted by the MCO or any member of the organization;
(g) The MCO continues to use the services of
a health care practitioner whose license has been suspended or revoked by the
licensing board; or
(h) The
director determines that the MCO was or is formed, owned, or operated by a
non-qualifying employer.
(2) The director will provide the MCO written
notice of intent to suspend the MCO's certification.
(a) The notice will:
(A) Describe generally the acts of the MCO
and the circumstances that would be grounds for suspension; and
(B) Advise the MCO of its right to a show
cause hearing and the date, time, and place of the hearing.
(b) The director will serve the
notice upon the MCO's designated in-state communication liaison and to the
registered agent or other officer of the corporation upon whom legal process
may be served at least 30 days before the scheduled date of the hearing.
(3) The show cause
hearing on the suspension must be conducted as provided in OAR 436-015-0008(6).
(4) An order of suspension will
suspend the MCO's authority to enter into new contracts with insurers for a
specified period of time up to a maximum of one year. During the suspension,
the MCO may continue to provide services under the contracts in effect at the
time of the suspension.
(a) The director may
set aside the suspension before the end of the suspension period if the
director is satisfied of the MCO's current compliance, ability, and commitment
to comply with ORS chapter 656, OAR 436-009, 436-010, 436-015, orders of the
director, and the certified MCO plan.
(b) Before the end of the suspension period
the director will determine if the MCO is in compliance with ORS chapter 656,
OAR 436-009, 436-010, 436-015, orders of the director, and the certified MCO
plan. If the MCO is in compliance the suspension will terminate on its
designated date. If the MCO is not in compliance the suspension may be extended
beyond one year without further hearing, or revocation proceedings may be
initiated.
(5) The
process for revocation of the certification of an MCO is as follows:
(a) The director will provide the MCO with
notice of an order of revocation which:
(A)
Describes generally the acts of the MCO and the circumstances that are grounds
for revocation; and
(B) Advises the
MCO that the revocation will become effective within 10 days after service of
such notice upon the MCO, unless within 10 days the MCO corrects the grounds
for the revocation to the satisfaction of the director or the MCO files an
appeal as provided in OAR 436-015-0008(7).
(b) The director will serve the order upon
the MCO's designated in-state communication liaison and to the registered agent
or other officer of the corporation upon whom legal process may be
served.
(c) A show cause hearing on
the revocation will be conducted as provided in OAR 436-015-0008(6).
(d) If the director affirms the revocation,
the revocation is effective 10 days after service of the order upon the MCO
unless the MCO appeals the order.
(6) After revocation of an MCO's authority to
provide services under these rules has been in effect for three years or
longer, the MCO may petition the director to restore its authority by making
application as provided in these rules.
(7) Notwithstanding section (5) of this rule,
in any case where the director finds a serious danger to the public health or
safety and sets forth specific reasons for such findings, the director may
immediately revoke the certification of an MCO without providing the MCO a show
cause hearing. Such order will be final, unless the MCO requests a hearing as
provided in OAR 436-001-0019 within 60 days of the mailing date of the order
revoking the MCO certification.. OAR 436-015-0008(6) outlines the process for
review.
(8) Insurer contractual
obligations to allow an MCO to provide medical services for workers are null
and void upon revocation of the MCO certification by the director.
Statutory/Other Authority: ORS
656.260
& 656.726(4)
Statutes/Other Implemented: ORS
656.260
