Or. Admin. Code § 309-019-0248

Current through Register Vol. 63, No. 10, October 1, 2024

Section 309-019-0248 - ACT Admission Process

(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.

Or. Admin. Code § 309-019-0248

MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16; MHS 18-2016, f. 11-28-16, cert. ef. 11/30/2016; MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17; MHS 6-2017, f. & cert. ef. 6/23/2017; MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18; MHS 4-2018, amend filed 02/27/2018, effective 3/1/2018; BHS 44-2023, amend filed 12/22/2023, effective 1/1/2024

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