Mandatory enrollment in coordinated care organization
- • exemptions
(1) Except as provided in subsections (2), (3), (4) and (5) of this section and ORS 414.632 (Services to individuals who are dually eligible for Medicare and Medicaid) (2), a person who is eligible for or receiving health services must be enrolled in a coordinated care organization to receive the health services for which the person is eligible. For purposes of this subsection, Medicaid-funded long term care services do not constitute health services.
(2) Subsections (1) and (4) of this section do not apply to:
(a) A person who is a noncitizen and who is eligible only for labor and delivery services and emergency treatment services;
(b) A person who is an American Indian and Alaskan Native beneficiary;
(c) An individual described in ORS 414.632 (Services to individuals who are dually eligible for Medicare and Medicaid) (2) who is dually eligible for Medicare and Medicaid and enrolled in a program of all-inclusive care for the elderly; and
(d) A person whom the Oregon Health Authority may by rule exempt from the mandatory enrollment requirement of subsection (1) of this section, including but not limited to:
(A) A person who is also eligible for Medicare;
(B) A woman in her third trimester of pregnancy at the time of enrollment;
(C) A person under 19 years of age who has been placed in adoptive or foster care out of state;
(D) A person under 18 years of age who is medically fragile and who has special health care needs;
(E) A person receiving services under the Medically Involved Home-Care Program created by ORS 417.345 (Medically Involved Home-Care Program) (1); and
(F) A person with major medical coverage.
(3) Subsection (1) of this section does not apply to a person who resides in an area that is not served by a coordinated care organization or where the organization’s provider network is inadequate.
(4) In any area that is not served by a coordinated care organization but is served by a prepaid managed care health services organization, a person must enroll with the prepaid managed care health services organization to receive any of the health services offered by the prepaid managed care health services organization.
(5) As used in this section, “American Indian and Alaskan Native beneficiary” means:
(a) A member of a federally recognized Indian tribe;
(b) An individual who resides in an urban center and:
(A) Is a member of a tribe, band or other organized group of Indians, including those tribes, bands or groups whose recognition was terminated since 1940 and those recognized now or in the future by the state in which the member resides, or who is a descendant in the first or second degree of such a member;
(B) Is an Eskimo or Aleut or other Alaskan Native; or
(C) Is determined to be an Indian under regulations promulgated by the United States Secretary of the Interior;
(c) A person who is considered by the United States Secretary of the Interior to be an Indian for any purpose; or
(d) An individual who is considered by the United States Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut or other Alaskan Native. [Formerly 414.737]
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.