APD/SSP/CW

Regional Meetings
2015

Tips and Tools

Packet 3

Office of Payment Accuracy and Recovery 8/15/15

http://www.oregon.gov/oha/healthplan/Pages/regionals.aspx

Left blank intentionally

Table of Contents Tips and Tools

[1] DMAP -Health Plan Enrollment

o

OHP Enrollment. Questions? Who to call____________________________2

Who is exempt from enrollment? Carve out populations________________3

Disenrollment requests want to change plans ______________________5

Disenrollment requests want open cared/fee for service ______________6

How the enrollment cycle runs____________________________________7

Address changes for clients receiving Mental Health residential treatment__8

[2] Office of Payment Accuracy and Recovery- Client Maintenance Unit

o

How to avoid duplicate primes___________________________________10

What is Program Integrity? _____________________________________12

OPAR Recovery and Cost Avoidance Report_________________________13

[3] Department of Human Services

o

Storage of Sensitive Documents__________________________________14

Sharing of information SSP and CW_______________________________16

Mandatory reporting___________________________________________20

[4] Aging and People with Disabilities

o

Medicare Buy-In eligibility facts__________________________________24

[5] Department of Human Services/ Oregon Health Authority

o

Administrative Hearing Requests_________________________________27

How to make payments online___________________________________30

Your Oregon Health Plan enrollment

Important information

You have enrollment options

Most clients are enrolled in a network of providers called a coordinated care
organization (CCO). You may be able to change your CCO in the first 30 to 90 days of
enrollment. Contact OHP Client Services at 1-800-273-0557 to learn more about your
options.

If you are an OHP Plus client, you are required to be in a coordinated

care organization (CCO) unless:
You are American Indian or Alaska Native. You can choose to still get care through
Indian Health Services or a tribal health center after you enroll in a plan. Call us if
you want to enroll in a plan.
You get care from a provider not in your plan, and changing providers would
negatively affect your health.
You are in your last 3 months of pregnancy and want to stay with your current
provider.

Who should you call if you have questions?

Call your coordinated care organization (CCO) if you:

Need help making an appointment.

Need help finding a provider or want to change your provider.
Have questions about coverage or services offered.
Get a bill.

Call OHP Client Services at 1-800-273-0557 (TTY 711) if you:

Want to change your coordinate care organization (CCO) or enroll.

Need a new Oregon Health ID card or client handbook.
Get a bill and are not in a CCO.
Need help making an appointment and are not in a CCO.
Have questions about coverage and are not in CCO.

Call OHP Customer Service at 1-800-699-9075 (TTY 711) if you:

Have questions about eligibility.

Become pregnant or your pregnancy ends.
Change mailing addresses, email addresses or phone numbers.
2
For more information about the Oregon Health Plan, visit www.ohp.oregon.gov.

Topic

Enrollment / Disenrollment
Carve Out Populations

Provided by

Health Services - DMAP

Enrollment and disenrollment is more flexible for carve out populations. These special
populations may have special care needs and include:

HNA Heritage Native American

Medicare Dual Eligibles
Child Welfare
OYA Oregon Youth Authority

HNA
HNA clients will not auto assign with any level of coverage in MMIS. An exemption is
no longer necessary to prevent enrollment. HNA clients can opt in or out of enrollment,
at any level of coverage, at any time.
Medicare Dual Eligibles
Clients who are eligible for both Medicaid (OHP) and Medicare will not auto assign with
a medical level of coverage in MMIS. An exemption is no longer necessary to prevent
medical enrollment but clients can be manually enrolled with medical coverage if they
choose. These clients will continue to auto assign with dental and/or mental health
coverage depending on the coverage available in the clients service area. Medicare
Dual Eligible clients can request a plan change at any time.
Child Welfare
Chile Welfare clients will not auto assign with a medical level of coverage in MMIS. An
exemption is no longer necessary to prevent medical enrollment but clients can be
manually enrolled with medical coverage. These clients will continue to auto assign
with dental and/or mental health coverage depending on the coverage available in the
clients service area. Clients receiving BRS, PRTS, or other residential care may have
an SAE (service area exception) to maintain the clients enrollment within the county of
responsibility.
OYA
OYA clients will not auto assign with a medical level of coverage in MMIS. An
exemption is no longer necessary to prevent medical enrollment but clients can be
manually enrolled with medical coverage. These clients will continue to auto assign
with dental and/or mental health coverage depending on the coverage available in the
clients service area.

Health Services/DMAP 7.2015

3

Enrollment /Disenrollment Carve Out Populations (cont)

Disenrollment is typically at the end of the month but clients in these carve out
populations can be disenrolled mid-month if there are access to care issues.
** Please note extra care is necessary at the branch level to ensure these clients
remain enrolled at the desired level of coverage. For example, an HNA client who is
enrolled with a CCOA and moves to a new service area will not be auto assigned to the
CCOA in the new service area. If the client wishes to remain enrolled with a CCOA
he/she will need to be manually enrolled in the new service area. Similarly, a Medicare
dual eligible client who is enrolled with a CCOA will not be auto enrolled with a CCOA if
he/she moves to a new service area. The client will need to be enrolled manually if
CCOA enrollment is desired in the new service area. Manual re-enrollment may also
be necessary if clients loose eligibility, are auto disenrolled, and eligibility is restored.

Health Services/DMAP 7.2015

4

Topic
Provided by

Disenrollment Options
Requests to change plans
Health Services - DMAP

These guidelines are assuming there are no exemptions, service area exceptions
(SAE), or situations that would prevent enrollment and that the requested plan is
available in the client's service area. These disenrollment options apply only to selfsufficiency cases (AFS, HIX, FST, MOD). APD (SSD), OYA (OYA), and Child Welfare
(CSD) have different criteria for enrollment/disenrollment.
30-day OAR 410-141-3080(2)(a)(C)
Clients who have been enrolled with their current plan less than 30 days and were
either auto enrolled in error or manually enrolled in error can request to change plans.
These clients can be enrolled next weekly. They do not have to wait until the end of
the month for disenrollment.
12-Month New OHP Member OAR 410-141-3080(2)(a)(A)
Newly eligible clients who have been enrolled with only one plan may change their
enrollment once within 12 months following the date of the initial enrollment. The
business decision has been made to extend this option to the ACA population (HIX/
FST/ MOD) even if those clients have previous enrollment. Clients using this option will
have to wait until end of the month for disenrollment (next monthly).
Six-Months OAR 410-141-3080(2)(a)(B) the rule states 12 months
Clients who have been enrolled with their current plan at least six months can request
to change plans. These clients are disenrolled at the end of the month. We take into
consideration if a client is enrolled with a CCO that has recently rolled over to another
coverage type or service area so we count the entire enrollment when calculating the
six months, not just the most current enrollment. For example, if a client has been
enrolled with a CCOA for two months but was previously enrolled seamlessly with the
CCOG for at least four months then we can apply the six-month disenrollment criteria.
Re-Determination OAR 410-141-3080 (2)(a)(D)
Clients can change plans during eligibility renewal. These clients are disenrolled at the
end of the month. It can be difficult for CES and CCSU to identify these clients. We
can use the case dates in MMIS but this isnt always an accurate way to confirm when
a case was renewed.
Recipient Choice OAR 410-141-3080 (2)(a)(D)
Clients have one other option to change plans if the first four options listed above
cannot be applied. Formerly known as SB201, this option can be applied once during
the eligibility period if no other disenrollment options can be applied. Once this option
is used, clients cannot change plans again until they have been enrolled at least six
months or at renewal, whichever comes first.
Health Services/DMAP 7.2015
5

Topic

Disenrollment Requests
Want Fee for Service Open Card

Provided by

Health Services - DMAP

Disenrollment Requests
FFS (Fee for Service Open Card)

The Client Enrollment Services (CES) team has some limited access to exempt
clients in certain situations such as hospitalization or residential treatment.
Most requests for disenrollment to receive services FFS (fee for service, also
known as open card) are reviewed by the MAP Medical Unit to determine
whether or not the client meets criteria to be exempt from enrollment. This may
include but is not limited to:

Access to Care
Continuity of Care
Pregnancy Exemptions
Out-of-State Treatment

Please note this does not include medical exemptions for carve out populations
such as HNA, Medical Dual Eligibles, Child Welfare, and OYA. These special
populations are not programmed to auto assign with medical coverage. The
Medical Unit would review dental or mental health exemptions for these clients,
with the exception of HNA clients who do not auto assign with any level of
coverage. An exemption for HNA clients would prevent manual enrollment but is
not necessary to prevent auto assignment.
Requests are typically submitted by the care provider and would include chart
notes and other documentation to support the need for exemption. The Medical
Unit can review and approve exemptions for all levels of coverage; medical,
dental, and/or mental health. Clients can also request exemptions through the
Medical Unit.
For more information please contact the Medical Unit at 503-945-5772.

Health Services/DMAP 7.2015

6

HowtheEnrollmentCycleRuns

TheenrollmentcyclerunsfromThursdaythroughthefollowingWednesday.Enrollmentfor
clientsupdatedduringthecurrentenrollmentcyclewillbeeffectivetheMondayfollowingthe
endoftheenrollmentcycle.Aclientwhoisupdatedon08/05wouldbeeffective08/10.A
clientwhoisupdatedon08/13wouldbeeffective08/24.Anewenrollmentcyclebeginsevery
Thursday.

Examples:
ClientenrollmentdoneonMonday,TuesdayorWednesday,clientenrollsintomanagedcare
thefollowingMonday.(Actiondone8/5,clientenrolls8/10)
ClientenrollmentdoneonThursdayorFriday,clientenrollsintomanagedcare1weekfromthe
followingMonday.(Actiondone8/13,clientenrolls8/24)

Address Changes for Clients Receiving Residential Treatment

For individuals experiencing mental illness, residential treatment helps promote and
enhance skills needed to lead independent healthy lives. Residential treatment offers
support, stability, and rehabilitative care in homelike settings, preparing individuals to
live independently in their own communities.
Many clients receiving mental health residential treatment are in temporary placements
outside of their home community.
It is important to note that inappropriate address changes can disrupt care for these
individuals, affecting enrollment in their home coordinated care organization (CCO).
Please change only a clients mailing address for placement or temporary moves. When
you change a residential address or a FIPS county code, it triggers a change in CCO
enrollment.
Please use the guide below to help determine which address should be changed.

Is this address change temporary?

Yes

No

The new address is for a

facility or placement.

The new address is a

permanent move.

Change only the

Change the

mailing address

residential address

(Not the FIPs county code)

(Including the FIPs code)

The home CCO enrollment rule will take effect in September 2015
Although honoring a clients home CCO has already been a part of our regular business
practices, this September it will become rule.
Oregon Administrative Rule 410-141-3066 will ensure that Oregon Health Plan clients
leaving Oregon State Hospital care and who are receiving mental health residential
services have consistent coordinated care, regardless of placement setting.
Enrollment trainings are being provided to staff at the Oregon State Hospital in July and
August.

Address Changes for Clients Receiving Residential Treatment

8

A new way to identify clients receiving residential treatment services in MMIS

In MMIS, the Medical Case Management (MCM) indicator has been repurposed to
identify clients receiving mental health residential treatment services.
The MCM field will be flagged with Yes if that client is in a residential placement.
Updating the indicator is a manual process, so please contact CES.DMAP@state.or.us
if you believe a record is flagged incorrectly.

Clients receiving
residential treatment
services will be
flagged with Yes on
the MCM indicator.

Transitioning adult mental health residential treatment services into CCOs

OHA is committed to providing Oregonians the right service at the right time, in the right
setting for the appropriate length of time.
As part of that commitment and continuing efforts to expand the coordinated care model
in our state, OHA has coordinated several staff workgroups to meet the overall goal of
successfully transitioning adult mental health residential treatment into coordinated care
in July 2017.
For more information about the transition of adult mental health residential treatment
including project updates, fact sheets and other resources, please visit
www.oregon.gov/oha/amh/rtt.

Address Changes for Clients Receiving Residential Treatment

9

Topic
Prepared by

How to Avoid the Creation of a Duplicate

Prime
Client Maintenance Unit

How to Avoid Creating a Duplicate Prime

Using WEBM, FIND to Locate Clients:
To prevent duplicate primes and erroneous information WEBM, FIND should
always be used before setting up or adding anyone to a CM or SNAP case.
Workers should WEBM, FIND:
1. The clients social security number
2. The clients First and Last Name. If they have two last names search for
both sets, for example:
o Joshua Jackson Smith - Search Jackson Smith and Smith Jackson,
or
o Search without the space in the persons name. i.e.: JacksonSmith
This will save you an enormous amount of time in the long-run.
Using the Locate/Find Tool:
The next tip CMU offers is one that should be performed after searching with the
WEBM, FIND screens, but at the same time could be considered your VERY
BEST FRIEND, when adding clients or setting up new CM or SNAP cases.
Within CMUP and FSNEW case set up screens there is an Action Field (below the
first name) which is the LOCATE action. Using F11, which is a Find tool, you can
Locate/Find anyone by using their social security number and/or their Last, First
name. Follow these easy steps:
1. Use the clients social security number or if social security number is not

available search using the Last, First Name

2. Place an L in the Action field (below first name) in either CMUP or FSNEW

3. Hit F11 (this process is for Finding or Pulling over individuals from person

list)
4. If it prompts you, select the correct person from Person List

Please note if ever trying to add someone using the social security number
and you get an error message that says social security number is already in
Client Maintenance Unit 7.2015
10

How to Avoid Creating a Duplicate Prime (cont)

use, please don't just give them a new prime, rather WEBMFIND their social
security number.
CMU has seen an increase in requests to merge prime numbers recently due to
the notices sent regarding missing social security numbers. These steps will
ensure you are selecting the correct person and not creating duplicate primes.
These are ultimately Time Saving Tips that will reduce your workload, reduce
administrative costs and improve customer service.
As always, if you have any questions, or need assistance CMU is here to help.
CMU can be reached at 503-378-4369, Fax 503-373-0357, or E-Mail at
client.maintenance@state.or.us

These tips can also be found at http://inside.dhsoha.state.or.us/asd/opar/opar-cmu.html

Client Maintenance Unit 7.2015

11

Topic

Prepared by

What is program integrity and how

does OPI fit in?
Office of Program and Integrity (OPI)

Program Integrity is the extent to which a program has actually been delivered as
intended.
The mission of the Office of Program Integrity (OPI) is to support Department of
Human Services (DHS) and Oregon Health Authority (OHA) programs in ensuring
compliance with state and federal laws and rules; and to assist with improving
program accuracy through high quality and timely accuracy review services and
information sharing for select program and program areas.
Our vision for OPI is to be recognized as an indispensable partner in ensuring DHS
and OHA program quality and integrity and to have our work product readily
incorporated into organizational program integrity discussions and decision
making.
Our Quality Control Unit exists to assist programs with ensuring compliance with
federal quality control review requirements, review and provide valuable program
effectiveness feedback to field offices and state and federal agencies. The work of
this unit often leads to the establishment of best practices for accuracy and
effectiveness of select programs. Collaboration and communication with program
areas is essential to the units continued success.
Our Quality Assurance Unit exists to promote accurate, consistent and effective
program delivery through statewide targeted review processes, presentation of error
trends training and publication of accuracy related information and best practices.
Reviews are conducted at approximately 73 SSP branches, 47 APD and AAA
branches and the OHA OHP Processing Center (branch 5503). Reviews are
completed at local offices by a team of reviewers to promote coaching at the
individual worker level and effective communication with local leadership.
Our CMS Waiver Review unit exists to work collaboratively with DHS/OHA
Central Office staff as well as local offices throughout the state to ensure consistent
quality and accurate application of policy and rule as required by the Center for
Medicare/Medicaid Services Title XIX 1915(c) Home and Community Based
Services waiver, K-State Plan Option.

Office of Program Integrity 7.2015

12

OPAR Recovery and Cost Avoidance

7/1/2013 through 6/30/2015
$ Recovery and Cost Avoidance combined = $308 mil out of $178 mil for the biennium
(+72.5%)

Unit
Estate
Administration
Medical Payment
Recovery (TPL)
Overpayment
Recovery
Personal Injury
Lien
Provider Audits
Data Match
Total $ Recovery
Health Insurance
Group (TPL)
Fraud
Investigations
Data Match
Total Cost
Avoidance
Total Combined

$
Recovery
to Date
$45.4 mil

Variance
to Date
+18.8%

OHA
Med

Program Split
APD
LTC
SNAP TANF
100%

$14.8 mil

+52.7%

75%

25%

$14.8 mil

+3.9%

6%,

5%

$4.9 mil

+40.2%

95%

$2.3 mil
$1.92 mil
$82.5 mil
$160.9 mil

+15.5%
100%
+119.6%
45%
+21.3%
Cost Avoidance
+123.5%
75%

$5.76 mil

+25.4%

8%

$58.9 mil
$225.7 mil

+73.5%
+104.1%

45%

57%

ERDC

27%

5%

5%

25%

29%

1%

25%

25%

53%

31%

29%

1%

8%

Overall Total
$308.3 mil +72.6%

$RecoveryTotal
$85,000,000
$80,000,000
$75,000,000
$70,000,000

CostAvoidanceTotal
Revenue
Total

$300,000,000
$200,000,000
$100,000,000
$

CATotal

Combined
$400,000,000
$200,000,000

Combined

$
200709

200911

201113

201315
13

Office of Self-Sufficiency Programs

Sandy Dugan, Administrator, DHS CW/SSP
Operations
Kim Fredlund, SSP Deputy Director
Authorized Signature
Topic:

Other

Action Request
Transmittal

Number: SS-AR-14-018
Issue Date: 12/15/2014
Due Date: Immediately

Subject: Storage of Sensitive Documents for SSP

Applies to (check all that apply):
All DHS employees
Area Agencies on Aging
Aging and People with Disabilities
Children, Adults and Families
County DD Program Managers

County Mental Health Directors

Health Services
Office of Developmental
Disabilities Services(ODDS)
Other (please specify): CAFTransmittals-SS

Reason for Action: To meet requirements of confidentiality and safety for SSP
cases, sensitive information such as TA-DVS, A&D, mental health and HIV must
be secured from disclosure for electronically stored documents in EDMS. This
document provides clarification regarding storage of sensitive documents in
alignment with the Family Services Manual.
Action Required: Until system modifications are made to support the additional level
of security needed, effective immediately, do not scan the following sensitive
documents into EDMS:
A&D and Mental Health documentation from a treatment provider pertaining to
diagnosis, prognosis or progress in treatment. (See Family Services ManualConfidentiality of Client Information #16 Alcohol/drug (A&D) and Mental Health
information.)
HIV/AIDS documentation of any kind. (See Family Services Manual- Confidentiality
of Client Information #18 HIV/AIDS.)
TA-DVS documentation if there is a safety concern. This includes when:
o The alleged perpetrator is a DHS employee;
o The alleged perpetrator is a community partner and has access to TRACS
and other case files;
SS-AR-14-018

DHS 0080 (11/13)

14

o The alleged perpetrator is part of the household and has access to case
records;
o The survivor believes that the alleged perpetrator may have some way to
access the records.
(See Narration of Domestic Violence.)
How sensitive documents should be stored:
A. Documents related to current eligibility: Keep all sensitive documents related
to current eligibility in the local office. Any documents related to current eligibility
that are not considered sensitive can be scanned into EDMS.
a. Use a sticky note in TRACS to flag the case for sensitive documents
stored locally in paper files: The sticky note should say Sensitive
documents held locally in (Branch#), MM/DD/YY so that it is known that a
paper file exists locally.
B. When sending paper files in boxes to be archived by IRMS: Instead of
including sensitive documents with your regular archiving, they should be put in a
separate box containing only the documents that cannot be scanned into EDMS.
The box should be clearly marked on the box identification label DO NOT SCAN
CONTAINS SENSITIVE INFO.
a. Please note: It is important that the box with sensitive information be
clearly marked otherwise the documents will be scanned into EDMS.
b. Be sure to narrate in TRACS the case name, what was sent, method of
delivery and both accession numbers (for regular non-sensitive case files
and sensitive case files).
If you are unsure whether a document meets sensitive criteria, check with the worker.
Field/Stakeholder review:
If yes, reviewed by:

Yes

No

If you have any questions about this action request, contact:

- Kairi.j.orejuela@state.or.us
Contact(s): Kairi Orejuela, EDMS Expansion Project:
Rishona Hinsee, TANF Policy:
Lisa Buss, TANF Policy:
Amy Sevdy, TANF Policy:
Courtney Hill, SSP Operations:
Cher LeFore, Business Integrity Manager:

SS-AR-14-018

Rishona.D.Hinsee@state.or.us
Lisa.buss@state.or.us
Amy.sevdy@state.or.us

courtney.m.hill@dhsoha.state.or.us

chere.lefore@state.or.us

DHS 0080 (11/13)

15

Topic

Sharing Information on Common

Cases SSP and CW

Prepared by

FAQ - DHS

Q. For purposes of sharing, is it still a Common Case if CW has moved to

the concurrent plan (Adoption, Guardianship or Another Planned Permanent
Living Arrangement APPLA)?
May SSP share information with CW when a CW case has moved to the
concurrent plan, including cases in which CW seeks Termination of Parental
Rights (TPR)?
Yes, it is still a common case. If the family has a case open with CW and a case
open with SSP (TANF, SNAP, ERDC), there is a common case between CW and
SSP for purposes of sharing information. When CW is requesting information from
SSP, the request needs to fall under the following purposes: safety, eligibility,
service coordination. If the request for information does not fall under one of these
criteria areas, please contact your supervisor.
Types of information that can be shared from SSP can include household
composition, current and past addresses and phone numbers, whether the family
is receiving any services and the outcomes of those services. This information is
important for CW to address safety of the family home and conflicting or
duplication of services. SSP needs information from CW about service
coordination, persons in the home, and any payments the family may be receiving
from CW that impact eligibility for services.
When CW moves from reunification to a concurrent plan, CW continues to engage
legal parents in case planning and service coordination. CW is assessing child
safety, permanency and the wellbeing needs of the child throughout the life of a
case and may determine the concurrent plan is no longer in the childs best
interests and return to a reunification plan. This is also true when CW is pursuing
Termination of Parental Rights (TPR) to free children for the purposes of
Adoption.
A case is no longer considered a common case when CW discontinues providing
services to the parents and family. This happens when at least one of the
following occurs: (1) The Court has relieved CW of providing services; OR (2) The
parental rights have been relinquished or the parental rights are terminated and
the child is legally freed for adoption.
Example: Minor child has been in foster care for 12 months. The CW worker has
attended Court and the Court ordered that CW pursue adoption planning for the
child. CW contacts the SSP worker of the legal parents and indicates that a TPR
hearing is set next month and the CW worker would like to know who the parents
have listed as their household composition as well as current address and phone
Sharing of Information 7.2015
16

number as the worker has been unable to locate the parents for over a month. It is
appropriate for SSP to provide CW with the household
composition/address/phone numbers as it relates to safety of the child and service
coordination. Although there is a TPR hearing set in the next month, the CW
worker still has to make efforts to engage with the family and determine if the
concurrent plan is still applicable to the childs safety, permanency and wellbeing.
Q. May CW and SSP share hardcopy or electronic documents regarding a
common case with the other program?
As a general rule, hardcopy or electronic documents should NOT be shared.
Q. Are there times when the CW worker should contact the SSP worker with
information about a common case?
Yes, the CW worker should share verbally or by email (but not an electronic or
hard copy of documents) the following information with the SSP worker during
each point in the CW case.
If CW has made the case a Sensitive Case, the CW worker should tell the SSP
worker the information being shared is from a Sensitive CW Case.
Screening
The reason for CW involvement includes but is not limited to, the allegations.
Exceptions to sharing:
Identification of caller/reporter of child abuse
Names of alleged perpetrators
Why Share?
Because SSP has information about who is in the household and possibly
who visits the home and might have other information that can inform CW
about the identified child safety issues.
SSP can partner with CW on services and benefits that can address the
child safety issues.
CPS Assessment

Present Danger has been identified and a Protective Action implemented

Impending Danger Safety Threats have been identified and an Initial Safety
Plan implemented
Safety Service Provider information (grandma will visit during certain hours
for dinner and bedtime; neighbor supervises when father visits child, etc.)
Conditions for Return
Child considered safe at the conclusion of the assessment
Child considered unsafe at the conclusion of the assessment and a case
will be opened and transferred

Sharing of Information 7.2015

17

Child is considered safe at the conclusion of the assessment but the family
is identified as having moderate to high needs and, in Differential
Response Counties, referrals have been made to community providers or
SPRF services (share specific referrals)
Names of people who should not have contact, or not have unsupervised
contact, with the child(ren)
The names of people who should not have contact, or not have
unsupervised contact, with the child(ren) should be redacted by SSP prior
to releasing records to clients.

Why Share?
Because SSP has information about who is in the household and possibly
who visits the home and might have other information that can inform CW
about the identified child safety issues.
SSP can partner with CW on services and benefits that can address the
child safety issues.
Case Transfer

Notify SSP when transferring case to new CW case worker and provide
new CW contact information
Invite SSP to Child Safety Meeting
Discuss Conditions for Return
Discuss Ongoing Safety Plan

Why Share?
SSP worker might have information that will inform CW worker about the
familys current situation and how it impacts child safety and can identify
and connect to resources for the child and family to support the CW Safety
Plan.
Permanency (On-Going)

Invite SSP to Family Decision Meetings

Discuss modifications in Ongoing Safety Plan as appropriate
Discuss Conditions for Return (criteria that must exist prior to children
returning home)
Discuss Expected Outcomes (sustained changes in the family condition
that allow case closure)
Service Coordination
Notify SSP of case closure

Why Share?

Sharing of Information 7.2015

18

 SSP worker might have information that will inform CW worker about the
familys current situation and how it impacts child safety and can identify
and connect to resources for the child and family to support the CW Safety
Plan.

Q. Should SSP document information received from CW regarding a

common case? If so, where should it be documented?
The SSP worker may document the CW information in TRACS unless CW
identifies the information involves a Sensitive Case. For a CW sensitive case, the
SSP worker should narrate in regular TRACS that this is a common case
identified as a Sensitive Case by CW and, therefore, all future narratives will be
documented in the hard file and locked up at the workers desk, consistent with
SSP sensitive case handling.
If CW shares names of people who should not have contact, or not have unsupervised
contact, with the child(ren), SSP must redact these names prior to releasing records to
clients.

Q. Should CW document information received from SSP regarding a

common case? If so, where should it be documented?
The CW worker should document the SSP information in OR-Kids.

Sharing of Information 7.2015

19

SHORT INTERVAL TRAINING

(MANDATORY REPORTING)
(Revised 5/18/15)

Mandatory Reporting points:

As employees of DHS we are required by law (ORS 419B.005 to 419B.045 and ORS 124.050
TO 124.095) to be Mandatory Reporters and are obligated to report alleged abuse of children
Any DHS staff having reasonable cause to believe that a child or older adult (age 65 or older)
has suffered abuse or that any person has abused a child or older adult has a duty, under the
laws of the state of Oregon, to immediately report the suspected abuse to the proper authority.
As mandatory reporters, we must report child and elder* abuse and neglect 24 hours per day,
seven days per week. This requirement applies whether we observe the abuse or neglect
during our work activities or on our personal time, and whether we know the child (e.g., family
member, child of a friend) or they are a stranger to you.
*This rule also applies to alleged abuse of individuals regardless of age, who reside in a nursing
facility. (OAR Chapter 411, Div. 20 Rules, effective 1/1/15)
Note: Adult Protective Services (APS) administrative rule uses the term older adult, while the ORS
124 statutes use the term elderly person. Older adult and elderly person mean the same.
What is reasonable cause to believe?
The definition of reasonable is:
Suitable; just; proper; ordinary; fair; usual.
The term reasonable is a generic and relative one and applies to that which is appropriate for a
particular situation.
What is abuse?
As it relates to the statutes on the reporting of child abuse (ORS 419B.005 to 419B.050)
419B.005 (1)(a) Abuse means:

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(A) Any assault, as defined in ORS chapter 163, of a child and any physical injury to a child
or elderly person which has been caused by other than accidental means, including any
injury which appears to be at variance with the explanation given of the injury. For older
adults, physical abuse as defined in OAR 411-020-0002.
(B) Any mental injury to a child which shall include only observable and substantial
impairment of the childs or mental or psychological ability to function caused by cruelty to the
child with due regard to the culture of the individual. For older adults, verbal or emotional
abuse as defined in OAR 411-020-0002.
(C) Rape of a child, which includes but is not limited to rape, sodomy, unlawful sexual
penetration and incest, as those acts are described in ORS chapter 163.
For older adults, sexual abuse as defined OAR 411-020-0002.
(D) Sexual abuse, as described in ORS chapter 163. For older adults, sexual abuse as
defined in OAR 411-020-0002.
(E) Sexual exploitation. For older adults, sexual abuse as defined in OAR411-020-0002.
(F) Negligent treatment or maltreatment of a child, including but not limited to the failure to
provide adequate food, clothing, shelter or medical care that is likely to endanger the health
or welfare of the child. For older adults, neglect and abandonment as defined in OAR 411020-0002 .
Note: For older adults, elder abuse also includes financial exploitation, wrongful restraint of
involuntary seclusion as defined in OAR 411-020-0002. Financial abuse is the most common
type of elder abuse.
(G) Threatened harm to a child, which means subjecting a child to a substantial risk of harm
to the childs health or welfare.
(H) Buying or selling a person under 18 years of age as described in ORS 163.537.
(I) Permitting a person under 18 years of age to enter or remain in or upon premises where
methamphetamines are being manufactured.
(J) Unlawful exposure to a controlled substance, as defined in ORS 475.005, that subjects a
child to a substantial risk of harm to the childs health or safety.
Note: 419B.005 (1)(b) additionally states:
Abuse does not include reasonable discipline unless the discipline results in one of the
conditions described in paragraph (a) of this subsection.

Dont leave room for doubt, if you have to question whether or not it is abuse..
REPORT IT!!!!!!!

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How and to whom do you report?

Child Abuse:
ORS 419B.015 outlines the report form and content this way:
A person making a report of child abuseshall make an oral report by telephone or otherwise
to the local office of the Department of Human Services, to the designee of the department or
to a law enforcement agency within the county where the person making the report is located
at the time of the contact.
The report shall contain, if known:
o The names and addresses of the child and the parents of the child or other persons
responsible for care of the child,
o The childs age,
o The nature and extent of the abuse, including any evidence of previous abuse,
o The explanation given for the abuse and any other information that the person making
the report believes might be helpful in establishing the cause of the abuse and the
identity of the perpetrator
To make a report of abuse you should call either your local Child Welfare office or one of the
many dedicated Child Abuse Hotlines throughout the State. In addition, you can call either 911
or your local law enforcement number.
We have included a comprehensive list of child abuse reporting phone numbers for your
convenience, please refer to the website (see link below) for the most current phone numbers.
Child Abuse and Neglect Reporting Numbers Link:
http://www.oregon.gov/DHS/children/abuse/cps/cw_branches.shtml

Elder Abuse:
o You may report suspected cases of abuse to your Local Aging and People with
Disabilities (APD) or Area Aging Agency (AAA) office.
o In addition, you may call (855) 503-SAFE (7233) to report abuse of a vulnerable adult or
child.
o To report abuse of an adult, 3 options are provided, including one option for over age
65. The automated phone tree will direct the caller to the local APD or AAA office to
report abuse.*
*Note: Most local APD/AAA offices do not have after hours staffing. In such cases, call your
local LEA (Law Enforcement Agency), or 911 for an emergency.
Remember, just because you see law enforcement show up, or because you know another
person has reported an incident; it does not relieve you of your duty to report. If you have
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reason to believe that there has been an incident of abuse or neglect you must report it
immediately, without exception.
Reporting time frames:
Mandatory reporters are required to make an "immediate" report- immediate means "without
undue delay". Such reports cannot wait until later, a more convenient time, or the next
business day. Even if the child or elderly adult is not currently in danger the reporter is required
to report immediately.
Immunity of person making report in good faith
ORS 419B.025 states:
Anyone participating in good faith in the making of a report of child abuse and who has
reasonable grounds for the making thereof shall have immunity from any liability, civil or
criminal, that might otherwise be incurred or imposed with respect to the making or content of
such report. Any such participant shall have the same immunity with respect to participating
in any judicial proceeding resulting from such report.
Additional points to consider:
As it relates to reporting abuse there is no distinction between your work activities or on your
personal time.
Failure to report could result in progressive discipline up to and including dismissal from state
service and could lead to criminal and civil penalties.
Resources for managers:
More extensive training on Mandatory Reporting for Agency employees is available through
the DHS/OHA Learning Center (Course # C00962)
Mandatory Reporting of Child Abuse Video Link:
http://www.oregon.gov/DHS/abuse/mandatory_report.shtml
For more information or to find your local Aging and Aging and People with Disabilities
Services office please refer to the following link:
http://www.oregon.gov/dhs/spwpd/pages/offices.aspx
For more information on Adult Abuse Investigation and Protection:
http://www.oregon.gov/dhs/spwpd/adult-abuse/Pages/index.aspx

Additional Links:
http://www.oregon.gov/DHS/abuse/mr_employees.shtml
https://apps.state.or.us/Forms/Served/de9061.pdf
23

Topic
Provided by

About Medicare Buy-In

Medicare Buy In Unit

The Department pays the Medicare, Part A and/or Part B premium for certain
individuals who are eligible for Medicare. The Buy-In specialists manually initiate the
buy-in process and ensure eligible recipients are accreted correctly and in a timely
manner for the buy-in of Medicare Parts A and B. The Buy-In Specialists research and
resolve discrepancies generated from the States Buy-In master record and Social
Securitys master health insurance records submitted by either Centers for Medicare
and Medicaid (CMS) or the Social Security Administration.
The state pays an enormous capitation rates for Medicaid clients who are eligible to
enroll in Medicare and have not done so. This averages about $550/month for one
person; if it is a husband and wife, it will be $1100.00 each month. As soon as the client
is enrolled with Medicare, that capitation rates drops dramatically. Therefore, the Buy-In
Unit sets up payment of the Medicare premiums for the client, reducing the use of the
Medicaid plan. Buy-In also pays the Medicare premiums for clients who are not MSP
eligible because the state saves money when the client has Medicare.
Medicare Eligibility and IDs
To be eligible for buy-in, the client must first be eligible for Medicare. To be eligible for
Medicare:
Client must be age 65 years old, and have been a resident of the United States for 5
years; or
The client has been disabled (SSA criteria differs from Medicaid) for 24 months; or
Any person who is ESRD (kidney), regardless of age.
Medicare ID numbers are comprised of a social security number (not always the
persons own SS#), followed by an alpha character A, B, T, etc., or an alpha numeric
combination ex: B6, C1, D6, etc., for those drawing Medicare benefits on someone
elses record. The suffix at the end of the social security number is called a BIC
(Beneficiary Identification Code). While there are too many BICS to remember, there
are a few BICS that you should understand, as it will make your job and ours easier.
Most importantly, our clients will benefit by our getting it right the first time, avoiding buyin rejections or terminations.
Below are a few examples of Medicare IDs where client draws entitlement benefits on
their own record. The Medicare ID in these cases will include clients own social security
number:
Medicare BuyIn Unit 7.2015
24

123456789A Clients own record. BIC A indicates that client is insured or has
worked enough to earn free Part A benefits. There are some exceptions to this, but
there is no way of telling by looking at the ID. Clients with free Part A are not eligible,
nor do they need, Part A buy-in but may potentially qualify for Part B buy-in.
123456789M On clients own record. BIC M indicates client is not insured (meaning
they do not have enough work quarters to be eligible for free Part A), and may be
eligible for Part A buy-in to cover the premium.
123456789T On clients own record; BIC T is an indicator that client is ESRD.
BIC B, C, D, etc.: These are BICS that indicate that the Medicare beneficiary is on
someone elses record, for example, Spouse, Parent and divorced or widowed benefits.
Invalid Medicare IDs: There are a few examples of invalid (they look like Medicare IDs,
but they are not) Medicare IDs that sometimes show up on SSB lines and in MMIS; the
two common examples of invalid Medicare ID appear with AI or DI--these are not valid
Medicare IDs. Please correct or delete these from client files when you see them.
Social Security Office
1460B- The 1460B form is only for clients that need to enroll for Medicare. Please do
not send a client to the local SSA office if all they need is a Medicare Part B buy-in.
SSA notice that your clients Buy-in has stopped.
If your client informs you that they have received a notice from SSA indicating that the
State of Oregon will no longer be picking up the premiums, and you believe that this
should not be the case, before you do anything else, please contact your Medicare BuyIn Specialist. Save yourself the trouble of contacting SSA, and save your client this
unnecessary step as well. Generally, that SSA notice is a result of a coding/update that
had triggered a buy-in termination. It is a termination generated within our system that
has prompted SSA to send that notice. In these cases, SSA cannot fix it, but we can.
Buy-In Terminology and Procedures
CMS: When Buy-In Specialists refer to CMS, we are talking about the Centers for
Medicare and Medicaid Services, which is the Federal Agency that oversees Medicare
program. While the Social Security Administration handles the Medicare application and
appointment process, CMS is the federal entity that gives final approval or rejection on
buy-in premium requests.
Please remember that the Medicare Buy-In Team has direct access to CMS sub-system
which displays specific client Medicare information. We often refer to the CMS subsystem to obtain information before it is displayed in MMIS/TBQ screens. We are often
able to indentify discrepancies that prevent the successfulness of processing Medicare
Buy-Ins.
When we ask you to make correction to your clients case i.e. name, date of birth,
Medicare number etc please be aware if the correction is not done or is not
done in a timely manner it will cause a interruption in getting the Buy-in
processed.
Medicare BuyIn Unit 7.2015
25

The importance of accuracy: The less errors made on client files will help minimize
delays and interruptions for processing Buy-ins.
Buy-in File
The Buy-in file is now processes weekly. The data goes to CMS every Friday instead
of the 25th of the month. This change is very beneficial for the client.
SMB/SMF retro process
Buy In also pays three months retro for SMB/SMF cases. MMIS is not designed to set
up a retro eligibility date; the worker has to submit a Form 148 to CMU and then notify
their buy in specialist as soon as Form 148 processes. Please do not contact us until
CMU confirms the 148 has been processed.
Here are some Buy-In transaction codes that we send to CMS:
61 Request to purchase the Medicare Part A and the Part B premiums.
84 Same as 61 code
75 Request to purchase earlier premium (retro buy in)
50 Code to dispute the Medicare Part B billing
51 Code to terminate the buy in.
Here are some examples of transaction codes that Buy-in receives from CMS:

1161/1184 Buy-in has processed, allowing the state to pick-up Part A and/or
Part B premiums.
1165/1167 we can dispute the billing if the client is not on Medicaid or the
billing date is not correct.
15 Client lost their Medicare benefits.
16- SSA/CMS indicates that the client is deceased
1728 Client is no longer living in Oregon
2161s A, B, C, D, E CMS rejected our request to purchase the Medicare
premiums because the data that the state submitted did not match CMS
records; or the client does not have Medicare; or the BIEC code submitted is
wrong; or CMS is telling us that the client already lost their Medicare benefits.
1750 CMS accepted our request to dispute or terminate the buy in.
1751 CMS accepted our request to stop the buy in.
4375 CMS accepter our request to pick up earlier Medicare premiums.
4999 CMS is telling us that the client has Medicare Part B only and the BIEC
code submitted is wrong. This happens when the worker adds the QMM
descriptor to the case. Part A buy in is a manual process. The state will not
automatically pick up the Part A premium by just adding the QMM descriptor to
the case. These transaction codes can be found in MMIS in the Medicare tab
under the Medicare combined panel.

Medicare BuyIn Unit 7.2015

26

Office of Self Sufficiency Programs

Office of Client and

Community Services/Healthy
Kids

Sandy Dugan, Administrator, DHS CW/SSP

Field Services
Karen House, Manager of the Office of Client and
Community Services, Medical Assistance
Programs, Oregon Health Authority
Authorized Signature

Action Request
Transmittal

Number: SS-AR-13-013
Issue Date: 12/13/2013

Topic: Other
Subject: Administrative Hearing Request Procedures
Transmitting (check the box that best applies):
New policy
Policy change
Policy clarification
Executive letter
Administrative Rule
Manual update
Other: Procedural change
Applies to (check all that apply):
All DHS employees
Area Agencies on Aging
Aging and People with Disabilities
Children, Adults and Families

County DD Program Managers

Policy/rule number(s):
Effective date:

OAR 410-200-0015
October 1, 2013

County Mental Health Directors

Health Services
Office of Developmental Disabilities
Services (ODDS)
Other (please specify): SSP transmittal
group; OCCS CSU team; all staff who
determine eligibility and support staff
who receive or respond to client requests
Release no:
Expiration:

Action Required: Although OCCS medical cases have been centralized at OHP
Customer Service (Branch 5503), local DHS branches may still receive requests for
medical assistance hearings. This transmittal is intended to provide direction to DHS
field staff in processing these requests.
As of October 1, 2013, requests for hearings in medical assistance programs may be
made verbally as well as in writing.
SS-AR-13-013

DHS 0078 (11/13)

27

Note: Requests for DMAP service denial hearings must still be made in writing.
Requests for medical assistance hearings may continue to be made via the MSC 443.
When staff receive verbal hearing requests for medical cases, the following procedures
are followed:
Complete the DHS/OHA section at the top of the MSC 443 and date stamp the
form;
Complete the claimants portion of the form after asking the claimant the
necessary questions;
Note the receipt of the request in TRACS, and submit the MSC 443, along with
the DHS 443C cover sheet through the normal DHS process either electronically
to CAF Hearings or via fax number: 503-373-7492;
If the claimants request includes other DHS programs in addition to medical
assistance, such as SNAP, TANF or ERDC, do the following:
o Medical programs and SNAP because both SNAP and medical
program hearing requests may be made verbally, mark both Medical and
SNAP and submit the form according to the procedures listed above;
o Medical programs and TANF, ERDC or other programs:
If the request is made in person, ask the claimant to sign the
MSC 443 before submitting the form.
If the request is made telephonically or through an electronic method:
Complete the form for Medical and submit it so that the medical
assistance hearing will not be delayed;
Mail a copy of the form to the claimant with an explanation that
the form must be signed in order to be considered complete in
the TANF and ERDC programs.
Cover Oregon and OHA have developed a separate hearing (appeal) request form
(CO-P-00012/0443MM) for medical, tax credit or cost-sharing reduction cases. If
claimants submit these forms to local DHS offices, they should be forwarded
electronically to:
5503.Hearings@dhsoha.state.or.us or to:

SS-AR-13-013

28
DHS 0078 (11/13)

appeals@coveroregon.com
FAX: 855-253-2060
Mail: Cover Oregon
Attn: Appeals
PO Box 4410
Tualatin OR 97062
Field/stakeholder review:

Yes

No

If yes, reviewed by:

Filing Instructions:

If you have any questions about this policy, contact:

Contact(s): Vonda Daniels
541-690-6139
Jewel Kallstrom 503-947-2316
Yer Vue-Xiong
503-945-5855
Christy Garland 503-947-5519
Joyce Clarkson 503-945-6106
Carol Berg
503-945-6072
Email: OCCS Medical Policy

SS-AR-13-013

29
DHS 0078 (11/13)

DIDYOUKNOW?
Sometypesofpaymentscanbemadeonlineat:https://apps.oregon.gov/ecommerce/dhsoha/eps

AccountsReceivableFormoneyowedtothestateforreasonsotherthanDHS/OHAprogramssuchas
paymentofbacktaxesorforhomecareworkerswhowanttopurchasealicense.
DHS/OHAOverpaymentsUsedtomakepaymentsforSNAP,TANF,MedicalandERDCoverpayments.
EPDUsedtopayaparticipantfeefortheEPD(EmployedPersonswithDisabilities)program.
MaternalandChildHealthUsedforpractiionerstopaytrainingfees.
OHADWSWaterSystemSurveyFeeUsedbycampgroundstopaywaterlicensingfees.
Theonlineoptionisveryeasytomanueverandselfexplanatory.Afterenteringpersonalandpayment
informationonecanmakeapaymentusingadebitorcreditcardandhavetheoptiontoreceiveanemail
receipt.
Note:Ifapaymentisgreaterthan$3,000,theusershouldcontacttheirbankfirstsothebankdoesntdecline
thepayment.
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